Harrison, Peter - The Nursing and Midwifery Council

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Conduct and Competence Committee

Substantive Hearing

2 May-8 June and 3-6 July 2017

Nursing and Midwifery Council, 2 Stratford Place, Montfichet Road, London, E20 1EJ

Name of registrant: Peter Harrison

NMC PIN: 88E1169E

Part(s) of the register: RN5, Registered Nurse (sub part 1)

Learning disabilities (16 July 1991)

Area of registered address: England

Type of case: Misconduct

Panel members: Hilary Nightingale (Chair, Lay member)

Caroline Healy (Registrant member)

Janet Leonard (Registrant member)

Legal Assessor: Lachlan Wilson (2-5 May, 16 May-8 June and

3-6 July 2017)

Jane Rowley (8-15 May 2017)

Panel Secretary: Nilima Ali

Representation:

Nursing and Midwifery Council (NMC): Represented by Greg Unwin, Counsel (2 May-

8 June 2017), and Neil Jeffs, Case Presenter

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(3-6 July 2017), instructed by the NMC

Regulatory Legal Team

Mr Harrison: Mr Harrison was not present in person and not

represented in his absence. He participated by

telephone on 24 May and 6 June 2017

No case to answer: 1.1 (paragraphs 1-12 of Schedule A only), 1.3

and 4.1 (paragraphs 1-32 of Schedule E only)

Facts found proved by admission: 1.1, 1.2, 1.4, 1.6.1, 1.8, 1.9, 1.10, 1.11, 1.12, 2

(in its entirety), 3 (in its entirety), 4 (in its

entirety), 5 (in its entirety), 6 (in its entirety) and

7 (in its entirety)

Facts found proved: 1.5, 1.6.2, 1.6.3 and 1.7

Facts found not proved: N/A

Fitness to practise: Impaired

Sanction: Striking off order

Interim Order: Interim suspension order: 18 months

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This was a multi-registrant hearing relating to Peter Harrison, Registrant A, Registrant C

and Registrant D. Separate determinations were produced for each registrant.

Determination on service – Tuesday 2 May 2017

The panel received information from Mr Unwin on behalf of the Nursing and Midwifery

Council (“NMC”) that the Notice of Hearing had been served in accordance with The

Nursing and Midwifery Council (Fitness to Practise) Rules 2004 (“the Rules”). The panel

accepted the advice of the legal assessor.

The Notice of Hearing was sent by first class post and the Royal Mail ‘signed for’

service on 29 March 2017 to Mr Harrison’s registered address as recorded on WISER,

the system supporting the NMC’s Register. The letter provided details of the allegations,

the times, dates and venue of the hearing and, amongst other things, information about

his right to attend, be represented and call evidence, as well as the panel’s power to

proceed in his absence.

The Notice of Hearing was signed for, as received, in the printed name of ‘HARRISON’

on 30 March 2017.

The panel concluded that service had been effected in accordance with Rules 11 and

34.

Determination on proceeding in the absence of Mr Harrison – Tuesday 2 May 2017

Mr Unwin invited the panel to proceed in the absence of Mr Harrison, pursuant to Rule

21(2)(b).

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Mr Unwin referred the panel to Mr Harrison’s completed ‘Standard Directions Form’,

signed 19 October 2014, in which Mr Harrison indicated that “I will not attend a hearing”.

Mr Unwin further referred the panel to an undated letter from Mr Harrison in which he

provided a response to the substance of the allegations. Mr Harrison concluded that

letter by stating “I hope that this information helps the NMC reach what they consider [a]

fair decision regarding my continued fitness to practise”. Mr Unwin informed the panel

that beyond that information, there had been no recent response from Mr Harrison in

relation to these proceedings.

In light of the above, Mr Unwin submitted that there was sufficient material before the

panel upon which it could be satisfied that Mr Harrison was aware of this substantive

hearing and his right to attend, be represented, or provide written representations. He

submitted that the panel could further be satisfied that Mr Harrison had chosen not to

attend or engage actively in this hearing, seeking rather to rely on previously submitted

written representations.

Mr Unwin submitted that there was no information to suggest that an adjournment of the

hearing at this stage would ensure Mr Harrison’s attendance on a future occasion, there

being no indication that he would attend a hearing on a future date.

Mr Unwin reminded the panel that it had a power to proceed in the absence of a

registrant. He invited the panel to have regard to the strong public interest in its

expeditious consideration of these historic and serious allegations. He contended that

the panel could properly adjudicate upon the charges, in the absence of Mr Harrison,

using its own discretion when assessing all the evidence and taking account of all

matters raised.

Mr Unwin informed the panel that the NMC sought to rely upon approximately 30

witnesses in this hearing, 15 of whom were due to attend in person to give evidence.

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In closing, Mr Unwin submitted that the panel could properly conclude that Mr Harrison

was aware of the times and dates of this hearing and that he had voluntarily absented

himself.

The panel considered whether to exercise its discretion to proceed in Mr Harrison’s

absence, in accordance with Rule 21(2)(b). The panel had regard to all the information

before it, including the submissions from Mr Unwin, and accepted the advice of the legal

assessor.

The panel, in considering this matter, had regard to the public interest in the expeditious

disposal of the case, the potential inconvenience caused to a party or any witnesses to

be called by that party, and fairness to Mr Harrison. The panel gave careful regard to

the judgment in the case of R. v Jones (Anthony William) (No.2) [2002] UKHL 5 and

exercised the “utmost care and caution” in coming to its decision, with close regard to

the overall fairness of proceedings. The panel was mindful that whilst a registrant has a

right to be present in regulatory proceedings, that registrant may also voluntarily absent

themselves such as to enable the panel to decide to proceed in their absence.

The panel took note that the Notice of Hearing, sent on 29 March 2017 to Mr Harrison’s

registered address, was signed for in the printed name of ‘HARRISON’ on 30 March

2017. It took further note that during the course of the NMC’s investigation into the

allegations against Mr Harrison, he had engaged with his regulator to the extent of

completing and returning various NMC correspondence and providing a letter in which

he responded to the allegations. In all of those circumstances, the panel was satisfied

that Mr Harrison was aware of this hearing and that he had voluntarily absented himself.

Moreover, there had been no request for an adjournment. In any event, the panel

considered that adjourning the hearing would serve no purpose as, on the basis of the

information before it, it would be highly unlikely to secure Mr Harrison’s attendance on a

future occasion.

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The panel was aware that there was some disadvantage to Mr Harrison in not being

present to give his account of events or challenge the evidence relied upon by the NMC,

and in relation to the personal and professional impact any adverse findings may have

against him. However, in the panel’s judgement, it could make allowance for the fact

that the NMC’s evidence would not be tested in cross-examination and, of its own

volition, could explore any inconsistencies in the evidence which the panel itself

identified, as well as any matters referred to by Mr Harrison in his written

representations to the NMC. Furthermore, the panel considered that any disadvantage

to Mr Harrison was as a result of his decision to absent himself from the hearing,

waiving his right to attend/be represented.

The panel was mindful of the public interest in the expeditious disposal of cases. There

were approximately 15 live witnesses, due to give evidence on behalf of the NMC, who

would be inconvenienced by an adjournment of these proceedings. The allegations in

this case dated back to 2008 and the panel was particularly mindful that any continued

delay in these matters could further impact upon the witnesses’ recollection of events.

In all of the circumstances, the panel concluded that it was reasonable, appropriate and

in the public interest to proceed today, and that it would not be unfair to Mr Harrison to

hear the case in his absence.

For all these reasons the panel determined to proceed in the absence of Mr Harrison.

The panel will draw no adverse inference from his absence in its findings of fact.

Charge read – Tuesday 2 May 2017

That you, whilst employed by Castlebeck Care (Teesdale) Limited as a Regional

Operations Director/ Regional Operations Manager between 2008 and June 2012:

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1 In relation to Winterbourne View:

1.1 Did not ensure that Winterbourne View met any or all of the national minimum

standards for independent healthcare, under the Care Standards Act 2000,

listed in Schedule A

1.2 Did not ensure that Winterbourne View was compliant with any or all of the

Health and Social Care Act 2008 essential standards listed in Schedule B

1.3 Did not apply to register with the Care Quality Commission as the accountable

officer at the hospital under Part 2 of The Controlled Drugs (Supervision of

Management and Use) Regulations 2006.

1.4 Did not ensure that an action plan was submitted to the Healthcare Commission

following an inspection on 24 March 2009

1.5 Did not ensure that Individual X was registered with the Care Quality

Commission as Manager of Winterbourne View at any time from January 2010

1.6 Following a whistle blowing complaint from Individual O on 11 October 2010:

1.6.1 Did not ensure that any or all identified staff were suspended;

1.6.2 Did not ensure that an investigation was promptly conducted;

1.6.3 Did not ensure that a Serious Untoward Incident Form was completed.

1.7 Did not ensure that one or more patients who were admitted to the Hospital

were suitable for admission;

1.8 Did not ensure that staff at Winterbourne View received sufficient training to

provide appropriate care

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1.9 Did not ensure that all staff at Winterbourne View received adequate

supervision and/or supervision records

1.10 Did not ensure that there were adequate systems in place for the analysis

and/or review of patient incidents at Winterbourne View

1.11 Did not ensure that there were adequate systems in place to prevent excessive

use of restraint

1.12 Did not ensure that patients at Winterbourne View were protected from verbal

and physical abuse by members of staff;

2 In relation to Rose Villa:

2.1 Did not ensure that Rose Villa was compliant with any or all of the Health and

Social Care Act 2008 essential standards listed in Schedule C

3 In relation to Croxton Lodge:

3.1 Did not ensure that Croxton Lodge was compliant with any or all of the Health

and Social Care Act 2008 essential standards listed in Schedule D

4 In relation to Arden Vale:

4.1 Did not ensure that Arden Vale met any or all of the national minimum

standards for independent healthcare, under the Care Standards Act 2000, for

independent healthcare listed in Schedule E

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4.2 Did not ensure that Arden Vale was compliant with any or all of the Health and

Social Care Act 2008 essential standards listed in Schedule F

5 In relation to Cedar Vale

5.1 Did not ensure that Cedar Vale met any or all of the national minimum


listed in Schedule G

5.2 Did not ensure that Cedar Vale was compliant with any or all of the Health and

Social Care Act 2008 essential standards listed in Schedule H

6 In relation to Willow House

6.1 Did not ensure that Willow House was compliant with any or all of the Health

and Social Care Act 2008 essential standards listed in Schedule I

7 In relation to The East Midlands Centre for Neurobehavioural Rehabilitation

7.1 Did not ensure that The East Midlands Centre for Neurobehavioural

Rehabilitation was compliant with any or all of the Health and Social Care Act

2008 essential standards listed in Schedule J

And light of the above your fitness to practise is impaired by reason of your misconduct.

SCHEDULE A

No. Inspection date Standard

Private and Voluntary

Healthcare

Regulations 2001

Assessment

Outcome

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1. 1 December 2008 C24 Controlled

Drugs 15(5) Not met

2. 1 December 2008 M8 Suicide

Prevention 44(1)(c) Not met

3. 1 December 2008

C9 Human

Resources Policies

and Procedures

18(2)(a) Not met

4. 1 December 2008 M22 Patient's

Records 21(1)(a)(i)(ii) Not met

5. 1 December 2008 C14 Complaints

Process 23(5) Almost met

6. 1 December 2008

C15 Information

about Patient

Complaints

23(3)(a)(b) Not met

7. 1 December 2008 M10 Resuscitation

Procedures 15(2)(b) Not met

8. 1 December 2008 M27 Quality of Life

for Patients 16(4)(a) Not met

9. 1 December 2008

M42 The Rights of

the Patients under

the Mental Health

Act

47 Almost met

10. 1 December 2008 M44 Section 17

Leave 9(1)(e)(f) Not met

11. 1 December 2008 C17 Health Care

Premises 25(2)(a) and (d) Not met

12. 1 December 2008 C21 Health and

Safety Measures 25(5)(a) Not met

13. 24 March 2009 C24 Controlled

Drugs 15(5) Not met

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14. 24 March 2009 M8 Suicide

Prevention 44(1)(c) Not met

15. 24 March 2009 M22 Patient's

Records 21(1)(a)(i)(ii) Not met

16. 24 March 2009

C15 Information

about Patient

Complaints

23(3)(a)(b) Not met

17. 24 March 2009 M10 Resuscitation

Procedures 15(2)(b) Not met

18. 24 March 2009 M27 Quality of Life

for Patients 16(4)(a) Not met

19. 15 December

2009

C24 Controlled

Drugs 15(5) Almost met

20. 15 December

2009

C23 Ordering and

Storage of

Medicines

25(2)(d) Almost met

21. 15 December

2009 M6 Staff Training 18(2)(a) Almost met

22. 15 December

2009

C1 Information for

Patients 7 Almost met

23. 15 December

2009

A9 Health and

Safety 25(2)(d) Almost met

SCHEDULE B

No. Inspection dates Essential Standard Judgement

1. 17, 18 & 24 May and

2 June 2011

Outcome 4: Care and welfare of

people who use services Major Concerns

2. 17, 18 & 24 May and Outcome 7: Safeguarding people who Major Concerns

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2 June 2011 use services from abuse

3. 17, 18 & 24 May and

2 June 2011

Outcome 9: Management of

medicines Major Concerns

4. 17, 18 & 24 May and

2 June 2011

Outcome 12: Requirements relating

to workers Major Concerns

5. 17, 18 & 24 May and

2 June 2011 Outcome 14: Supporting workers Major Concerns

6. 17, 18 & 24 May and

2 June 2011

Outcome 16: Assessing and

monitoring the quality of service

provision

Major Concerns

7. 17, 18 & 24 May and

2 June 2011 Outcome 17: Complaints Major Concerns

8. 17, 18 & 24 May and

2 June 2011

Outcome 19: Notification of death or

unauthorised absence of a service

user who is detained or liable to be

detained under the Mental Health Act

1983

Major Concerns

9. 17, 18 & 24 May and

2 June 2011

Outcome 20: Notification of other

incidents Major Concerns

10. 17, 18 & 24 May and

2 June 2011 Outcome 21: Records Major Concerns

SCHEDULE C


1. 3, 7, 14 & 16 June

and 1 July 2011

Outcome 1: Respecting and involving

people who use the services Major Concerns

2. 3, 7, 14 & 16 June

and 1 July 2011

Outcome 4: Care and welfare of


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3. 3, 7, 14 & 16 June

and 1 July 2011

Outcome 7: Safeguarding people who

use services from abuse Major Concerns

4. 3, 7, 14 & 16 June

and 1 July 2011


Medicines

Moderate

Concerns

5. 3, 7, 14 & 16 June

and 1 July 2011 Outcome 14: Supporting staff Minor Concerns

6. 3, 7, 14 & 16 June

and 1 July 2011 Outcome 17: Complaints Minor Concerns

7. 3, 7, 14 & 16 June

and 1 July 2011 Outcome 21: Records

Moderate

Concerns

SCHEDULE D


1. 8 March 2011 Outcome 4: Care and welfare of

people who use services Minor Concerns

2. 8 March 2011

Outcome 21: People's personal

records, including medical records

should be safe and kept confidential

Minor Concerns

3. 8 March 2011


Medicines

Moderate

Concerns

4. 6 & 11 June 2011 Outcome 4: Care and welfare of


5. 6 & 11 June 2011 Outcome 7: Safeguarding people who


6. 6 & 11 June 2011 Outcome 13: Staffing Major Concerns

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7. 6 & 11 June 2011 Outcome 21: Records Moderate

Concerns

SCHEDULE E


1. 7 April 2006

C20 Patients, staff and anyone

visiting the registered premises are

assured that all risks connected with

the establishment, treatment and

services are identified, assessed and

managed appropriately

Almost met

2. 7 April 2006

M32 Serious/untoward incidents,

adverse health events and near

misses are handled effectively and

are learnt from

Almost met

3. 7 April 2006 M35 Patients are restrained

appropriately and safely Almost met

4. 7 April 2006

C9 Clients receive care from

appropriately recruited, trained and

qualified staff

Almost met

5. 7 April 2006

M5 The numbers, type and skills of

clinicians ensure that patients are

appropriately treated and cared for at

all times

Almost met

6. 7 April 2006

M13 Each patient has a care plan

that addressed their needs

appropriately

Almost met

7. 7 April 2006 M27 The care provided recognises

the patients' personal needs Almost met

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8. 7 April 2006 M28 Patients financial interests are

safeguarded Almost met

9. 7 April 2006

M29 Arrangements for the restriction

and security of patients are clear and

effective

Almost met

10. 7 April 2006

M42 Patients and their nearest

relatives are able to exercise their

rights and entitlements under the

Mental Health Act 1983 and its Code

of Practice

Almost met

11. 7 April 2006

C17 Patients receive treatment in

premises that are safe and

appropriate for that treatment

Almost met

12. 7 April 2006 C21 The appropriate health and

safety measures are in place Almost met

13. 28 November 2006 C13 Children receiving treatment are

protected effectively from abuse Almost met

14. 28 November 2006

C20 Patients, staff and anyone

visiting the registered premises are

assured that all risks connected with

the establishment, treatment and

services are identified, assessed and

managed appropriately

Almost met


M7 All potential environmental and

clinical risks are assessed and

managed to ensure a safe

environment is maintained for

patients, staff and the general public

Almost met

16. 28 November 2006 M8 Patients are protected from self

harm, including risks of suicide Almost met

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17. 28 November 2006 M30 Appropriate arrangements are

made for the observation of patients Almost met


M32 Serious/untoward incidents,

adverse health events and near

misses are handled effectively and

are learnt from

Almost met


M33 The families and carers of

patients who die unexpectedly, and

the staff who were involved in their

care are supported sensitively

Almost met


M34 All attempts are made to prevent

absconding. When patients do so,

effective arrangements are in place to

handle the absconding/

Almost met


M1 Patients receive treatment and

care that reflects the Mental Health

National Service Framework

Not met


C7 Appropriate policies and

procedures are in place to help

ensure the quality of treatment of

service users

Almost met


C9 Clients receive care from

appropriately recruited, trained and

qualified staff

Almost met


C12 Patients and healthcare

professionals are not infected by

blood borne viruses

Almost met


M2 Patient treatment and care is

informed by clear communication

between staff

Almost met

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M5 The numbers, type and skills of

clinicians ensure that patients are

appropriately treated and cared for at

all times

Almost met

27. 28 November 2006 M6 Patients receive treatment and

care from appropriately trained staff Almost met


M23 Patients are informed about their

rights, their treatment and how to

obtain independent advocacy

Almost met

29. 28 November 2006 M26 Patients are not discriminated

against Almost met


M29 Arrangements for the restriction

and security of patients are clear and

effective

Almost met


C6 Patients' views are obtained by

the establishment and used to inform

the provision of treatment and care

and prospective patients

Not met


C17 Patients receive treatment in

premises that are safe and

appropriate for that treatment

Almost met

33. 18 October 2007 C20 Risk Management Policy Almost met

34. 18 October 2007 M7 Risk assessment and

management Almost met

35. 18 October 2007 M8 Suicide prevention Almost met

36. 18 October 2007 M1 Working within the Mental Health

National Service Framework Almost met

37. 18 October 2007 C7 Policies and Procedures Almost met

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38. 18 October 2007 C9 Human Resources Policies and

Procedures Almost met

39. 18 October 2007 C12 Healthcare workers and blood

borne viruses Almost met

40. 18 October 2007 M6 Staff Training Almost met

41. 18 October 2007 M13 CPA Care Planning and Review Not met

42. 18 October 2007 C6 Patient views Almost met

43. 18 October 2007 C17 Health Care Premises Not met

SCHEDULE F

No. Inspection dates Essential Standard Judgment

1. 3, 13 & 14 June 2011 Outcome 1: Respecting and involving

people who use the service Major concerns

2. 3, 13 & 14 June 2011 Outcome 2: Consent to care and

treatment Major concerns

3. 3, 13 & 14 June 2011 Outcome 4: Care and welfare of

people who use the service Major Concerns

4. 3, 13 & 14 June 2011 Outcome 7: Safeguarding people who


5. 3, 13 & 14 June 2011 Outcome 9: Management of medicine Major Concerns

6. 3, 13 & 14 June 2011 Outcome 10: Safety and suitability of

premises Major Concerns

7. 3, 13 & 14 June 2011 Outcome 12: Requirements relating

to workers

Moderate

Concerns

8. 3, 13 & 14 June 2011 Outcome 13: Staffing Major Concerns

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9. 3, 13 & 14 June 2011 Outcome 14: Supporting workers Major Concerns

10. 3, 13 & 14 June 2011



provision

Major Concerns

11. 3, 13 & 14 June 2011 Outcome 17: Complaints Major Concerns

12. 3, 13 & 14 June 2011 Outcome 21: Records Major Concerns

SCHEDULE G

No. Inspection date Standard

Private and

Voluntary Healthcare

Regulations 2001

Assessment

Outcome

1. 27 May 2008

M15 Patients with

Developmental

Disabilities

15(1)(a) Almost met

2. 27 May 2008 M6 Staff training 18(2)(a) Almost met

3. 27 May 2008

M13 CPA Care

Planning and

Review

21(1)(a)(i)(ii) Almost met

4. 27 May 2008 C6 Patient's views 16(3) & 17(2) Almost met

5. 13 January 2009 C20 Risk

Management Policy Not met

6. 13 January 2009 C25 Infection

Control Not met

7. 13 January 2009

M7 Risk

assessment and

management

Not met

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8. 13 January 2009 M9 Infection control Not met

9. 13 January 2009

M32

Serious/untoward

incidents, adverse

health events and

near misses are

handled effectively

and are learnt from

Not met

10. 13 January 2009

M35 Patient

restraint and

physical

interventions

Not met

11. 13 January 2009 M21 Patient

discharge Almost met

11a 13 January 2009 C7 Policies and

Procedures Almost met

12. 13 January 2009

C9 Human

Resources Policies

and Procedures

Not met

13. 13 January 2009 C10 Practising

Privileges Not met

14. 13 January 2009 C2 Patient centred

care Not met

15. 13 January 2009

M26 Anti-

discriminatory

practice

Not met

16. 13 January 2009 M27 Quality of life

for patients Not met

17. 13 January 2009 M46 Discharge of Almost met

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detained patients

18. 13 January 2009 C17 Health Care

Premises Not met

19. 1 & 2 June 2009 C20 Risk

Management Policy Not met

20. 1 & 2 June 2009

M7 Risk

assessment and

management

Not met

21. 1 & 2 June 2009

M30 Appropriate

arrangements are

made for the

observation of

patients

Not met

22. 1 & 2 June 2009 M31 Managing

disturbed behaviour Not met

23. 1 & 2 June 2009

M32 Management

of serious/untoward

incidents, adverse

health events and

near misses

Not met

24. 1 & 2 June 2009 C4 monitoring

quality Almost met

25. 1 & 2 June 2009 M4 Clinical Audit Not met

26. 1 & 2 June 2009 M20 Transfer of

patients Not met

27. 1 & 2 June 2009 C2 Patient Centred

Care Almost met

28. 1 & 2 June 2009 M13 CPA Care

planning and Almost met

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review

29. 1 & 2 June 2009

M14 Information for

patients on their

treatment

Not met

30. 1 & 2 June 2009

M26 Anti-

discriminatory

practice

Almost met

31. 25 January 2010 M20 Transfer of

patients 9(1)(a) & 16(1) Not met

32. 25 January 2010 C2 Patient Centred

Care 15(1) & 16(1)(3) Almost met

33. 25 January 2010

M13 CPA Care

planning and

review

15(1) & 16(1)(3) Almost met

34. 25 January 2010

M14 Information for

patients on their

treatment

15(1) & 16(1)(3) Almost met

SCHEDULE H

No. Inspection date Essential Standard Judgement

1. 7 June 2011 Outcome 4: Care and welfare of

people who use the service Major Concerns

2. 7 June 2011 Outcome 7: Safeguarding people who

use services from abuse

Moderate

Concerns

3. 7 June 2011 Outcome 11: Safety, availability and

suitability of equipment Minor Concerns

4. 7 June 2011 Outcome 13: Staffing Moderate

Concerns

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5. 7 June 2011



provision

Moderate

Concerns

6. 7 June 2011 Outcome 20: Notification of other

incidents

Moderate

Concerns

SCHEDULE I



people who use the service Minor concerns


use services from abuse

Moderate

concerns

SCHEDULE J



people who use services Minor concerns


use services from abuse Minor concerns

3. 23 June 2011 Outcome 13: Staffing Moderate

concerns

Mr Harrison’s response to the charges – Tuesday 2 May 2017

Mr Unwin informed the panel that Mr Harrison had, during the course of the NMC’s

investigation, submitted two separate written responses to the allegations (dated 19

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October 2014 and 10 June 2015). Mr Harrison made admissions to a number of the

allegations in his earlier response, however he denied all the allegations in his later

response.

In those circumstances Mr Unwin did not invite the panel to find any charges proved by

virtue of Mr Harrison’s earlier admissions, as it could not be said that Mr Harrison’s

admissions were unequivocal.

Background – Tuesday 2 May 2017

The background to the allegations was as follows:

Introduction

Winterbourne View was an independent purpose built hospital in South Gloucestershire

which opened in December 2006. It was owned and operated by Castlebeck Care

(Teesdale) Limited (“Castlebeck”). It was designed to accommodate 24 patients in two

separate wards. It was registered as a hospital with the stated purpose of providing

assessment and treatment and rehabilitation for adults with learning disabilities.

On 31 May 2011, BBC Panorama broadcast the documentary “Undercover Care: The

Abuse Exposed” which showed undercover footage by a reporter (Individual R, also

referred to as Witness 2) of staff (Nurses and Support Workers) abusing and mistreating

vulnerable Winterbourne View patients. After the transmission, staff were suspended,

the Care Quality Commission (“CQC”) inspected the Hospital, and patients were moved

to other locations. A Serious Case Review process was initiated. By the end of June

2011, Winterbourne View was closed.

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As a result of the police investigation, nine Support Workers and two Nurses involved at

Winterbourne View were prosecuted and convicted in 2012 for 38 offences of neglect

and abuse of patients.

The BBC had been contacted by a whistle-blower, Individual O (also referred to as

Witness 3), formerly a Charge Nurse at Winterbourne View, reporting to Registrant C. In

October 2010, Individual O raised in an email a number of concerns about the attitudes

of staff, the treatment of patients and the aggressive culture at Winterbourne View,

which foreshadowed some of the abuse captured in the documentary. No meaningful

action had been taken to address any of the concerns.

The four registrants in this case had management responsibilities in respect of

Winterbourne View during the time that abuse and mistreatment of patients was

undoubtedly taking place. Registrant A, a Senior Manager, was the Acting Manager,

then Registered Manager, of Winterbourne View from 2008 until 2010, and reported to

Mr Harrison. In 2010, Registrant A moved to act as Manager of another Home but

continued to offer support to Registrant C, who was appointed Manager of

Winterbourne View. Registrant A, however, remained the Registered Manager of

Winterbourne View with the CQC. Registrant D was appointed as Deputy Manager from

June 2010, reporting to Registrant C. Registrant C reported to Mr Harrison, the

Regional Director of Operations for South West England, who from 2009 had

responsibility for nine Castlebeck Units.

Reports and reviews of the systemic failures at Winterbourne were authored or

commissioned by Castlebeck, CQC, NHS South Gloucestershire Primary Care Trust (in

coordination with other involved Primary Care Trusts (“PCT”)) and Avon and Somerset

Police. Other Department of Health and agency reports also followed from the

Panorama broadcast.

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Of particular relevance to this hearing were the CQC Compliance Report published in

July 2011 and the Serious Case Review, commissioned by the South Gloucestershire

Adult Safeguarding Board, published in July 2012.

Many of the failings at Winterbourne View were a matter of record. It was not alleged by

the NMC that any of the registrants in this case played a direct role in the abuse or

mistreatment of patients. Nor was it alleged that they directly witnessed or necessarily

knew the full extent of the abuse that was occurring on their watch. The Panorama

documentary evidenced, for example, falsified reporting of restraint events by staff. The

Serious Case Review explored the complexity of the causes of, and failures to, prevent

institutional abuse of adults with learning difficulties.

The charges against the four registrants were intended to reflect actions and omissions

by them in their respective roles, in positions of responsibility as members of the senior

nursing and management team. These included issues around the recruitment,

management and disciplining of staff; training and supervision; the investigation and

reporting of incidents; and the lack of proactive steps to recognise and reduce the

excessive use of restraint. A number of allegations were brought to the attention of the

registrants, involving the individuals subsequently proven to be perpetrating abuse. In

several instances the responsibility was joint. The NMC alleged that these actions and

omissions were liable to contribute to missed opportunities and the failure to protect

vulnerable patients from harm.

Two registrants, Registrant A and Mr Harrison, faced charges in relation to their

responsibilities for other Castlebeck Units where there were management and

operational failings, some with similarity to those at Winterbourne View.

Before taking over as Acting Manager at Winterbourne View, Registrant A was the

Manager of Arden Vale, a Castlebeck learning disabilities hospital in Coventry. A

Healthcare Commission inspection report from October 2007 identified a number of

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shortcomings. After the BBC Panorama documentary, Individual Z (also referred to as

Witness 8), who had worked for a short time at Arden Vale while Registrant A was

Manager, contacted the helpline number with concerns she had raised at the time with

the then Manager about the frequent and unnecessary resort by staff to restraint of

patients.

From October 2010 Registrant A, although still the CQC Registered Manager for

Winterbourne View, became Acting Manager for Chesterholme, another Castlebeck

hospital in Northumberland. The CQC inspection in June 2011 identified major or

moderate concerns with eight essential standards.

When the abuse at Winterbourne View came to light, the CQC carried out reviews and

inspections of all the other Castlebeck services in England. Of the nine Units for which

Mr Harrison had responsibility, two were closed: Arden Vale and Rose Villa. Major

concerns were found with two: Croxton Lodge and Cedar Vale. Minor and moderate

concerns were identified with another two: Willow House and Warwick Lodge (the East

Midlands Centre for Neurobehavioural Rehabilitation).

Castlebeck Ltd

Castlebeck was registered with Companies House in 1986 and the Headquarters were

in Darlington. It was a specialist provider of healthcare and support for people with

learning disabilities, complex needs and behaviours that challenged services. It also

offered specialist support for people with mental health needs, people on the autistic

spectrum with and without a learning disability, and for people with acquired brain

injuries with associated challenging behaviour.

Castlebeck provided services in locations in the Midlands, North East England and in

Scotland. Winterbourne View and Rose Villa were the only two services that the

company had in the South West of England.

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Castlebeck went into administration in 2013 and its services were taken over by the

learning disability provider, the Danshell Group (“Danshell”).

Winterbourne View Hospital

Winterbourne View was a purpose built independent hospital in South Gloucestershire,

located in a business park in the northeast of Bristol. It was registered as a hospital with

the purpose of providing assessment and treatment and rehabilitation of people with

learning disabilities, many of whom had additional complex needs such as mental

health problems or conditions such as epilepsy or autistic spectrum disorders.

The people placed there were NHS patients, who were admitted through one of three

principal routes:

a. The patient had acute mental health needs which could not be met by local NHS

inpatient services, whether because they were assessed as too vulnerable,

challenging or otherwise unsuitable.

b. The patient had a learning disability but their mental health needs or challenging

behaviour meant they could no longer remain within their existing social care

service.

c. The patient was already placed in a specialist hospital but were being moved

closer to home, as a step down or step up in care, or as a court requirement.

During its five years of operation, services were commissioned at Winterbourne View for

48 patients, involving nine PCTs; 35 of these patients were admitted under a provision

of the Mental Health Act. Of the 13 admitted informally, six were detained following their

admission.

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The majority of patients were under the age of 50, with an equal number of men and

women. The average length of stay was 19 months. 13 admissions lasted for under six

months, but eight patients were at the Hospital for over three years, of whom two were

there for over four years. Some patients had particularly high care needs; for example,

Patient H who was admitted at an early stage, was only able to move one arm and her

head, and she required constant care. She could make sounds but was not able to

speak.

There were eighteen patients at the Hospital during the BBC Panorama filming.

Layout

The Hospital comprised three floors: Lower Ground, Upper Ground, and First. These

were variously referred to by witnesses as ground, middle and top, or first, second and

third.

On the Lower Ground Floor were the entrance, reception and public area, consultation

rooms, office shared by the Manager and Deputy Manager, the administrative team

office, kitchen and laundry.

The patient floors were accessed via a stairway near reception on the ground floor.

However, visiting family members (for example, Patient D’s mother, also referred to as

Witness 12), at some time, were told they were not allowed to visit the patient floors.

The Upper Ground Floor contained 12 patient bedrooms. This was considered as a

rehabilitation ward, intended for patients who might be considered ready for transition

back into the community. It was referred to by some patients as the ‘moving on’ ward.

Near the stairs were the dining room, a quiet lounge, an education room and activity

room. There was a medication room, which was locked when not in use. At the end of

the corridor, at the junction of the T-shaped layout, were a nursing office and a larger

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patient lounge, which opened to the garden area. The visibility of the patient floors from

the nursing office window was described as not particularly good.

The First Floor was a secure ward requiring a code or key to access, sometimes

referred to as the ‘Assessment Floor’, for patients requiring additional support and

assistance. Although the intention was that patients, after assessment, would move

down for rehabilitation and ultimately out of the service, in practice there were patients

who remained in Winterbourne View for years. The layout was similar to the Upper

Ground, with a dining room, activity room and quiet lounge near the stairs, and the

nursing office and lounge at the junction of the two corridors.

The patient lounges were the main focus for the patients, where they spent most of their

time during the day. They featured in the undercover footage.

Staffing and Organisation

Winterbourne View was intended to be a learning disability nurse-led service. The

Psychiatrist reported to the Clinical Director and had no management responsibility for

any of the staff working directly with patients.

Medication for all patients was prescribed by the local GP, and prescriptions dispensed

by the local pharmacy. Nurses were to complete the medicines administration record

sheets prepared by the Psychiatrist when they administered the medications.

Support Workers (also known as Healthcare Assistants) were responsible to the Nurse

in charge. Their duties were to support patients in developing daily living skills, follow

individual patient care regimes, maintain relevant documentation, and act as a Key

Worker when required or an escort for activities. They were required to be aware of

health and safety and safeguarding issues, and to bring all incidents to the attention of

the Nurse in charge.

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There were usually between three and five Support Workers on duty per floor, including

one Senior Support Worker. Staffing numbers would vary and sickness and

absenteeism was relatively high. Staff turnover was particularly high.

There would be one or sometimes two Nurses on duty per floor. Nurses mainly saw

each other during handover, for about 15 minutes at the start of the new shift. Many

staff members worked long shifts with day shifts running from 08:00 to 20:00 and night

shifts from 20:00 to 08:00. Witnesses suggested that Nurses would spend a lot of their

time in the office completing paperwork and dealing with medication.

Nursing staff reported to the Charge Nurses who were expected to have Registered

Nurse Learning Disability/Registered Nurse Mental Health qualifications. Charge Nurses

were responsible for the provision of nursing care, assessment of risk and care needs,

as well as all aspects of record keeping. Their responsibilities included assisting with the

induction of new staff; line managing Nurses; and a responsibility to escalate issues of

inappropriate attitudes or conduct by staff. The Charge Nurses were accountable to the

Manager and the Deputy Manager.

The Registrants

Registrant A was employed by Castlebeck as Senior Manager for the Midlands/South

West region. As Senior Manager she had responsibility, together with Mr Harrison, for

the delivery of care services and setting and maintaining acceptable operational

standards.

There was a pattern of Registrant A stepping in as Hospital Manager in different

locations, where failings had been identified. Prior to 2008 she was the Manager of

Arden Vale. She became Acting Manager of Winterbourne View in June 2008 following

an internal investigation into practices under the previous Manager, Individual AA, and

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Deputy Manager, Individual BB. Registrant A was formally registered as Manager of

Winterbourne View with the CQC on 5 May 2009. She remained the formally Registered

Manager until the closure of Winterbourne View in June 2011. However, she ceased to

act as the Unit Manager from January 2010 when Registrant C took on the role.

Registrant C had been employed as a Senior Staff Nurse at Winterbourne View from

January 2008 having previously worked as a Manager for the NHS. He was promoted to

Charge Nurse, and then to Deputy Manager, under Registrant A. He became the

Hospital Manager from January 2010 until his suspension after the Panorama

broadcast.

Between January 2010 and October 2010 Registrant A regularly visited Winterbourne

View and retained responsibility for supporting and supervising Registrant C, although

Registrant C had a formal reporting line to Mr Harrison. Registrant C commented in his

disciplinary hearing that he would call Registrant A if he had a problem. From October

2010 to February 2012 Registrant A was Acting Manager of Chesterholme and her line

management arrangements transferred from Mr Harrison to another Regional

Operations Director.

Registrant D was the Deputy Manager of Winterbourne View from June 2010 until May

2011, reporting to Registrant C. Registrant D became a Registered Nurse in 2004 and

this appeared to have been her first formal management position. The Castlebeck job

descriptions for Manager and Deputy Manager were almost identical. Both were

required to have Registered Nurse Learning Disability/Registered Nurse Mental Health

registration and a Registered Manager’s award. They were expected to be conversant

with relevant external requirements such as the CQC. Each was responsible for the

provision of nursing care, the coordination and distribution of staffing and other

resources. Registrant D was also responsible for dealing with any deficiencies in service

provision.

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The evidence suggested that Registrant D assumed particular responsibility for incident

forms, raising alerts and reporting on Serious Untoward Incidents (“SUI”). Witnesses

suggested that neither Registrant C nor Registrant D were proactive in spending time

on the patient floors. During his five weeks of filming, Individual R identified two

occasions on which Registrant D briefly attended the patient floors, on each occasion

when someone called down for a Manager’s assistance with a restraint. Registrant D

played a role in ongoing safeguarding procedures after the BBC documentary was aired

and was not subject to internal disciplinary proceedings.

Mr Harrison was the Castlebeck Regional Operations Director, responsible for nine

Castlebeck Units from 2009. The job description for Regional Operations Director

included ensuring that all Units complied with all appropriate statutory standards and

requirements as regulated by CQC (and others). He registered as Responsible

Individual for Arden Vale in 2005. Although he did not register as Responsible Individual

for Winterbourne View until February 2009, his responsibilities as Regional Operations

Manager, prior to 2009, were almost identical. In his Castlebeck interview he confirmed

that he was responsible for Winterbourne View at the time Registrant A was brought in

as Manager (June 2008). Mr Harrison usually visited Winterbourne View about once a

month. He stated that he was kept informed of serious incidents at Winterbourne View.

Mr Harrison also stated that the position of Responsible Individual for the Units was

taken over by the Managing Director, Individual CC, in 2010; however, he confirmed

that his remit remained to support the Managers of these Units. He was, according to

Castlebeck Human Resources (“HR”), the most senior member of staff with direct

responsibility for the nine Units, with responsibility to supervise, guide, support and

manage operational practices at a senior level, and ensure compliance with regulatory

standards. Mr Harrison was the CQC Registered Responsible Individual from 16

February 2009 onwards.

Winterbourne View: Charges

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Given the number of sub-charges against the registrants, the facts were grouped under

the following headings for the purpose of the NMC’s opening submissions:

Healthcare Commission Inspections 2008-2009 (Registrant A charges 2.1, 2.4; Mr

Harrison charges 1.1, 1.2, 1.4)

By June 2008 Registrant A was a Senior Manager and the Acting Manager responsible

for Winterbourne View. Mr Harrison had responsibility as the Regional Operations

Manager/Director.

On 1 December 2008 the Healthcare Commission completed an unannounced

inspection of Winterbourne View. A number of the Healthcare Commission national

minimum standards were not met, including concerns about ligature risks, signing for

controlled drugs, record keeping, training and appraisals. Following the inspection two

statutory notices were issued in relation to Health and Safety Measures and Health

Care Premises.

The Healthcare Commission completed a follow up inspection in March 2009 in order to

inspect the standards which had not been met during the previous inspection. The

Healthcare Commission were unable to inspect all of the standards due to patients

presenting with challenging behaviour. However, standards re-inspected were still not

being met and Winterbourne View was required to provide an action plan. There was no

record of this action plan being submitted.

The CQC conducted an announced inspection on 15 December 2009. There were

concerns about controlled drugs procedures and staff training.

Registration of Registrant C as Manager (Registrant A charge 2.7; Registrant C charges

5, 6; Mr Harrison charge 1.5)

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All of the registrants were required to be aware of regulatory requirements. The CQC

should have been notified of the new management arrangements at Winterbourne View

in January 2010. However, an application to register Registrant C as Manager was not

received until April 2011. The CQC replied stating that further documentation was

required for the application to be accepted. Registrant A was unable to register as

Manager of Chesterholme because she was still the Registered Manager of

Winterbourne View. In an email dated 5 May 2011 Individual CC asked Mr Harrison if

he had advised the CQC that Registrant A was no longer the Manager at Winterbourne

View. Mr Harrison replied that they had only been informed verbally at their last visit

(although this appeared to have been before Registrant C was appointed). Mr Harrison

said that sending the appropriate written notification had “completely slipped my mind”.

Registrant A was also the Accountable Officer under the Controlled Drugs Regulations.

Registrant C should also have applied to be appointed as the Accountable Officer.

Individual O’s whistle-blowing email (Registrant A charge 2.8; Registrant C charge 16;

Registrant D charge 4; Mr Harrison charge 1.6)

It was the NMC’s case that all four registrants were aware of the contents of the whistle-

blowing email sent by Individual O, which raised some 20 concerns about the culture

and treatment of patients including serious allegations about members of staff

subsequently shown to be involved in the abuse in the Panorama documentary. The

email was sent directly to Registrant C. Registrant D had a copy of the email in a senior

staff meeting a few days later. Individual O forwarded the email to Registrant A who

replied and forwarded it to Mr Harrison saying “this man is not going away. I will see him

Monday”. This meeting did not take place. Registrant C contacted SGC the following

month but “didn’t think there were safeguarding issues”. Around this time Individual O

resigned. The first meeting with Mr Harrison, Registrant C, the CQC and SGC was not

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until February 2011. Alerts were not raised until April 2011 and there was no SUI until

May 2011.

It was the NMC’s case that Registrant C should have considered suspending any of the

named staff. Registrant A and Mr Harrison should have provided Registrant C with

guidance and supervision to ensure that the issues were dealt with in a robust manner

and that appropriate action was taken to protect patient safety. Registrant C said in his

police interview that he was waiting for the Company to take the lead. Both Registrant A

and Mr Harrison sought to blame Individual O for not taking action, in their investigatory

interviews.

Suitability for admissions and staffing levels (Registrant C charges 18, 35, 41; Mr

Harrison charge 1.7)

Registrant C was responsible as Manager for ensuring appropriate staffing levels and

allocation of resources.

Individual T (Witness 10) recalled that she was placed on a night shift during her

preceptorship as the only Nurse on duty when she should have been supervised. She

further noted that Patients G, H and M, who were funded on a 2:1 or 1:1 basis, were not

in fact observed on that basis as there was insufficient staff.

The responsibility for admitting patients to Winterbourne View was with the Manager of

the service and Mr Harrison. Registrant C and Mr Harrison were aware of the difficulties

with staffing, resourcing and training, and the limitations of the service that

Winterbourne View was able to provide. Among the patients admitted when Registrant

C was Manager was Patient A, who needed 1:1 supervision as she would hit staff and

other patients. She would scream and cry and spit and, in the view of Witness 9,

needed to be looked after by staff with specialist training. Patient M had particularly

challenging behaviour, including faecal smearing and biting herself and staff. She

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needed 1:1 supervision at all times and had her meals separately. Patient F, who

featured in the BBC Panorama documentary, was also admitted when Registrant C was

Manager.

Registrant C said, in his interview, that he wanted to stop admissions and was not

satisfied that Patient F was suitable for Winterbourne View. He said that he had only

agreed to her admission under corporate pressure. There was no record of Registrant C

raising the issue in the minutes of regional meetings.

Mr Harrison stated, in his interview, that he was aware there were staffing issues,

especially in respect of enhanced observation levels. He said that he had requested

extra staff from Individual CC but that, when granted, it led to an increase in patient

numbers. Mr Harrison said he was not aware that Registrant C had refused to admit

patients due to staffing levels.

Staff training, supervision and induction (Registrant A charges 2.9, 2.10, 2.11;

Registrant C charges 37, 38, 42, 43; Registrant D charges 19, 20; Mr Harrison charges

1.8, 1.9)

Staff training was identified as out of date when Witness 19 attended in 2008, and in the

Healthcare Commission inspection report under the management of Registrant A.

The 2011 CQC inspection report identified numerous shortfalls in staff achieving training

requirements. It was the view of staff that there was insufficient specialist training for

patients with learning disabilities and mental health issues.

Individual H (Witness 11), Individual T and Individual O considered that the local

induction was inadequate and did not include specific information on how the Unit was

managed and the patients’ individual needs or care plans.

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The Castlebeck Supervision Policy required regular supervision of individual members

of staff with six sessions per year. The CQC inspection of staff records identified limited

or no supervision records for most staff. Annual medication competency checks had not

been completed at the time of inspection.

Analysis of incidents, excessive restraint, protection from abuse (Registrant A charges

2.11, 2.12, 2.13; Registrant C charges 40, 45, 46; Registrant D charges 23, 24; Mr

Harrison charges 1.10, 1.11, 1.12)

The ‘MAYBO’ training received by staff focused on restraint techniques, rather than de-

escalation and avoidance strategies. The numerous incident, alerts, and concerns

raised by Individual O and others, should have alerted members of the management

team that restraint was being resorted to far too readily and excessively by staff on the

patient floors. Incident reports recorded inappropriate methods, such as a patient being

restrained with a pillow over her mouth. Incident reports were provided to the

management team, but there was no recording or analysis of incidents to identify

whether there were patterns or high risk times of day. Individual O recalled that he

received a dismissive response from Registrant A when he suggested this.

The CQC inspection found that incidents in the daily care records did not correspond

with the incident reports. There was no analysis of the necessity and frequency of

restraints. The incidents summarised in the Serious Case Review and as depicted in the

Panorama footage demonstrated the failure to protect patients from abuse.

Arden Vale

Arden Vale was a purpose-built 31 bed hospital situated on the edge of Coventry, for

patients with a learning disability and challenging behaviour. Mr Harrison was the

Responsible Individual for Arden Vale from the time of its opening in October 2005.

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There was an unannounced inspection by the Healthcare Commission and the Mental

Health Act Commission in April 2006. 12 standards were ‘almost met’ and

recommendations were made.

The next unannounced inspection was on 28 November 2006. That inspection found

that not every employee had received safeguarding training; incidents were not being

reported in writing to the Commission; and staffing files did not reflect guidelines in

place at the time. 20 standards were ‘almost met’ or ‘not met’. Recommendations were

made and an action plan submitted.

According to Castlebeck HR, Registrant A was the Manager of Arden Vale from May

2007 until June 2008 (Items 1-32 of Schedule E did not therefore apply). She formally

became Registered Manager of Arden Vale in October 2007. There had previously

been a number of temporary Managers in place. The Healthcare Commission

conducted an unannounced inspection on 18 October 2007. 11 standards were ‘almost

met’ or ‘not met’ including issues not addressed from previous reports. There were no

local protocols and procedures on the prevention of suicide and homicide, as there

should have been. Fewer than 25% of staff had received an appraisal and not all staff

had received mandatory training.

Individual Z worked at Arden Vale for three weeks from the beginning of October 2007.

She was alarmed at the frequency of restraints being used. Staff informed her that they

were not aware of behavioural techniques and made inappropriate comments about

how they would respond to patients’ behaviour. She witnessed unnecessary restraints

during the time she was at Arden Vale. She also noted a common practice of staff

borrowing medication from another patient when a patient’s medication ran out.

Individual Z raised her concerns with the Deputy Manager and asked to see the

Manager. She wrote, and provided, a report of her concerns. She could not recall the

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name of the Manager; she said that this Manager had been brought in recently to get

Arden Vale ‘back into shape’: It could thus be reasonably inferred this was Registrant A.

Although Individual Z was told her concerns would be treated with the highest

importance, she was not provided with any information following the concerns she

raised. She asked to be transferred and then resigned because of her experiences at

Arden Vale.

There was a Healthcare Commission inspection of Arden Vale in 2009 (not in

evidence). Arden Vale remained within Mr Harrison’s responsibility.

Multiple concerns and incidents were brought to the attention of the CQC in the lead up

to the next inspection on 3 June 2011. From that visit, the CQC’s concerns were that

there was a closed regime with a culture of putting the needs of staff before the needs

of patients; relatives and commissioners were not given access to the patient floors;

incidents were not always recorded or reviewed; and inexperienced staff were working

long shifts in a challenging environment. There was a further visit which included a

review of staff files. The report published in July 2011 found major concerns with a wide

range of outcomes, including that patients did not experience safe and effective care,

and were not safeguarded from physical and emotional harm; that complaints were not

listened to; and that restraint was not proportionate. The Compliance Inspector, Witness

24, concluded that the abusive and detrimental regime at Arden Vale was significantly

related to management failures.

Following another inspection on 15 August 2011, all patients were moved to other

accommodation and Arden Vale was closed on 25 August 2011.

Rose Villa

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Rose Villa was registered as a nine bed care home with nursing for accommodation,

treatment and diagnostic procedures. It opened in Autumn 2009 and was not registered

to take detained patients. It was frequently used as a ‘step down’ facility for patients

from Winterbourne View. The CQC visited on five dates in June and July 2011.

Many essential standards were not being met. There were major concerns that the

Home operated a strict and controlled environment which was not respectful of patients’

individual needs. Furthermore, care was not person-centred and appropriate action had

not been taken following serious incidents. A warning notice was issued.

In September 2011 a further inspection of Rose Villa was completed. There were major

and moderate concerns with the outcomes reviewed. It appeared that there had been a

lack of communication between the Acting Manager and the Operations Director to

ensure a management presence on site so that patients and staff felt supported. Rose

Villa was subsequently closed by Castlebeck.

Croxton Lodge

Croxton Lodge was a learning disability hospital in Melton Mowbray which opened in

January 2007. It provided assessment, treatment and rehabilitation to adults with

learning disabilities, mental health needs and substance abuse problems. Mr Harrison

was registered as the Responsible Individual.

In a routine inspection in March 2011, only minor concerns were identified by the CQC.

However, in view of the incidents at Winterbourne View, further visits were conducted in

June 2011. There were major concerns in respect of a number of outcomes. Care plans

were out of date and conflicted with risk assessments. An unnecessary and

inappropriate restraint was witnessed. Nothing was done to review the information in

incident and accident forms. There were concerns about staffing and observation levels.

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A warning notice was issued. A follow up review was conducted on 5 September 2011

and the Unit was found to be compliant. The hospital is now operated by Danshell.

Cedar Vale

Cedar Vale was a 16 bedded hospital near Nottingham which opened in December

2004. It provided care to men with learning disabilities and autistic spectrum disorders.

In a Healthcare Commission inspection in May 2008, a number of standards were found

not to be met. A follow up inspection was conducted in January 2009, by which time

safeguarding concerns had been raised. The report found breaches of the following

regulations: not ensuring patients; privacy and dignity, poor standards of cleanliness

hygiene and maintenance of the building; failures in documentation; recording and

notification of serious incidents; and failure to achieve regular staff appraisals. A

statutory enforcement notice was sent to Mr Harrison as the Responsible Individual.

In a follow-up inspection in June 2009 a number of improvements were noted but the

hospital was still not meeting standards. Some standards were still not being met in the

following inspection in January 2010.

Cedar Vale was inspected in June 2011 as a result of the issues at Winterbourne View.

A number of moderate and minor concerns were identified, which included a concern

over staff following reporting procedures; the level of staffing support for outside

activities; and notifiable incidents that were not reported to the CQC. A warning notice

was issued, and in the follow up inspection in September 2011, the Unit was compliant.

Willow House

Willow House was a small residential home providing care and accommodation for up to

eight people with a disability. It opened in December 2006. It was inspected in June

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2011 and there were minor and moderate concerns in relation to two outcomes. The

major concern was that the service was implementing punitive measure, such that

patients were punished for displaying challenging behaviour rather than supported and

encourage for positive behaviour. The service was compliant with these outcomes in the

follow up inspection in November 2011.

Warwick Lodge

The East Midlands Centre for Neurobehavioural Rehabilitation (“Warwick Lodge”),

which opened in the summer of 2010, was a hospital providing a service for people who

had an acquired brain injury. It was inspected by the CQC in June 2011. There were

minor concerns about care records and training in restraint techniques. There were

moderate concerns about staffing levels given the high dependency needs of the

patients.

Determination on admissibility of evidence – Tuesday 2 May 2017

Ms Norris, on Registrant D’s behalf, raised an objection to the NMC seeking to put

before the panel, as part of its case, the BBC Panorama documentary “Undercover

Care: The Abuse Exposed”. She contended that viewing the documentary in this

substantive hearing would be highly prejudicial to all the registrants involved in this

case, who were not in fact seen in the footage at all. She submitted that, in cases of

abuse, it was ‘human nature’ to “look for someone to blame”; she expressed concern

that that ‘someone’ could be Registrant D.

Ms Norris argued that the documentary, which showed “horrific abuse”, made for

“deeply disturbing” viewing and did not take matters any further. She contended that the

documentary did not provide a balanced perspective of Winterbourne View, nor did it

depict instances of care that benefitted patients.

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Ms Norris went on to submit that the documentary demonstrated “a criminal conspiracy”

in which staff members were working together to abuse patients and conceal that

abuse. She argued that the management team were reliant on staff members correctly

recording incidents in incident forms.

Ms Norris submitted that the Serious Case Review summarised events as depicted in

the footage in any event and, thus, there was no need for the documentary to be

viewed.

Mr Unwin submitted that this was a professional panel, able to put aside any emotive or

prejudicial effect of watching the documentary. He submitted that the documentary

provided a far better understanding of conditions at Winterbourne View than that which

could simply be gleaned from reading summary descriptions. He further submitted that

the documentary provided “important” and “valuable” evidence as regards incidents that

took place at the time in contrast with information contained in incident forms and other

documentation before the panel.

Mr Unwin contended that the documentary was relied upon by the NMC in support of

specific allegations, for example the incident involving Patient F on 3 March 2011

(charge 24 as against Registrant C), the manner in which that incident was reported,

and whether the incident was reviewed. He further contended that there were particular

staff members, featured in the documentary, who formed the subject matter of specific

charges faced by all four registrants. The significance of this, he submitted, would be

made plain when the documentary was viewed. He went on to submit that the abuse

highlighted in the documentary spoke directly to the charges that related to the

widespread use of restraint and abuse; in that regard, he argued that the documentary

was the best available evidence of what had taken place in Winterbourne View at the

time and the staff members involved.

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As regards the relevance of the documentary, Mr Unwin submitted that it not only

depicted incidents of abuse and inappropriate restraints, it also provided an insight into

the importance of reviewing incident forms, and the degree to which management were

responsible for ensuring that such forms represented an accurate and satisfactory

account of what had taken place.

Mr Unwin made plain that it was not the NMC’s case that the registrants involved in this

case had witnessed the restraints/incidents depicted in the footage. He further

submitted that the documentary was not the sole and decisive evidence in respect of

any of the charges, nor was it required in order for the panel to adjudicate upon the

charges. That said, he submitted that it was relevant in understanding why the events

as shown in the footage were investigated and what in fact was taking place in

Winterbourne View at the time; in that regard, he submitted that it was key in

considering the extent to which the events were attributable to management failings, or

rather were the actions of unsupervised staff members. He further submitted that the

documentary depicted an incident, arguably of assistance as suggested by Ms Norris,

where a Support Worker had advised a colleague on how to complete an incident form

in order to conceal the true nature of the incident. To that extent, he submitted that the

footage was not disadvantageous to the registrants.

As regards any prejudicial effect of viewing the documentary, Mr Unwin informed the

panel that it was the NMC’s intention to present the documentary early on in the facts

stage of this hearing, as opposed to immediately prior to the panel deliberating on the

facts. In that regard, he submitted that the panel would have been presented with all the

evidence upon which the NMC sought to rely, and thus in possession of all the relevant

evidence, prior to its deliberations.

In reaching its decision on the application the panel considered the submissions of both

advocates. It accepted the advice of the legal assessor, who referred to Rule 31 of the

Rules:

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Evidence

31.—(1) Upon receiving the advice of the legal assessor, and subject only to the

requirements of relevance and fairness, a Practice Committee considering an allegation

may admit oral, documentary or other evidence, whether or not such evidence would be

admissible in civil proceedings (in the appropriate Court in that part of the United

Kingdom in which the hearing takes place).

The legal assessor further advised the panel that, as regards relevance, it was not the

NMC’s case that the documentary directly depicted management failings; rather, the

panel was being invited to infer that as instances of abuse had taken place, it must give

rise to management failings. It was, he advised, a matter for the panel to determine

whether this satisfied the “robustness” of the requirement of relevance.

The legal assessor also advised the panel to give careful consideration to the prejudicial

effect, if any, of viewing the documentary in respect of its consideration of the specific

allegations, the risk being that it may result in the panel reaching wrong conclusions in

this case.

As to the matter of relevance, the panel was mindful that the BBC Panorama

documentary was in fact the ‘starting point’ in this case; it was as a result of the

documentary that abuse at Winterbourne View was uncovered and subsequent

investigations undertaken. The panel took into account that the documentary was not

the sole and decisive evidence in respect of the allegations; rather, it provided useful

context as regards the working environment at the time, in addition to identifying specific

instances of abuse and particular staff members, which form the subject matter of some

of the allegations. The panel was mindful that the registrants did not have sight of the

documentary prior to it being aired; they thus relied on information provided by staff

members, upon which management decisions were based.

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The panel was satisfied, on the basis of the above, that the requirement of relevance

was met.

The matter for particular consideration was, therefore, the issue of fairness. This is an

experienced and professional panel. It considered that any unfairness, or prejudicial

effect of the documentary, would be mitigated by its duty to assess the evidence

appropriately and by its ability to attach what weight it deemed appropriate to the

footage. The panel was further satisfied that this course of action would accord with the

public interest in ensuring that the evidence in this case was explored fully.

Accordingly, the panel rejected Ms Norris’ application and thus determined to admit the

BBC Panorama documentary into evidence.

Determination on submission of offering no evidence in respect of charge 1.3 –

Wednesday 3 May 2017

On Tuesday 2 May 2017, after the charges were formally read into the record, Mr Unwin

informed the panel that the NMC did not intend to offer any evidence in respect of

charge 1.3 against Mr Harrison. He explained that this charge was relevant to

Registrant C who, it was the NMC’s case, ought to have applied to register with the

CQC as the Accountable Officer. Thus, the NMC did not seek to pursue this allegation

against Mr Harrison. Mr Unwin informed the panel that this proposed course of action

had been communicated to Mr Harrison.

For the purpose of expediency and efficient time management, particularly in light of the

NMC’s draft timetable of this substantive hearing, the panel was of the view that it was

not necessary to reach a decision on this matter until such time as it was deemed

appropriate. However, Ms Norris, on behalf of Registrant D, invited the panel to

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adjudicate upon the wider matter of the NMC offering no evidence, prior to hearing the

evidence of Witness 2 and viewing the BBC Panorama documentary (Wednesday 3

May 2017).

In reaching its decision on the matter, the panel had regard to the submissions made by

Mr Unwin and accepted the advice of the legal assessor.

The panel was mindful that the NMC had no jurisdiction to withdraw an allegation at a

substantive hearing. It took into account, however, Mr Unwin’s submission which made

plain that the NMC did not intend to offer any evidence in respect of charge 1.3.

The panel carefully considered all the documentation and was satisfied that, in light of

the NMC’s concession that it no longer sought to pursue this allegation against Mr

Harrison as it was not relevant to him, there was no longer a realistic prospect of charge

1.3 being found proved. The panel further had in mind that it is not in the public interest

to pursue a factual charge if there is no evidence to prove it.

Accordingly, Mr Harrison had no case to answer in respect of charge 1.3.

Determination on application to admit the witness statement and associated

exhibit of Witness 17 – Wednesday 3 May 2017

Mr Unwin made an application to admit into evidence the NMC witness statement of

Witness 17, Senior Associate Consultant at CPEA Ltd, and the Serious Case Review

(exhibited by her) which she completed following transmission of the BBC Panorama

documentary.

Mr Unwin told the panel that no objection to this course of action had been raised by

any of the four registrants in this case.

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In reaching its decision the panel had regard to the submissions made by Mr Unwin and

it accepted the advice of the legal assessor. In considering whether or not to admit into

evidence the documents in question, the panel had regard to the requirements of Rule

31 of the Rules and considered whether the evidence was relevant, whether it would be

fair to admit it and, if so, whether it would be appropriate to exercise its discretion in

favour of admitting it. The panel was mindful that the admission of the statement of an

absent witness should not be regarded as a routine matter.

The evidence of Witness 17 spoke not to the allegations directly, but rather assisted in

providing a useful contextual narrative to these matters. On that basis, the panel was

satisfied that the requirement of relevance was met.

Panels in regulatory proceedings perform an inquisitorial and investigatory role. In order

to perform this role, panels require the best evidence available. The panel accepted that

the best form of evidence is obtained by calling witnesses live before it. That being said,

the panel was mindful that the NMC’s proposal to admit into evidence the documents in

question, without calling Witness 17 to give evidence in this hearing in person, was not

objected to by the registrants in this case.

The panel bore in mind the disadvantage in not being able to assess a witness’

demeanour when giving evidence. However, it was mindful that Witness 17’s evidence

was contained within a written statement, supported by a signed statement of truth. Her

evidence, along with all other documentary evidence relied upon by the NMC, had been

served on Mr Harrison, in advance of and in preparation for this hearing.

The panel was satisfied that the admission of Witness 17’s witness statement and

associated exhibit would accord with the public interest in ensuring that the evidence in

this case was explored fully. Having considered this application with care, taking

account of the public interest in the expeditious disposal of this case and fairness in

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these proceedings, the panel determined that it would be fair to admit the documents. In

reaching this conclusion, the panel was mindful of the potential limitations of receiving

evidence in this manner and would, in due course, attach appropriate weight to the fact

that Witness 17’s written account could not be explored by way of oral evidence and

questions of clarification from the panel.

Determination on application to hear evidence by video link and to admit NMC

witness statements, and associated exhibits, into evidence – Monday 8 May 2017

Mr Unwin made an application, under Rule 31 of the Rules, to hear the evidence of

Witness 9, Witness 6 and Witness 13 by WebEx, an internal video link facility. In

support of his application, he submitted that the panel had a wide discretion to receive

evidence, in any format, subject to the requirements of relevance and fairness.

Mr Unwin referred the panel to the case of Nursing and Midwifery Council v Ogbonna

[2010] EWCA Civ 1216, which provided guidance in respect of the admissibility of

hearsay evidence. In particular, it was held that where a witness’ evidence spoke to

disputed matters, and that evidence was sole and decisive, panels should be slow to

receive that evidence as hearsay; in those instances, witnesses should be made

available in order for disputed matters to be put to them and for their evidence to be

tested.

Moreover, by way of background, Mr Unwin informed the panel that early on in these

proceedings, prior to each registrant’s case being considered by an Investigating

Committee, each registrant was provided with a list of witnesses upon whom the NMC

intended to rely. The registrants were invited to indicate whether the contents of the

witnesses’ statements were agreed and whether there was agreement to the

statements being ‘read’ as the witnesses’ evidence in chief. He referred the panel to the

responses provided by Mr Harrison and Registrant A in this regard.

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Mr Unwin further informed the panel that there had been additional communication

between the NMC and the registrants, not least for the purpose of this application,

indicating which witnesses the NMC intended to call as live evidence, and those

witnesses for whom it was intended their statements be ‘read’. He told the panel that no

response had been received from the absent registrants (Mr Harrison, Registrant A and

Registrant C). He did, however, remind the panel of Registrant A’s comments on day

one of these proceedings, in which she indicated that she did not wish to hear the NMC

witnesses’ testimonies and that she did not have any questions to put to them in cross-

examination.

Mr Unwin submitted that the video link facility relied upon was of an acceptable quality,

subject to the witness having the necessary technology and establishing a sufficient

connection. He submitted that receiving evidence by video link would enable the panel

to see the witness’ demeanour and ask any question of the witness which it would

otherwise do so in the presence of that witness. In that regard, he contended that no

unfairness would be caused to the registrants about whom the relevant witnesses would

give evidence, as the evidence could be tested in the usual manner.

Mr Unwin confirmed that the witnesses subject to this application had been provided

with all the relevant documentary evidence in advance of, and in preparation for, this

hearing.

[The positions recorded by the names of the witnesses below denoted the roles

undertaken by those witnesses at the material time]

Witness 9 (Support Worker, Winterbourne View)

Mr Unwin informed the panel that Witness 9, who resides in Bristol, had been warned to

attend the hearing in the first scheduled week, which she duly did. Following

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rearrangements to the provisional hearing timetable, Witness 9 did not give evidence as

scheduled.

Mr Unwin invited the panel to receive Witness 9’s evidence by video link. He submitted

that, from a case management perspective, receiving her evidence in this form allowed

for greater flexibility in respect of her availability. He submitted that whilst it was not

“impossible” for Witness 9 to return to London in order to give evidence in these

proceedings, the NMC was anxious not to request her attendance in person, given the

inconvenience already caused to her in the week prior.

Mr Unwin explained that Witness 9, a Support Worker in Winterbourne View at the

material time, spoke to a number of general issues including training and induction. She

was not, he submitted, a key or sole witness in respect of any specific incident or

allegation.

Mr Unwin informed the panel that no objection had been raised, in principle, by Ms

Norris as regards witnesses in general giving evidence by video link, as she would have

the opportunity to put Registrant D’s case to the witness and test the witness’ evidence

in cross-examination.

Witness 6 (Patient E’s mother)

Mr Unwin informed the panel that Witness 6 spoke to a discrete matter, namely an

alleged conversation she had had with Registrant A. Registrant A, in her signed NMC

‘Standard Directions Form’ dated 20 October 2014, indicated that she disagreed with

the evidence of Witness 6.

Mr Unwin told the panel that Witness 6 had limited availability in the coming weeks,

owing to work and other personal commitments. In those circumstances, she had

requested that she avoid making the journey to London, from Plymouth, in order to give

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evidence in person at the hearing. He submitted that, as this witness’ evidence was

confined to a specific incident, and as it was not reliant on significant documentation,

her evidence could properly be received by video link.

By way of information, Mr Unwin informed the panel that there was some scope for

Witness 6 to attend the hearing in person on Wednesday 10 May 2017, if deemed

necessary.

Witness 13 (Independent Consultant, subsequently employed as Group Director of

Nursing and Patient Safety, Danshell)

Mr Unwin informed the panel that Witness 13 had put the NMC on notice of health

issues that impaired her ability to travel to London. She therefore requested that she

give evidence remotely.

Mr Unwin submitted that Witness 13’s evidence did not speak directly to any specific

allegation. He explained that Witness 13’s role at the time was that of an Independent

Consultant, and she conducted a review (in 2011) of clinical safety and culture in

respect of 12 (non-Winterbourne View) Castlebeck Units. The report arising from that

review, as exhibited by her, was included in the evidence bundle before the panel and

was, as far as he was aware, a matter of public record. From October 2011, she was

appointed Group Director of Nursing, and played a role in Mr Harrison’s appeal hearing.

Mr Unwin submitted that decisions/findings made in local disciplinary proceedings would

not be relevant to these regulatory proceedings. That being said, any issues raised

during the course of such local proceedings may well be of some relevance to the

panel.

Mr Unwin informed the panel that whilst it was not “impossible” for Witness 13 to attend

the hearing in person, this course of action might present some difficulty to the witness.

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Mr Harrison, in his signed NMC ‘Standard Directions Form’ dated 19 October 2014,

indicated that he did not agree with the content of Witness 13’s statement. Registrant A,

in her signed NMC ‘Standard Directions Form’ dated 20 October 2014, indicated that

she agreed with the content of Witness 13’s statement.

Mr Unwin made a further application to admit into evidence the NMC witness

statements and associated exhibits of the following witnesses:

Witness 18 (Support Worker and subsequently Activities Coordinator, Monroe House)

Mr Unwin submitted that Witness 18’s evidence was not central to any disputed

allegation; rather he spoke of his general experience at Winterbourne View over a

period of two weeks in 2008. Witness 18 was, in the NMC’s view, a non-contentious

witness.

Registrant A, in her signed NMC ‘Standard Directions Form’ dated 20 October 2014,

indicated that she agreed with the content of Witness 18’s statement.

Witness 19 (Clinical Lead, Intensive Community Support Team, South Gloucestershire

Primary Care Trust)

Mr Unwin informed the panel that Witness 19’s evidence was relevant to charge 2.2 as

against Registrant A, which was admitted by her at the outset of this hearing. He

referred the panel to Registrant A’s signed NMC ‘Standard Directions Form’ dated 20

October 2014, in which she indicated that she agreed with the content of Witness 19’s

statement. Mr Unwin therefore submitted that as there was no suggestion that Witness

19’s evidence was contentious, his statement could properly be ‘read’ as his evidence in

chief.

Witness 20 (Senior Assessor, Healthcare Commission/CQC)

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Mr Unwin informed the panel that Witness 20 had recently experienced a significant and

serious personal event such that she was unable to attend the hearing.

Mr Unwin told the panel that Witness 20’s involvement in these matters was confined to

two unannounced Healthcare Commission inspections of Winterbourne View (1

December 2008 and 26 March 2009). In light of Registrant A’s signed NMC ‘Standard

Directions Form’, he submitted that it could properly be said that the substance of

Witness 20’s evidence was not in dispute by Registrant A. Whilst Mr Harrison did not

admit the charges about which Witness 20 gave evidence, he did not indicate any

specific challenges to her evidence. It was therefore unclear as to whether Mr Harrison

challenged the findings of Witness 20’s inspections or the degree of responsibility

attributable to him in the circumstances. In any event, Mr Unwin told the panel that

Witness 7 would give evidence about the specific responsibilities of each registrant in

this case, which might assist the panel in considering any contentious issues.

Mr Unwin invited the panel to conclude that Witness 20’s witness statement could be

‘read’ as her evidence in chief.

Witness 21 (Detective Constable, Avon and Somerset Constabulary)

Mr Unwin informed the panel that Witness 21’s witness statement related primarily to

the police investigation conducted into allegations of abuse and ill treatment of patients

in Winterbourne View. She exhibited material seized by the police during the course of

its investigation, as well as Registrant C’s police interview under caution in which he

responded to the allegations.

In the absence of any challenge to the authenticity of documents exhibited by Witness

21, Mr Unwin invited the panel to conclude that her witness statement could be ‘read’ as

her evidence in chief.

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Witness 22 (Interim Project Manager and subsequently Head of Governance, Danshell)

Mr Unwin told the panel that Witness 22 did not give direct factual evidence in respect

of any specific allegation, but rather she exhibited a number of Castlebeck policies.

Mr Unwin referred the panel to Registrant A’s signed NMC ‘Standard Directions Form’

dated 20 October 2014, in which she indicated that she agreed with the content of

Witness 22’s statement. In the absence of any challenge to her evidence, Mr Unwin

invited the panel to conclude that Witness 22’s witness statement could be ‘read’ as her

evidence in chief.

Witness 23 (Senior Assessment Manager, Healthcare Commission (2005-2009), CQC

Compliance Manager (2009)

Mr Unwin informed the panel that the NMC had initially intended on calling Witness 23

to give evidence in person at the hearing. For case management purposes, and in light

of ongoing issues with the hearing timetable, this position was reviewed.

By way of information, Mr Unwin explained that Witness 23 inspected Arden Vale in

April 2006, November 2006 and October 2007, and Croxton Lodge in June 2011.

Mr Harrison, in his signed NMC ‘Standard Directions Form’ dated 19 October 2014,

indicated that he agreed with the content of Witness 23’s statement and agreed to her

statement being ‘read’ as her evidence in chief. Registrant A, in her signed NMC

‘Standard Directions Form’ dated 20 October 2014, indicated that she agreed with the

content of Witness 23’s statement.

Mr Unwin submitted that whilst there might be general questions about CQC

methodologies which could be put to Witness 23, any such questions could properly be

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put to Witness 5, a witness who was due to give evidence in person. As no specific

factual dispute as regards Witness 23’s evidence had been raised by either Mr Harrison

or Registrant A, Mr Unwin invited the panel to conclude that her witness statement

could be ‘read’ as her evidence in chief.

Witness 24 (Compliance Manager, CQC)

By way of information, Mr Unwin told the panel that Witness 24 inspected Arden Vale in

June 2011. He referred the panel to Mr Harrison’s signed NMC ‘Standard Directions

Form’ dated 19 October 2014, in which he indicated that he agreed with the content of

Witness 24’s statement and agreed to her statement being ‘read’ as her evidence in

chief.

In the absence of any factual challenge to her evidence, Mr Unwin submitted that

Witness 24’s witness statement could properly be ‘read’ as her evidence in chief.

Witness 25 (CQC Compliance Inspector); Witness 26 (CQC Compliance Inspector);

Witness 27 (Healthcare Assessor for the Healthcare Commission and subsequently

CQC Compliance Manager); Witness 28 (CQC Compliance Inspector); and Witness 29

(CQC Compliance Inspector)

Each named witness was a CQC Compliance Inspector who carried out inspections of

non-Winterbourne View Units in 2011. In each case, Mr Harrison, in his signed NMC

‘Standard Directions Form’ dated 19 October 2014, indicated that he agreed with the

content of the witness’ statement and agreed to their statement being ‘read’ as their

evidence in chief.

In the absence of any factual challenge to their evidence, Mr Unwin submitted that each

witness’ statement could properly be ‘read’ as their evidence in chief. In any event, he

submitted that in their respective roles, each witness would subsequently have carried

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out a large number of inspections; in that regard, it was unlikely that their factual

recollection of relevant events would go above and beyond any documentation

exhibited by them.

Witness 30 (Castlebeck Interim Operations Director, September 2011)

Mr Unwin informed the panel that it was the NMC’s intention that Witness 30 attend the

hearing in person to give evidence; Witness 30 was not, however, able to attend on the

date proposed. Mr Unwin explained that Witness 30 could travel to London for the

purpose of the hearing, however, Registrant A, in her signed NMC ‘Standard Directions

Form’, dated 20 October 2014, indicated that she agreed with the content of Witness

30’s statement. Furthermore, Mr Harrison, in his signed NMC ‘Standard Directions

Form’ dated 19 October 2014, indicated that he agreed with the content of Witness 30’s

statement and agreed to his statement being ‘read’ as his evidence in chief.

Mr Unwin told the panel that Witness 30 chaired the disciplinary hearings held in

relation to Registrant C and Registrant A. Mr Unwin submitted that any decisions or

findings from the disciplinary hearings would not be relevant to the panel in adjudicating

upon the charges before it. That being said, Witness 30’s evidence was important

insofar as he referred to the registrants’ responses during the course of the disciplinary

hearings.

In the absence of any factual challenge to his evidence, Mr Unwin submitted that

Witness 30’s witness statement could properly be ‘read’ as his evidence in chief.

Panel’s decision

In reaching its decision, the panel had regard to the submissions made by Mr Unwin

and accepted the advice of the legal assessor, who referred the panel to Rule 31 of the

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Rules and to the NMC’s ‘Telephone evidence guidance’ (effective from 26 September

2016).

In respect of Mr Unwin’s application to hear the evidence of Witness 9, Witness 6 and

Witness 13 by video link, the panel carefully considered the following:

The panel took into account that neither Witness 9’s nor Witness 13’s evidence spoke

directly to any specific allegation, insofar as the panel’s ability to adjudicate upon the

charges. Witness 9 spoke of general matters arising from her experience as a Support

Worker at Winterbourne View, and Witness 13 exhibited a report she produced

following her review, in 2011, of 12 (non-Winterbourne View) Castlebeck Units. Witness

13 also played a role in Mr Harrison’s appeal hearing, the findings of which would not be

relevant for the purpose of this substantive hearing.

As regards Witness 6, the panel was mindful that her evidence was confined to a

discrete matter, namely an alleged conversation between herself and Registrant A in

around 2009. Registrant A, in her undated written response to the allegations, indicated

that she did not recall the alleged conversation, nor did she recall Witness 6.

On the information before the panel as to the substance of each witness’ evidence, the

panel was satisfied that the requirement of relevance was met.

Panels in regulatory proceedings perform an inquisitorial and investigatory role. In order

to perform this role, panels require the best evidence available. The panel accepted that

the best form of evidence is obtained by calling witnesses live before it. The panel was

satisfied that receiving evidence by video link would allow all parties to see the witness’

demeanour when giving evidence, and thus allow the panel to assess the witness’

credibility.

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The panel was mindful of its earlier decision to proceed in the absence of Mr Harrison.

With this in mind, the panel considered that any potential unfairness or disadvantage to

him in allowing this application would be as a result of his decision to absent himself

from the hearing and thus not be in a position to cross-examine the witnesses in any

event. That being said, the panel was acutely aware of its obligation to ensure fairness

in these proceedings. In that regard the panel, of its own volition, would explore any

inconsistencies in the NMC evidence which the panel itself identified, as well as any

matters referred to by Mr Harrison in his written representations to the NMC.

As at the time of the application, the panel had already read through all the

documentary evidence adduced by the NMC, as well as the written responses provided

by Mr Harrison. Whilst it was unclear, at this stage, the extent to which the witnesses’

credibility may be challenged by the absent registrants in this case, the panel was of the

view that any potential unfairness to Mr Harrison in acceding to Mr Unwin’s application

would be mitigated by their giving evidence by video link, because their evidence would

be subject to exploration and testing. Further, the panel would be able to put Mr

Harrison’s responses to the witnesses in question, to see their demeanour when giving

evidence and thus assess their credibility.

The panel was mindful that Witness 9’s, Witness 13’s and Witness 6’s evidence was

contained in written witness statements, supported by signed declarations of truth,

which, along with all other documentary evidence relied upon by the NMC, had been

served on Mr Harrison.

Having considered this application with care, taking into account the public interest in

the expeditious disposal of this case and fairness in these proceedings, the panel

considered that it was fair to allow Witness 9, Witness 13 and Witness 6 to give

evidence by video link.

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The panel wished to reaffirm the importance of each witness being provided with their

witness statements and associated exhibits in preparation for receiving their evidence

by video link.

In respect of Mr Unwin’s application to admit into evidence the witness statements and

associated exhibits of Witness 18, Witness 19, Witness 20, Witness 21, Witness 22,

Witness 23, Witness 24, Witness 25, Witness 26, Witness 27, Witness 28, Witness 29

and Witness 30, the panel considered the following:

The witnesses subject to this application were not relied upon by the NMC as principal

witnesses in respect of any specific allegation, but rather their evidence was ancillary

and would provide a contextual narrative in respect of some of the charges concerning

primarily Mr Harrison, and Registrant A. From the information before the panel as to the

substance of the witnesses’ evidence, the panel was satisfied that the requirement of

relevance was met.

As to fairness, the panel was mindful that no factual challenge had been raised by either

Registrant A or Mr Harrison in respect of the contents of the witnesses’ evidence. The

witnesses’ evidence was therefore non-contentious.

The panel bore in mind the disadvantage in not being able to assess the witnesses’

demeanour when giving evidence. However, it was mindful that the witnesses’ evidence

was contained within written statements, supported by signed declarations of truth.

Their evidence, along with all other documentary evidence relied upon by the NMC, had

been served on Registrant A and Mr Harrison, in advance of and in preparation for this

hearing.

The panel was satisfied that the admission of the witnesses’ statements and associated

exhibits would accord with the public interest in ensuring that the evidence in this case

was explored fully and that decisions were reached on the best available evidence.

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Having considered this application with care, taking account of the public interest in the

expeditious disposal of this case and fairness in these proceedings, the panel

determined that it would be fair to admit the documents. In reaching this conclusion, the

panel was mindful of the potential limitations of receiving evidence in this manner and

would, in due course, attach appropriate weight to the fact that the witnesses’ written

accounts could not be explored by way of oral evidence and questions of clarification

from the panel.

Submission on application to amend the header of the charges – Monday 15 May

2017

The panel raised a concern that the dates set out in Schedule E (April 2006 to October

2007) fell outside the time period identified in the header of the charges against Mr

Harrison. The panel therefore sought clarification from the NMC in respect of charge

4.1, in particular as to the commencement of Mr Harrison’s engagement at Arden Vale

and the subsequent applicability or otherwise of the provisions set out in Schedule E.

Mr Unwin referred the panel to the evidence which confirmed that Mr Harrison was the

appointed Responsible Individual for Arden Vale from 2005. He acknowledged,

however, that the time period identified in the header of the charges was incorrect; he

submitted that it was, most likely, an administrative error. He thus made an application

to amend the header as follows:


Operations Director/ Regional Operations Manager between 2006 and June 2012…

Mr Unwin that the proposed amendment only impacted upon charge 4.1, had no

bearing on the remaining allegations, and that the substance of the remaining

allegations remained unchanged.

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The legal assessor referred the panel to Rule 28 of the Rules, which states:

28.—(1) At any stage before making its findings of fact … the Conduct and Competence

Committee, may amend—

(a) the charge set out in the notice of hearing; or

(b) the facts set out in the charge, on which the allegation is based,

Unless, having regard to the merits of the case and the fairness of the proceedings, the

required amendment cannot be made without injustice.

(2) Before making any amendment under paragraph (1), the Committee shall consider

any representations from the parties on this issue.

The legal assessor emphasised the requirement to consider representations from the

parties before making any amendment to a charge. She advised that it was in the

interests of justice and fairness for reasonable attempts to be made to contact Mr

Harrison in order to seek his representations on the application. She advised that the

proposed amendment was substantial in that, without it, there was arguably no case for

Mr Harrison to answer in respect of charge 4.1.

Mr Unwin provided an undertaking for contact to be made with Mr Harrison as advised.

The panel afforded Mr Unwin sufficient time to do so, and decided to reserve its

judgement in respect of this application until such time as Mr Unwin was in a position to

address the panel on this matter.

On Tuesday 16 May 2017, Mr Unwin provided the following update to the panel:

Mr Harrison, in his written representations to the NMC, asserted that he assumed

responsibility for Arden Vale in 2007. The NMC witness relied upon in support of charge

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4.1 against Mr Harrison was Witness 23; it was Witness 23’s evidence that Mr Harrison

was the ‘Responsible Individual’ of Arden Vale from its opening in October 2005. In

making that assertion, Witness 23 appeared to rely upon a certificate of registration in

which Mr Harrison was identified as the ‘Responsible Individual’. The ‘Date of

Registration’ was recorded as 27 October 2005. The certificate date, however, was 6

November 2007.

Mr Unwin acknowledged that this document was inconclusive in regard to Mr Harrison’s

position in 2006. He informed the panel that steps were being taken to locate the

original certificate and that, until such time as the position was clarified, contact with Mr

Harrison was being postponed.

On Thursday 18 May 2017, Mr Unwin provided the following update to the panel:

Witness 23 had informed the NMC that there was no record of a certificate of

registration pre-dating 2007. As such, the NMC did not seek to proceed in respect of

paragraphs 1-32 of Schedule E. Mr Unwin told the panel that Mr Harrison would be put

on notice of the application and would be given an opportunity to respond to it. It was

therefore Mr Unwin’s intention to make a formal application to amend the header of the

charges on Friday 19 May, in order to give sufficient time to Mr Harrison to respond,

should he wish to do so.

Determination on application to amend the header of the charges – Friday 19 May

2017

On Friday 19 May 2017, Mr Unwin made a formal application to amend the header of

the charges against Mr Harrison to read as follows:

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Operations Director/ Regional Operations Manager between 2007 and June 2012…

Mr Unwin submitted that the proposed amendment was relevant only to charge 4.1. In

light of this application, the NMC sought to withdraw paragraphs 1-32 of Schedule E.

In regard to the notice period afforded to Mr Harrison in respect of this application, Mr

Unwin informed the panel that communication to Mr Harrison about the proposed

amendment was not sent until approximately 16:00 the previous day. As an aside, Mr

Unwin explained that earlier communication had been sent to Mr Harrison, at the

panel’s request, in relation to any further representations he may wish to make in

response to the allegations; no response had been received from Mr Harrison, as at the

time of Mr Unwin’s submission. Mr Unwin further informed the panel that the NMC had

sent communication in the months leading up to this substantive hearing, and that no

response from Mr Harrison had been received. Mr Unwin submitted that other than his

early engagement with the NMC, Mr Harrison appeared to have disengaged from these

proceedings.

Mr Unwin outlined the evidential basis for the application. Whilst Witness 7 was unable

to specify at what stage Mr Harrison took over responsibility of Units in the Midlands

region, she confirmed that Mr Harrison was in post, in a role almost identical to that of

Regional Operations Director, prior to her commencing her employment in 2008. In any

event, Witness 7 confirmed that Registrant A, as Senior Manager, reported to Mr

Harrison. Witness 7 also confirmed that Registrant A was employed as Manager of

Arden Vale between May 2007 and June 2008.

Mr Unwin directed the panel’s attention to the Healthcare Commission inspection report,

following an announced inspection of Arden Vale on 18 October 2007. The report noted

that, since Arden Vale’s registration in 2005, there had been a number of temporary

Managers in post. It went on to state that during the inspection visit, the Healthcare

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Commission had registered the current Manager, Registrant A, as a fit person to run the

establishment.

Mr Unwin then directed the panel’s attention to a copy of the notes from the

investigatory meeting held with Mr Harrison on 3 August 2011. In relation to Arden Vale,

Mr Harrison said that he “did not commission Arden or appoint Managers”. He went on

to confirm, however, that he had appointed Registrant A’s predecessor. In that regard,

Mr Unwin submitted that if Registrant A was in post at Arden Vale from May 2007, Mr

Harrison must have been in post prior to that. In any event, Mr Harrison appointed

Registrant A as Manager of Arden Vale.

In those circumstances, Mr Unwin submitted that the evidence of Mr Harrison himself,

during the investigation meeting, supported the inference that he must have been

responsible for Arden Vale at least by the time of the October 2007 inspection.

As to whether the proposed amendment could be made without injustice, Mr Unwin

submitted that the substantial change was to effectively withdraw all paragraphs of

Schedule E that predated 2007. He said that Mr Harrison had been put on notice of the

substance of the charge in question, throughout these proceedings; it was Mr Harrison’s

case that he was responsible for Arden Vale from 2007. Mr Unwin conceded that there

was no evidence to demonstrate that, prior to 2007, Mr Harrison had responsibility for

Arden Vale. Mr Unwin submitted that it was unlikely that Mr Harrison’s response to the

allegations would have been any different, had the application to amend the header of

the charges been made earlier on in these proceedings.

In all of those circumstances, Mr Unwin submitted that the substance of charge 4.1

would not be altered significantly by correcting the dates in the header of the charges so

as to reflect the evidence.

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In reaching its decision, the panel had regard to the submissions made by Mr Unwin

and it accepted the advice of the legal assessor, who referred to Rule 28 of the Rules,

which states:

28.—(1) At any stage before making its findings of fact … the Conduct and Competence

Committee, may amend—

(a) the charge set out in the notice of hearing; or

(b) the facts set out in the charge, on which the allegation is based,

Unless, having regard to the merits of the case and the fairness of the proceedings, the

required amendment cannot be made without injustice.

As to the merits of the case, the panel took account of Mr Harrison’s undated written

statement to the NMC, in which he acknowledged that he “was part of the team that

failed to ensure that all of the vulnerable people within Castlebeck were protected from

abuse”. The panel further took note that it was Mr Harrison’s case that he assumed

managerial responsibility for the Midlands region in 2007. The panel had regard to the

documentary evidence referred to by Mr Unwin and was satisfied that the evidential

basis of his application made plain that Mr Harrison was responsible for Arden Vale at

least at the time of the Healthcare Commission inspection in October 2007.

The panel took note of the efforts made by the NMC to engage Mr Harrison in these

proceedings. The panel was informed that there was no working contact number on

record for Mr Harrison. It was further informed that attempts had been made, on

Thursday 18 May 2017 and in the months leading up to the hearing, to contact Mr

Harrison, and that these attempts had been unsuccessful. Whilst Mr Harrison had been

given less than 24 hours’ notice of this application, the panel considered that being

afforded more time was unlikely to result in a response from Mr Harrison, particularly in

light of his apparent disengagement in these proceedings.

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In all of the circumstances, the panel was satisfied that the proposed amendment would

not cause Mr Harrison any unfairness or injustice. It therefore agreed to Mr Unwin’s

application. The panel was mindful that the amendment would not bind it in regard to

any decision reached in respect of the allegations.

Mr Harrison’s position – Monday 22 May 2017

Mr Unwin informed the panel that on Friday 19 May 2017, Mr Harrison responded to an

email from his NMC Case Officer, in relation to the NMC’s application to amend the

header of the charges in this case. Mr Harrison stated that he would make himself

available to the panel, should it wish to hear from him. He also stated that he could not

attend the hearing in person, but that he could be contacted by email or telephone. Mr

Harrison, in his email, gave no objection to the NMC’s application to amend the header

of the charges in his case.

Determination on submission of offering no evidence – Monday 22 May 2017

Mr Unwin informed the panel that Mr Harrison was the Regional Operations Manager

with responsibility for the Midlands region from 2007, and was subsequently the

Regional Operations Director, with responsibility for Winterbourne View in 2008. Mr

Unwin told the panel that upon further review of the evidence in this case it appeared

that, prior to and including 2008, Winterbourne View was under the remit of another

Regional Operations Director, Individual GG. According to Registrant A, in her

investigation meeting on 17 August 2011, Mr Harrison resumed responsibility for

Winterbourne View in 2009. This was supported by Witness 7, who confirmed that Mr

Harrison was responsible for Winterbourne View from January 2009.

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In light of the above, Mr Unwin submitted that the NMC did not seek to proceed with

paragraphs 1-12 of Schedule A, which had been originally relied upon to support charge

1.1.

The panel was satisfied that there was no case for Mr Harrison to answer in respect of

paragraphs 1-12 of Schedule A in light of the submissions from Mr Unwin.

Mr Harrison’s response to the charges – Wednesday 24 May 2017

Mr Harrison participated in the hearing by telephone on 24 May 2017. He made

admissions to the following charges:

1.1

1.2

1.4

1.6.1

1.8

1.9

1.10

1.11

1.12

2.1

3.1

4.1

4.2

5.1

5.2

6.1

7.1

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Mr Harrison also admitted that by virtue of the above charges, his fitness to practise is

impaired by reason of his misconduct.

In accordance with Rule 24(5) of the Rules, the panel found proved the charges

indicated above, by virtue of Mr Harrison’s admissions.

Determination on facts – Monday 5 June 2017

In reaching its determination on facts, the panel had regard to all the evidence adduced,

including the oral evidence and the exhibited documents. It heard submissions from Mr

Unwin and accepted the comprehensive advice of the legal assessor.

The burden of proof rests entirely upon the NMC. Mr Harrison does not have to prove or

disprove anything. The standard of proof is the civil standard, namely the balance of

probabilities. This means that, for a fact to be found proved, the NMC must satisfy the

panel that what is alleged to have happened is more likely than not to have occurred.

The panel heard evidence on behalf of the NMC from the following witnesses who held

the positions (as listed below) at the relevant time:

Witness 1, Activities Coordinator, Wast Hills;

Witness 2, Researcher, BBC;

Witness 3, Charge Nurse, Winterbourne View;

Witness 4, Compliance Inspector, CQC;

Witness 5, Compliance Manager, CQC;

Witness 6, Patient E’s mother;

Witness 7, HR Director, Castlebeck (later Danshell);

Witness 8, Nurse, Arden Vale;

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Witness 9, Support Worker, Winterbourne View;

Witness 10, Nurse, Winterbourne View;

Witness 11, Support Worker, Winterbourne View;

Witness 12, Patient D’s mother;

Witness 13, Independent Consultant;

Witness 14, Head of Strategy and Commissioning, SGC;

Witness 15, Senior Practitioner, Safeguarding Team, SGC; and

Witness 16, Chief Operating Officer, Castlebeck.

Witness 1

Witness 1 was an anxious and nervous witness, who was evidently traumatised by the

events at Winterbourne View about which he spoke. His recall, on occasion, was poor;

this could understandably have been due to the passage of time. Although employed by

Castlebeck from September 2009 to June 2010, his specific experience of Winterbourne

View was limited to a period of approximately two months. His evidence was of some

assistance in providing a comparison, particularly of the systems in place and the

provision of care to service users, between his primary place of employment (Wast Hills,

Birmingham) and Winterbourne View.

Witness 1’s evidence was inconsistent and contradictory at times. In his exhibit entitled

‘My Responses To Some Questions Asked By The Media’, Witness 1 stated that “I had

many concerns and expressed them to a few different Managers, I discussed most of

them in person but those that I emailed always went unanswered”. In his oral evidence,

he confirmed that the only Manager at Winterbourne View to whom he had raised his

concerns was Registrant C. He also confirmed that he did not report any concerns, via

email, whilst at Winterbourne View. That being said, his evidence was consistent when

he spoke of his overall relationship with Registrant C, raising concerns with Registrant

C; and how ‘unreceptive’ Registrant C appeared when concerns were raised.

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The panel was satisfied that Witness 1 did his best to assist in these proceedings by

giving evidence. The usefulness and reliability of his evidence, however, was limited.

Witness 2

Witness 2 was balanced, fair and professional. He spoke not only of the instances of

abuse he directly observed, as depicted in the BBC Panorama documentary, but also of

the good care that was provided by some staff members to the patients at Winterbourne

View. He also acknowledged that as the Managers at Winterbourne View were not

regularly present on patient floors, they most likely did not or would not necessarily have

had knowledge of the abuse that was occurring.

As to the specific allegations in this case, Witness 2’s evidence was of limited value.

Overall, however, the panel was satisfied that he was a credible, consistent and reliable

witness and that he gave evidence in good faith.

Witness 3

Witness 3 gave evidence in respect of events which led to his whistle-blowing email,

addressed to Registrant C, dated 11 October 2010, as well as in respect of record

keeping, documentation, training and supervision, and incident reporting systems. He

presented as being very experienced in caring for patients with challenging behaviours.

He was balanced and fair, had a good recollection of the matters about which he spoke,

and was candid about what he could not recall. He also made concessions where

appropriate, acknowledging, for example, that he may have misunderstood the purpose

of a meeting that was held a few days after his whistle-blowing email, and whether or

not the copy of the email in Registrant D’s possession at that meeting was in fact his

whistle-blowing email. He was clear in his view as to his expectations, and the

accountabilities, of each registrant in this case.

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Witness 3’s prior relationship with Individual K was explored to some extent in cross-

examination, the implication being that when he commenced employment at

Winterbourne View, he had been “on the lookout” for abuse. The panel was not

persuaded by this line of questioning, and was satisfied, on the basis of Witness 3’s

evidence, that he did not seek out employment at Winterbourne View with an ulterior or

sinister motive. Furthermore, there was some suggestion that he, as a Charge Nurse,

ought to have taken action himself to address concerns he had identified. In this regard,

the panel was acutely aware that he worked in Winterbourne View for approximately

three months, during which time he was evidently persistent in his desire to effect

positive changes in Winterbourne View, frequently reporting and escalating his

concerns to management. Witness 3 was clearly traumatised by the abuse that was

uncovered in the BBC Panorama documentary; he was unable to work as a Registered

Nurse for some months after its transmission. He confirmed that he did not personally

witness the severity of the abuse depicted in the footage.

The panel was satisfied that Witness 3 was a credible, consistent and reliable witness

and that he gave evidence in good faith.

Witness 4

Witness 4 provided useful contextual evidence in respect of CQC methodologies and

documentation. Her testimony, insofar as her recollection and the documentation before

her allowed, was fair and balanced. She confirmed that she had undertaken only one

CQC inspection, in December 2009; she was thus unable to speak to wider issues in

respect of other inspections conducted at Winterbourne View. Due to the passage of

time and her limited involvement with Winterbourne View, her overall recall and the

value of her evidence, outside of her written NMC witness statement, were limited. That

being said, the panel was satisfied that she tried her best to assist in these proceedings.

Overall the panel was satisfied that she was a credible, consistent and reliable witness

and that she gave evidence in good faith.

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Witness 5

Witness 5 had a good understanding of her role as a witness in these proceedings,

providing factual evidence and not seeking to offer any personal views or opinions

unless specifically sought. She was a highly experienced Registered Nurse with a

background in mental health. She gave useful, contextual evidence in regard to CQC

methodologies in the inspection process (prior and subsequent to the BBC Panorama

documentary), and spoke more specifically about the CQC inspections in May 2011, in

which she took part. She was clear in her view as to the responsibilities and

accountabilities of each registrant in this case. Her testimony, insofar as her recollection

and the documentation before her allowed, was fair and balanced. Whilst her recall

about matters or details not contained in her NMC witness statement was limited, the

panel was assisted by her contemporaneous notes, made at the time of the inspection

in May 2011.



Witness 6

Witness 6, Patient E’s mother, had a clear recollection of the conversation she said she

had had with Registrant A after her (Witness 6’s) daughter had re-enacted an incident

when she had been “decked” by Individual U. She also recalled her feelings at the lack

of response she received from the various practitioners, including Registrant A, who

were present at the CPA meeting that took place directly after this conversation.

Witness 6 had had direct professional experience in a care setting and was engaged in

her daughter’s care. She told the panel that, from her point of view, she had had a

professional and positive relationship with Registrant A. Whilst she spoke of her

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subsequent lack of trust in Winterbourne View and its staff following transmission of the

BBC Panorama documentary, the panel was satisfied that she bore Registrant A no

malice and had no ulterior motive in giving evidence in these proceedings. In that

regard, the panel was mindful that her evidence to the NMC came about as a result of

her wish to assist her daughter in these proceedings.



Witness 7

Witness 7 provided considerable evidence in regard to Castlebeck processes, practices

and systems, and was clear in respect of the primary accountabilities of each registrant

in this case. There were, however, occasions when her testimony was not entirely

objective but rather veered into opinion evidence, speaking about what she would have

expected in the circumstances as opposed to what actually happened. It was also

apparent that she had formed opinions of the standards she had expected of some of

the registrants, whilst not being a clinician herself. There were, furthermore, occasions

when she did not provide direct responses to questions put to her. The panel therefore

accepted her evidence with some reservation.

That being said, the panel was satisfied that Witness 7 did her best to assist in giving

evidence in these proceedings. The panel was further satisfied that she was a

consistent witness and was credible and reliable in respect of matters in which she was

experienced.

Witness 8

Witness 8 was a measured and balanced witness. She had a good recollection of the

matters about which she spoke, and was candid about what she could not recall. The

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panel noted that she made a contemporaneous record of instances of restraint, as set

out in her NMC witness statement and in her report to the Manager of Arden Vale,

whose name she was unable to recall. The contemporaneous record was of

considerable assistance to the panel, bearing in mind the passage of time since the

allegations about which she spoke.

Witness 8 spoke of the Manager of Arden Vale (reasonably inferred to be Registrant A)

in positive terms, commenting on the support Registrant A had offered her during their

meeting and Registrant A’s undertaking to address the concerns raised in her (Witness

8’s) report. Witness 8 was candid in her acknowledgement that she did not follow up

with Castlebeck as to whether her concerns were indeed investigated.

It was evident to the panel that the events about which Witness 8 spoke had had an

impact on her. Her employment at Arden Vale was her first professional employment as

a Registered Nurse post qualification. She worked at Arden Vale for approximately

three weeks, during which time she had observed what she considered were excessive

restraints and abuse of patients. She took action in reporting her concerns to Registrant

A in the first instance, in her resignation letter to Castlebeck and again, after

transmission of the BBC Panorama documentary. Her account was consistent

throughout.

The panel was satisfied that Witness 8 was a credible and reliable witness and that she

gave evidence in good faith.

Witness 9

Witness 9 spoke of her experiences whilst working in Winterbourne View as a Support

Worker. Whilst not a qualified professional at the time, the panel took note that she

voiced opinions about the appropriateness or otherwise of matters not entirely within her

remit. She further spoke of her relationship with Registrant A in particularly negative

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terms; the panel was mindful that Registrant A was not aware of her evidence in this

regard and was thus not in a position to respond to it. The panel was therefore

somewhat hesitant about Witness 9’s objectivity.

Witness 9 gave evidence in regard to incidents of restraint about which, she said, she

had no particular concerns. For example, she spoke of an occasion when Patient G’s

wrist was broken following a restraint; it was Witness 9’s evidence that she observed

the Nurse involved restrain the patient, that she “[didn’t] believe it was particularly

forceful… we heard this ‘popping’ sound… I can honestly say I don’t think he did it

particularly forcefully”. The panel took further note that Witness 9 was named in a

complaint letter from Patient E, dated 22 July 2010, in which the patient described being

restrained by a number of staff members. The panel was concerned about the extent to

which the witness may have been inculcated into the ‘Castlebeck way’. The panel

therefore attached less weight to her evidence.

Witness 10

Witness 10 was a balanced, measured and compelling witness. She was open and

transparent in respect of her ongoing contact with Registrant D. This contact, she

confirmed, was limited primarily to social media.

Witness 10 provided useful contextual evidence in respect of the working environment,

processes and systems, incidents and incident reporting at Winterbourne View at the

material time. She had a good recollection of the matters about which she spoke, and

was candid about what she could not recall. Of the two patient incidents about which

she spoke, the panel took into account that her evidence was supported by

contemporaneous incident forms. In her oral evidence, she spoke in detail about the

particular incidents, telling the panel that she could recall the events very clearly. It was

apparent to the panel that these incidents, and the impact on the patients at

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Winterbourne View when they viewed the BBC Panorama documentary, were clearly

distressing for her.



Witness 11

Witness 11 did her best to assist the panel in giving evidence in these proceedings and

was candid about what she could not recall. However, there were a number of

inconsistencies and contradictions between her account as set out in her statement to

the police, her account in her NMC witness statement and her oral evidence; in

particular, with regard to the chronology as to when and to whom she reported the

incidents about which she spoke. In relation to one incident, Witness 11 asserted that

her account in her NMC witness statement, dated 24 November 2013, was more

accurate than her account in her police statement, dated 5 October 2011. In relation to

another incident, she relied on her account in her police statement as being an accurate

version of events, as opposed to her NMC witness statement. It was apparent to the

panel that the witness spoke of what she believed she would have done in the

circumstances, i.e. her view as to the appropriate ‘chain of command’ in regard to

reporting concerns, rather than basing her testimony on her recollection of actual

events.

Moreover, Witness 11 made a number of assumptions with regard to what she

considered to be a lack of action taken by Registrant D in response to concerns raised.

She acknowledged, however, that she made these assumptions as she was not aware

of what action, if any, had in fact been taken. When taken to the relevant documentary

evidence, she conceded that appropriate action had indeed been taken by Registrant D

and that nothing more could have been done by Registrant D.

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The inconsistencies and contradictions in Witness 11’s evidence fundamentally led the

panel to question its reliability. The panel therefore attached limited weight to her

testimony.

Witness 12

Witness 12 had a clear recollection of her visits and telephone conversations with her

son, Patient D, during the course of which he would report his concerns about

Winterbourne View. It was, however, apparent to the panel that management at

Winterbourne View did not inform the witness of, or involve her in, matters relating to

her son during his stay in Winterbourne View; for example, she was not privy to his care

records or incident forms, and was not asked to provide written comments or

statements following the disclosures by her son. Her limited involvement in wider

matters was such that her overall evidence was of limited value to the panel in its

consideration of the allegations. That being said, the panel was satisfied that the

witness did her best to assist these proceedings by giving evidence. It was further

satisfied that she gave evidence in good faith.

Witness 13

Witness 13 presented as a professional, measured and fair witness, who was highly

experienced at a senior level. She provided a very useful overview of Castlebeck and its

Units, and her evidence with regard to the accountabilities of members of the

management team was of considerable assistance to the panel. She had a clear

recollection of her observations, as set out in her report following her review of 12

Castlebeck Units (not including Winterbourne View) and was able to elaborate on her

report during the course of her oral evidence.



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Witness 14

Witness 14 was clear about the limited nature of his role in respect of these

proceedings. He was the Head of Strategy and Commissioning at South

Gloucestershire Council (“SGC”) at the material time; he was not a clinician. His

evidence was confined to a ‘document-scoping’ exercise. That being said, the panel

was satisfied that he did his best to assist in giving evidence in these proceedings. The

panel was further satisfied that he was a consistent witness and was credible and

reliable in respect of matters about which he was an expert.

Witness 15

Witness 15 was defensive in her responses and, when questioned on certain matters,

appeared unwilling to provide her professional judgement. She was not prepared to

comment on documentation she herself collated for the purpose of the NMC’s

investigation, notwithstanding the fact that she was not in post, as Senior Practitioner in

the safeguarding team at SGC, until April 2011 (despite asserting, in her witness

statement, that she had been employed in this role since April 2010). Furthermore,

when asked to provide her professional judgment on the increase in the number of

safeguarding alerts to SGC post transmission of the BBC Panorama documentary, she

appeared unconcerned by this and trivialised, to a degree, the contents of those alerts.

In the panel’s view, Witness 15 did not make a positive attempt to assist in these

proceedings. The panel attached limited weight to her evidence.

Witness 16

Witness 16 was a highly experienced ‘turn-around’ consultant and, as a Registered

Nurse, had a clear view of what constituted good nursing care, particularly from the

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point of view of patients. He was a compelling witness, whose evidence corresponded

closely with that of Witness 13. He made plain to the panel that, notwithstanding the

corporate failings in this case and the operational pressures faced by, in particular, Mr

Harrison, Registrant A and Registrant C, his expectations of each registrant in the

circumstances were clear. He acknowledged the wider, systemic failings in regard to

Winterbourne View, but was unwavering in his view of the role of Registered Nurses in

that environment.


and that he gave evidence in good faith.

The panel also heard evidence from Mr Harrison. He was open and transparent in his

responses, conceding that he limited his personal involvement in matters where he

ought not to have. He was candid in acknowledging that he left tasks for others to

complete and would not check up on progress. His accounts throughout were

consistent. The panel was satisfied that he was a credible and reliable witness and that

he gave evidence in good faith.

At the close of his final submissions on facts, Mr Unwin presented general observations

which he invited the panel to take into account. The panel were to bear in mind the

historical nature of these allegations and the effect which that had on witness

recollection and the quality and availability of evidence relating to matters which had

occurred some 7-8 years previously.

Further, there were evidential considerations to be had on account of Winterbourne

View's closure shortly after the Panorama broadcast, and the organisation's entering

into administration. This inevitably had an effect on the availability of documents

both before the panel, and also before the CQC. Quite distinct from those events, both

the CQC and SGC had changed their systems which also affected the availability of

documents. Despite there being a considerable amount of documents placed before

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the panel, therefore, those documents were nevertheless unlikely to amount to a

complete picture of what took place and what was available for inspection by the CQC.

Finally, Mr Unwin broadly submitted that the failures which had been alleged and

identified occurred both inside and outside Castlebeck. The Serious Case Review had

identified failings also by the CQC and SGC. Further, on this issue, those failings within

Castlebeck were not all attributable, nor attributed, to one registrant. The Serious Case

Review identified problems occurring at Winterbourne View prior even to Registrant A's

engagement there, and Witnesses 13 and 16 both gave evidence of considerable

failings on the part of the Board at Castlebeck.

The panel considered these observations to have been commendably made by Mr

Unwin in the interests of fairness for all parties.

The panel made the following findings of fact in respect of the charges:


Operations Director/ Regional Operations Manager between 2007 and June 2012:

1 In relation to Winterbourne View:

1.1 Did not ensure that Winterbourne View met any or all of the national minimum


listed in Schedule A

Admitted and found proved.

1.2 Did not ensure that Winterbourne View was compliant with any or all of the

Health and Social Care Act 2008 essential standards listed in Schedule B

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1.3 Did not apply to register with the Care Quality Commission as the accountable

officer at the hospital under Part 2 of The Controlled Drugs (Supervision of

Management and Use) Regulations 2006.

No case to answer.

1.4 Did not ensure that an action plan was submitted to the Healthcare Commission

following an inspection on 24 March 2009


1.5 Did not ensure that Individual X was registered with the Care Quality

Commission as Manager of Winterbourne View at any time from January 2010

It was Witness 5’s evidence that on 21 January 2011 the CQC issued a certificate of

registration in the name of Registrant A, as the CQC had been told that she was the

Manager of the Hospital. The certificate registered Registrant A to carry on the

regulated activities at the Hospital. At the time of Witness 5’s visit in May 2011, she was

informed by Registrant C that Registrant A did not work at the Hospital and was

managing another Castlebeck unit. Witness 5 said that the CQC had not received any

notification from Castlebeck as regards the new management arrangements at the

Hospital. She said that Registrant C’s application to register was received by the CQC

on 19 April 2011 (it was dated 11 April 2011) and rejected on 21 April 2011, on the

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basis that it did not contain all the required documents and an out of date application

form had been used citing earlier legislation.

Witness 7 stated that Registrant A was unable to register with the CQC as Manager of

Chesterholme as she was the Registered Manager of Winterbourne View at the time of

its closure. Individual CC emailed Mr Harrison on 6 May 2011 to establish whether

Registrant A had cancelled her registration with the CQC. Mr Harrison responded on the

same day, stating “Yes they have been informed but only verbally at their last visit to the

unit. I need to send the appropriate written notification to them which I have to admit

had completely slipped my mind”.

Whilst Mr Harrison had suggested, in his oral evidence, that “we had gone through the

registration process with the CQC, completed all the forms and application and

submitted [Registrant C’s] qualification and registration details… we were just

waiting…”, his email to Individual CC indicated otherwise.

Mr Harrison was the Responsible Individual for Winterbourne View at the material time,

and was the Regional Operations Director for nine Castlebeck Units. He had an

obligation to ensure that Winterbourne View fully complied with all appropriate statutory

requirements as regulated by the CQC; this encompassed the requirement to ensure

that the Hospital’s Manager was registered as such with the CQC. Registrant C, for

whom Mr Harrison was responsible, did not apply to register as Manager of

Winterbourne View until April 2011.

On the basis of the evidence before it, the panel was in no doubt that Mr Harrison failed

to discharge his duty as required. Accordingly, the panel found charge 1.5 proved.

1.6 Following a whistle blowing complaint from Individual O on 11 October 2010:

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1.6.1 Did not ensure that any or all identified staff were suspended;

1.6.2 Did not ensure that an investigation was promptly conducted;

1.6.3 Did not ensure that a Serious Untoward Incident Form was completed.

Charge 1.6.1 was admitted by Mr Harrison and found proved.

In respect of charges 1.6.2 and 1.6.3, the panel gave careful regard to the following

evidence:

Witness 3 explained that he sent his whistle-blowing email, in which he set out his

concerns in relation to Winterbourne View, to Registrant C on 11 October 2010. A

senior staff meeting was held a few days later, attended by Witness 3, Registrant C,

Registrant D and Individual F. Witness 3 said that Registrant C left the meeting early

and the concerns raised in Witness 3’s email were not discussed.

On 16 October 2010 Witness 3 forwarded a copy of his email to Registrant A,

highlighting that the issues raised in his email had not been addressed. Registrant A

replied to Witness 3, by email on 17 October 2010, stating that Mr Harrison, Regional

Operations Director, was aware of his concerns.

Registrant A responded to Witness 3’s email on the same day. She said that she was

aware of his concerns and was under the impression that Registrant C and Registrant D

had had a meeting with him the week before. She said that she would meet with him on

Monday 18 October when she was due to visit the Hospital. She also confirmed that Mr

Harrison was aware of his concerns and that she would advise Witness 3 as to Mr

Harrison’s input, if Witness 3 wanted him to ‘lead’.

Witness 3 responded to Registrant A on 17 October 2010. He said that he was not

aware that Registrant A was due to meet with him on 18 October; he confirmed that he

was not available to meet that day. He suggested meeting the following week. Witness

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3 did not hear anything further. He contacted the CQC on three occasions raising

concerns in relation to care practices at Winterbourne View but received no response.

He subsequently reported his concerns to BBC Panorama.

It was Witness 5’s evidence that the whistle-blowing concerns should have been

followed up with the whistle-blower, reported within the organisation, advice sought, and

promptly reported to the local authority safeguarding team and to the CQC.

The panel had sight of a document exhibited by Witness 7 in which she summarised a

telephone conversation with Mr Harrison on 16 May 2011; according to that summary,

Mr Harrison could not recall the final outcome of his meeting with the safeguarding team

and Witness 3. He went on to say “maybe not done it quite as we should have done”.

According to Witness 7’s note from the investigation meeting held with Mr Harrison on 3

August 2011, Mr Harrison confirmed that Registrant A emailed him a copy of Witness

3’s whistle-blowing email, which Mr Harrison picked up on the following Monday (18

October 2011). Mr Harrison, in his email response to Registrant A, suggested that the

matter be reported to the safeguarding team. Registrant C arranged discussions with

Individual DD in the safeguarding team. Mr Harrison chased Registrant C on 22

October, and was told that the matter had been escalated to Individual DD’s Manager.

Mr Harrison said, at the meeting, that as far as he was concerned, the safeguarding

process was instigated and was ongoing. In January 2011, Mr Harrison and Registrant

C met with the safeguarding team and the CQC to close off the matter. According to the

notes of the meeting, there was no suggestion to do anything else and the only

expectation was for Registrant C to start/complete an internal investigation.

Mr Harrison also confirmed, in the meeting, that he informed Individual CC of the

whistle-blowing complaint, and that it was discussed at Regional Operations meetings.

He was unable to provide an answer when asked why staff members were not

suspended. He said that he made an assumption that staff members would have been

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suspended. According to the notes of his disciplinary hearing on 7 March 2012, Mr

Harrison acknowledged that he should have been more involved in following through

with staff suspensions.

It was Witness 7’s view, in her investigation report into Mr Harrison, that there was a

“lack of urgency” on his part, as well as a “failure to grasp the seriousness of the

complaints which had been raised”.

In a letter from the Chief Executive Officer of Castlebeck to the Associate Director of

Strategic Commissioning and Safeguarding (Northumberland Care NHS Trust), dated

13 June 2011, it was reported that the whistle-blowing email was “received in October in

the week [Registrant A] was ceasing any involvement with Winterbourne View and other

services in the Midlands to move to Chesterholme and she was aware that the Hospital

Manager and Regional Operations Director were handling the whistleblower allegations

and had referred these onto adult safeguarding…” In a subsequent letter dated 13 July

2011, the Chief Executive Officer repeated that Registrant A had passed on the

responsibility (in relation to addressing Witness 3’s whistle-blowing email) to Mr

Harrison.

According to a document exhibited by Witness 15 entitled ‘Chronology of Significant

Events’, the requirement for a SUI was not identified until 4 May 2011. When this was

put to Mr Harrison in evidence, he replied “I couldn’t comment. As far as I was aware,

everything had been done… and I was regularly assured by [Registrant C] that this was

the case”.

It was apparent, from Mr Harrison’s oral evidence, that he was of the view that an

investigation was instigated by Registrant C; he said “[Registrant C] had been asked to

look into [Witness 3’s] concerns… HR were aware… and he followed the advice that

had been given”. He acknowledged however, in his oral evidence, that his meeting with

external agencies in relation to the whistle-blowing concerns “took too long”. According

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to Mr Harrison, the overall responsibility for taking control of such a situation lay with the

Managing Director (Individual CC) and the HR Director (Witness 7).

Mr Harrison was the Responsible Individual, and Regional Operations Director, for

Winterbourne View at the material time, and Registrant C reported to him. According to

Mr Harrison’s job description he had a “responsibility for the identification of all risks

which have a potential adverse affect on the Company’s ability to maintain quality of

care and the safety of patients… and for the taking of positive action to eliminate or

reduce these… [and] ensure that risk management is a key component of…

management including risk assessment and appropriate action plans”. On the basis of

the evidence before it, the panel reached the conclusion that Mr Harrison failed to

discharge this obligation.

It was evident that no prompt investigation was undertaken following Witness 3’s

whistle-blowing complaint in October 2010. There was nothing before the panel to

suggest that Mr Harrison had taken appropriate and proactive steps to supervise and

monitor Registrant C in addressing the concerns. Rather, he appeared to suggest that

there was little more required of him in the circumstances, having reported the concerns

to Individual CC and Witness 7. He said that it would have been for the appointed HR

representative to have met with Witness 3 and to have kept him updated as to the

progress of any investigation. As far as Mr Harrison was concerned, “I passed it on to

my Managing Director, who was the Responsible Individual”. Mr Harrison agreed to

meet with Witness 3 after he was notified of the whistle-blowing concerns. Mr Harrison

was aware that Registrant A’s responsibility for Winterbourne View had ceased by this

point. He was also of the view that Registrant C, who was directly accountable to Mr

Harrison, was taking some action in addressing Witness 3’s concerns. It was therefore

unclear to the panel as to why he had assumed that he had no further role to play in

these matters. In the panel’s view, Mr Harrison’s oral evidence was indicative of a

disregard for his personal accountability in the circumstances. The panel was in no

doubt that Mr Harrison failed to provide the appropriate level of guidance, direction and

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supervision to Registrant C in the circumstances, and failed to ensure that the Whistle-

blowing Policy was being complied with.

For all the reasons set out above, the panel found charge 1.6.2 and 1.6.3 proved.

1.7 Did not ensure that one or more patients who were admitted to the Hospital

were suitable for admission;

It was Witness 13’s evidence that the responsibility for admitting patients at the time

was with the Manager of the service and their Line Manager, the Regional Operations

Director.

According to Witness 13, Mr Harrison admitted during the appeal hearing that service

users had been inappropriately admitted to the services he was responsible for as

Regional Operations Director. Mr Harrison said that he had raised concerns about the

admission of patients with his Line Manager, but he said that he was “under pressure”

from the Board to admit patients for “financial reasons”. Witness 13 said that Mr

Harrison was a very senior Board level employee of Castlebeck and she was concerned

that a person of his seniority had not acted as a whistle-blower, when he had concerns

about the service that would have a significant impact on patient care.

According to the notes of the investigation meeting held with Registrant A on 17 August

2011, Registrant A stated that she would put blocks on admissions, which was backed

by Mr Harrison. She also said that her strongest advice to Registrant C was to be “very

very aware” of admissions and the pressures put on him by the relevant team.

At Mr Harrison’s appeal hearing on 17 May 2012, Mr Harrison said that he had asked

for “no more admission until staff were sorted”. He said that this “often was ok but

sometimes [he was] asked to take admissions”.

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In his oral evidence to the panel Mr Harrison suggested that he had “very little input on

who was admitted” to the Hospital, other than being involved in discussions with the

referral team and Registrant C. He said that the assessment procedure involved senior

management who “decided which admission was appropriate”. He said that he assisted

Registrant C, if they felt under pressure from senior management; he said that “we had

weekly conference calls about admissions… [the referral team], [Witness 7], [Individual

CC], the Unit Managers… also, we had been instructed to staff at minimum levels…

there were many discussions about the appropriateness of admission…” He went on to

say that if issues became apparent only after admission, there was not much that could

be done as the patient was already in the Hospital.

Mr Harrison said that there was “immense pressure to fill beds… unless we could give a

very good reason not to admit a [patient]”. He confirmed that he had raised his concerns

about admissions with his Line Manager. He also said that “there were no deliberate

admissions that were not considered appropriate”.

The panel had regard to Mr Harrison’s job description which made plain that he was

required to “work towards ensuring that every appropriate action is taken to ensure

occupancy targets are met and where possible maximum occupancy is obtained”. The

panel heard evidence that Winterbourne View operated as a profit-making company and

that the mechanism by which patients were admitted was financially driven. The panel

accepted that there was considerable pressure placed upon Units to admit patients in

order to secure maximum occupancy. However, Mr Harrison was also responsible “for

the identification of all risks which have a potential adverse affect on the Company’s

ability to maintain quality of care and the safety of patients… and for the taking of

positive action to eliminate or reduce these…” He was aware of the ongoing issues in

relation to staffing at Winterbourne View. He was aware of the patients’ high levels of

needs and challenging behaviour. He was aware of the ongoing concerns in relation to

the adequacy of the training provided to staff to ensure the safe provision of care. He

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was also aware that the level of supervision of staff at the Hospital was “not always”

adequate. The panel was in no doubt that he was in a position to take appropriate

action in ensuring that only those patients suitable for admission were admitted; there

was no evidence that he did so.

Accordingly, the panel found charge 1.7 proved.

1.8 Did not ensure that staff at Winterbourne View received sufficient training to

provide appropriate care


1.9 Did not ensure that all staff at Winterbourne View received adequate

supervision and/or supervision records


1.10 Did not ensure that there were adequate systems in place for the analysis

and/or review of patient incidents at Winterbourne View


1.11 Did not ensure that there were adequate systems in place to prevent excessive

use of restraint


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1.12 Did not ensure that patients at Winterbourne View were protected from verbal

and physical abuse by members of staff;


2 In relation to Rose Villa:

2.1 Did not ensure that Rose Villa was compliant with any or all of the Health and

Social Care Act 2008 essential standards listed in Schedule C


3 In relation to Croxton Lodge:

3.1 Did not ensure that Croxton Lodge was compliant with any or all of the Health

and Social Care Act 2008 essential standards listed in Schedule D


4 In relation to Arden Vale:

4.1 Did not ensure that Arden Vale met any or all of the national minimum

standards for independent healthcare, under the Care Standards Act 2000, for

independent healthcare listed in Schedule E

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4.2 Did not ensure that Arden Vale was compliant with any or all of the Health and

Social Care Act 2008 essential standards listed in Schedule F


5 In relation to Cedar Vale

5.1 Did not ensure that Cedar Vale met any or all of the national minimum


listed in Schedule G


5.2 Did not ensure that Cedar Vale was compliant with any or all of the Health and

Social Care Act 2008 essential standards listed in Schedule H


6 In relation to Willow House

6.1 Did not ensure that Willow House was compliant with any or all of the Health

and Social Care Act 2008 essential standards listed in Schedule I


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7 In relation to The East Midlands Centre for Neurobehavioural Rehabilitation

7.1 Did not ensure that The East Midlands Centre for Neurobehavioural

Rehabilitation was compliant with any or all of the Health and Social Care Act

2008 essential standards listed in Schedule J


Determination on interim order (upon adjourning) – Thursday 8 June 2017

No application was made by the NMC for the imposition of an interim order. Attempts

were made to contact Mr Harrison for his representations. These attempts were

unsuccessful.

In accordance with Article 31(2) of the Nursing and Midwifery Order (2001) and Rule

32(5) of the Rules, the panel considered whether an interim order should be imposed.

Article 31 of the Order outlines the criteria for the imposition of an interim order. The

panel may make an interim order on one or more of three grounds:

Where it is satisfied that it is necessary for the protection of members of the

public;

Where it is satisfied that such an order is otherwise in the public interest;

Where it is satisfied that such an order is in the interests of the registrant.

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The panel, having carefully considered the matter and having accepted the advice of

the legal assessor, was not satisfied that any of the three grounds were met. Therefore

no interim order will be placed on Mr Harrison’s registration.

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The hearing resumed on 3, 4 and the morning of 5 July 2017 ‘in camera’, and from the

afternoon of 5 July 2017 in public session.

Determination on misconduct and impairment – Wednesday 5 July 2017

Mr Harrison’s evidence

The panel heard evidence from Mr Harrison, by telephone, at this stage of the

proceedings.

Mr Harrison told the panel that he accepted its findings of fact. He said that they had

been “well-established”.

Mr Harrison told the panel that he was “put in charge of a very very large and well-

scattered area to support… it meant an awful lot of time spent moving to and from

different Units”, which meant that he was unable to dedicate sufficient time in each Unit

as he would have liked and which would have “made a difference”. He said “there was

nothing I could do about that, that was how the territory was divided between us

Regional Operations Directors”.

Mr Harrison told the panel that the primary lesson he had learned, as a result of the

failings identified at Winterbourne View, was “to say no to people when they’re putting

on extra pressure to take work on, and explain why I can’t do it… and be able to, and

have the courage to, say no to my employer”. He said that he was not able to offer the

support that was required, as he was “too thinly spread” and, as a result, “ultimately

everyone within the organisation suffer[ed] to a degree”.

Mr Harrison said that he had learned “to be more thorough in checking if things are

done… and not just accepting that they are done… that was the biggest thing for me…

[and] when my superior began to break up the team that was put in place, to be more

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robust in my challenges and make sure the support stays where it’s required, and

evidently where it was required”. He went on to say that he had learned “having the

courage to say no when people are asking unreasonable things of you… and

developing arguments for that… [and] when concerns are raised, to act upon them and

follow them through fully”.

Mr Harrison told the panel that he had not worked in a care environment since 2012, as

he was told by the NMC that he was not able to renew his nursing registration until the

conclusion of these proceedings.

In respect of his current employment status, Mr Harrison explained that he was privately

contracted to provide training to assist people in gaining their Level 4 Management

qualification. He said that, in his current role, he managed a team of approximately six

people. He primarily worked in one location, which enabled his team to “bring their

concerns to me and expect me to advise and support them… which I have to do a lot

more robustly… I go through processes with them and… rather than relying on others, I

follow through personally and made sure outcomes are achieved”. He told the panel

that working from one office made it easier to facilitate two-way communication.

As to remorse, Mr Harrison told the panel that “it’s difficult to put into words... it has had

a profound effect on me and my outlook towards things… [as to those most affected by

events at Winterbourne View] the people who suffered the horrible abuse… [and] its

wider than that… there were other members of the team who were put through

unnecessary trauma because of this… if [Winterbourne View] was managed better, it

could have been avoided”.

When asked to comment on the proactive steps he could have taken in the

circumstances, Mr Harrison said that he could have spent time within the Unit and

offered more direct support; that said, he stated that it was “difficult to give the support

that was obviously required… can’t do much remotely… reliance on reports and emails

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wasn’t enough. Really, the biggest support would be to ensure that there was sufficient

and experienced support available to a rapidly developing area… and being in a

position to put in a stronger case for that support to my superiors”.

Mr Harrison told the panel that there were instances of Root Cause Analyses “occurring

very robustly… we had investigated some incidents that resulted in dismissals…” In

relation to staff supervision, he said “I knew it wasn’t 100% up to date, but I knew there

had been huge improvements in the regularity of sessions…” In relation to those

charges concerning a failure to meet CQC standards, he said that he was “surprised…

how wide the issues had been… previous CQC reports were fine or only minor issues

identified. So, the change was quite surprising”.

Mr Harrison said that he was aware of one particular patient admission, referred to by

Witness 31 in his oral evidence to the panel on behalf of Registrant D, who was of

particular concern and who, in Witness 31’s view, contributed to an increase in patient

incidents. Mr Harrison said “we tried to ensure that we got the appropriate staffing levels

to manage and support the patients. That didn’t always happen. We took on the

admission expecting what we were told to expect, and it was quite different when the

patient arrived”. He said that issues in relation to patient admissions were reported

monthly in management reports, and discussed in weekly conference calls

When asked if he was aware of an increase in the number of restraints used on patients

at Winterbourne View, Mr Harrison replied, “not as an individual issue… some of the

patients were a lot more demanding [and] the demands on staff were increasing

proportionately”.

Mr Harrison said that he did have concerns about Registrant C’s performance as a

Manager “but those were concerns that could have been sorted with support… like

when my superiors decided to take [Registrant A] out of the area and [Registrant C did

not receive] the support that he needed”.

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Mr Harrison said that he accepted that “all the charges are serious, there’s no hiding

from that at all. Serious enough for an investigatory meeting, for this process to be gone

through, and rightly so. I don’t deny that”. He acknowledged that “public trust in the

profession is damaged because of the nature of what had happened… [that’s]

unavoidable”. In regard to public perception of him personally, he replied “loss of trust…

and anger in public opinion about what happened at Winterbourne View”.

Mr Harrison told the panel that he was unsure as to whether he would return to the

nursing profession. He did, however, make efforts to keep his nursing knowledge up to

date since 2012, by reading journals and keeping abreast of nursing news. He said that

he had undertaken relevant training in his current role which were, to a degree,

applicable to the nursing profession, including safeguarding, equality and diversity, first

aid and moving and handling.

In addition to his oral evidence, the panel was also provided with a letter written by Mr

Harrison which had been attached to his ‘Standard Directions Form’ dated October

2014. In that letter, amongst other things, Mr Harrison had written, “I accept fully that it

was my responsibility as part of the overall care team to ensure that he [sic] the people

within our care received the best possible care and I believe that I worked hard as part

of a team to achieve this in very difficult circumstances… I have been a Nurse now for

over 20 years and my record has been exemplary. I have never been subject to any

kind of investigation prior to this one… I asked for my appraisal and supervision records

to support this but they were never sent to me”.

Submissions

The panel then invited submissions on the matters of misconduct and current

impairment.

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As to misconduct, Mr Unwin referred the panel to the case of Roylance v General

Medical Council [2000] 1 A.C. 311, in particular to the judgment of Lord Clyde who

described misconduct as “a word of general effect, involving some act or omission

which falls short of what would be proper in the circumstances. The standard of

propriety may often be found by reference to the rules and standards ordinarily required

to be followed by a medical practitioner … [the] misconduct must be serious.”

Mr Unwin submitted that the case of Roylance was of some assistance in relation to

practitioners with management or administrative roles: “[Roylance] was both a

registered medical practitioner and chief executive of a hospital. In each capacity he

had a duty to care for the safety and well-being of the patients. As chief executive that

duty arose out of his holding of that appointment. As a registered medical practitioner he

had the general obligation to care for the sick. That duty did not disappear when he took

on the appointment but continued to co-exist with it.”

Mr Unwin also referred the panel to the case of Calhaem v General Medical Council

[2007] EWHC 2606 (Admin), in which Jackson J derived the following relevant

principles from a review of the authorities:

“(1) Mere negligence does not constitute ‘misconduct’ … Nevertheless, and depending

upon the circumstances, negligent acts or omissions which are particularly serious may

amount to “misconduct”.

(2) A single negligent act or omission is less likely to cross the threshold of ‘misconduct’

than multiple acts or omissions. Nevertheless, and depending upon the circumstances,

a single negligent act or omission, if particularly grave, could be characterised as

‘misconduct’”.

Furthermore, Mr Unwin referred the panel to the case of R (on the application of

Remedy UK Ltd) v General Medical Council [2010] EWHC 1245 (Admin), in which Elias

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LJ derived the following principles from Roylance and other authorities: “[Misconduct]

need not arise in the context of a doctor exercising his clinical practice…” but can be in

“the exercise of administrative or managerial functions, where they are part of the day to

day practice of a professional doctor. These functions include the matters identified in

Sadler, such as proper record-keeping, adequate patient communication, proper

courtesy shown to patients and so forth… the obligation to take responsibility for the

care of patients does not cease simply because a doctor is exercising managerial or

administrative functions one step removed from direct patient care. Depending upon the

nature of the duties being exercised, a continuing obligation to focus on patient care

may co-exist with a range of distinct administrative duties, even where other doctors

with a different specialty have primary responsibility for the patients concerned.”

Mr Unwin invited the panel to have regard to the NMC’s publications, ‘The NMC code of

professional conduct: standards for conduct, performance and ethics’ (November 2004)

(“the 2004 Code”) and ‘The code: Standards of conduct, performance and ethics for

nurses and midwives’ (May 2008) (“the 2008 Code”). He submitted that the Codes were

an important reference for assessing whether the facts found proved amounted to a

falling short of the standards expected of a Registered Nurse. He submitted that not

every breach of the relevant Code amounted to misconduct; the breach must be

sufficiently serious. He further submitted that a series of incidents not individually

serious enough to constitute misconduct may be considered cumulatively to be

sufficiently serious.

Mr Unwin submitted that in assessing the seriousness of the failings found proved, the

panel should have regard to its findings about what, if any, steps were taken by each

registrant, as well as its findings about the context of systemic corporate failings, and

what could reasonably be known by the registrants at the time, without the benefit of

hindsight.

Mr Unwin referred the panel to the following provisions of the Codes:

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Arden Vale: (the 2004 Code)

Charge 4.1

As a registered nurse … you are personally accountable for your practice. In caring for

patients and clients, you must:

act to identify and minimise risk to patients and clients.

Paragraphs 1.3, 1.4, 4.6, 8.1 and 8.3

Winterbourne View, Rose Villa, Croxton Lodge, Cedar Vale, Willow House and The

East Midlands Centre for Neurobehavioural Rehabilitation: the 2008 Code

Charges 1.1, 1.2, 2.1 and 4.2

The people in your care must be able to trust you with their health and wellbeing

To justify that trust, you must:

make the care of people your first concern, treating them as individuals and

respecting their dignity

work with others to protect and promote the health and wellbeing of those in your

care, their families and carers, and the wider community

provide a high standard of practice and care at all times

Paragraphs 4, 12, 15, 16, 22, 30, 31, 33, 34, 35 and 61

Charge 1.4

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Mr Unwin submitted that in light of the panel’s finding in respect of the corresponding

charge against Registrant A (charge 2.4), the panel was invited to disregard its finding

in respect of charge 1.4 for the purpose of this stage of the hearing.

Charge 1.5

Paragraphs 30 and 33

Charge 1.6 in its entirety

Paragraphs 22, 32, 54 and 61

Charge 1.7





Paragraphs 32, 33 and 34

Charge 1.8 and 1.9

Paragraphs 23, 29 and 31

Charge 1.10




Paragraph 22

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Charges 1.11 and 1.12







Paragraphs 16, 34, 35, 54 and 61

Charges 3.1, 5.1, 5.2, 6.1 and 7.1




Paragraphs 22, 30, 33 and 35

As to the matter of impairment, Mr Unwin submitted that this was not limited to the

question of whether a registrant presented a risk to the health, safety and/or welfare of

the public, but also encompassed a careful consideration of the public interest.

Mr Unwin referred the panel to the case of Council for Healthcare Regulatory

Excellence v (1) Nursing and Midwifery Council (2) Grant [2011] EWHC 927 (Admin), in

particular paragraphs 70, 71, 74, 75 and 76 of the judgment. He also referred to the

questions outlined by Dame Janet Smith in her 5th report on Shipman (as endorsed in

the case of Grant):

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“Do our findings of fact in respect of the [registrant’s] misconduct […] show that [his]

fitness to practise is impaired in the sense that [he]:

a. has in the past acted and/or is liable in the future to act so as to put a patient or

patients at unwarranted risk of harm; and/or

b. has in the past brought and/or is liable in the future to bring the [nursing]

profession into disrepute; and/or

c. has in the past breached and/or is liable in the future to breach one of the

fundamental tenets of the [nursing] profession; and/or

d. has in the past acted dishonestly and/or is liable to act dishonestly in the future.”

Mr Unwin reminded the panel that Mr Harrison had admitted that his fitness to practise

is impaired by reason of his misconduct. Nevertheless, Mr Unwin acknowledged that

impairment was a matter for the panel’s assessment and judgement.

Mr Unwin submitted that the panel had found, largely on the basis of Mr Harrison’s own

admissions, that Mr Harrison had failed to ensure that several Units within his

responsibility were compliant with essential regulatory standards. Mr Unwin contended

that Mr Harrison’s numerous failings at Winterbourne View, Rose Villa, and Arden Vale

were especially serious, including practices of inappropriate restraint, and at

Winterbourne View, abuse of extremely vulnerable patients. Mr Unwin reminded the

panel of Mr Harrison’s admission that, as Regional Operations Director, he did not

ensure that patients were protected from abuse. In those circumstances, Mr Unwin

submitted that Mr Harrison had acted in a way so as to put patients at unwarranted risk

of harm, brought the profession into disrepute and breached a fundamental tenet of the

nursing profession.

Mr Unwin invited the panel to give careful consideration to Mr Harrison’s evidence

during the course of these proceedings; Mr Harrison told the panel that he was unable

to spend sufficient time at Winterbourne View because of the large number of Units he

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was required to cover over a wide geographic area. Mr Unwin referred the panel to the

evidence of Witness 13 and Witness 16, who spoke of the proactive steps they would

have expected Mr Harrison to take in identifying issues, performance managing the Unit

managers and escalating concerns. They also spoke of Mr Harrison’s failure to act

appropriately when serious whistleblowing concerns were brought to his attention.

It was Mr Harrison’s evidence that he had reflected upon the importance of being more

robust in ‘pushing back’ when an employer were to put him in a position where he could

not provide the necessary support to others in the organisation. In light of this evidence,

Mr Unwin submitted that the panel may be concerned about the degree of Mr Harrison’s

insight into his specific failings and the relatively vague and general nature of his

reflection.

Panel’s decision

In reaching its decision, the panel had regard to all the evidence before it, and the

submissions made by Mr Unwin.

The panel accepted the advice of the legal assessor, who referred the panel to the

cases cited by the advocates and, additionally, to the case of Schodlok v General

Medical Council [2015] EWCA Civ 769. In that case, Lord Justice Vos criticised the

panel’s decision to take into account the proven incidents of non-serious misconduct in

determining that the doctor’s fitness to practise was impaired. He said that he was not of

the view that a few allegations of misconduct, which were held individually not to be

serious, could or should be regarded collectively as serious misconduct. However, the

legal assessor commended the remarks of Lord Justice Beatson, who commented that

a cumulative approach to the consideration of misconduct should in principle be open to

the panel, provided that this approach was made clear to the practitioner and that he or

she was aware that this was a possibility. He said that where there were a large number

of findings of non-serious misconduct, particularly where they were of the same or

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similar misconduct, it should in principle be open for a fitness to practise panel to find

that, cumulatively, they were to be regarded as serious misconduct capable of impairing

a practitioner’s fitness to practise.

The legal assessor also referred to the case of Johnson and Maggs v NMC [2013]

EWHC 2140 (Admin), which addressed the danger of judging conduct with the benefit of

hindsight.

The panel was advised that, in relation to impairment by reason of misconduct, it must

engage in a two stage process: it must first consider whether, on the facts found proved,

Mr Harrison’s failures and omissions amounted to misconduct; and second, if so,

whether his fitness to practise is currently impaired by reason of that misconduct.

The panel, in reaching its decision, accepted that there was no burden or standard of

proof at this stage and exercised its own professional judgement.

The panel was aware that not every instance of falling short from what would be proper

in the circumstances, and not every breach of the Code, would be sufficiently serious to

be described as misconduct, going to a registrant’s fitness to practise. Accordingly, the

panel had careful regard to the context and circumstances of the matters found proved.

With regard to the prevailing circumstances prominent in this case, the panel

considered the following:

The complex needs, challenging behaviours and vulnerabilities of the patient

group at Winterbourne View.

Mr Harrison joined Castlebeck in 1991, initially as a Staff Nurse. He was

promoted to Senior Staff Nurse, Charge Nurse, Deputy Manager, Manager,

Senior Manager, Area Manager, Regional Operations Manager and Regional

Operations Director. He therefore had significant knowledge and experience of

Castlebeck’s working practices.

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Mr Harrison had an overarching responsibility for all patients across all the Units

within his region. He was the designated CQC Responsible Individual of Arden

Vale, Winterbourne View, Croxton Lodge and Cedar Vale and, as a result, had

specific regulatory responsibilities and accountabilities over and above those in

his capacity as Regional Operations Director.

Mr Harrison’s higher degree of accountability and responsibility in light of his

seniority. He was the most senior member of staff with direct responsibility for the

nine Units, with responsibility to supervise, guide, support and manage

operational practices at a senior level, and ensure compliance with regulatory

essential standards.

Mr Harrison had direct access to the Castlebeck Board and had numerous

opportunities to effect positive change, particularly with regard to Winterbourne

View.

Mr Harrison’s direct line management of Registrant C was extremely limited and,

overall, insufficient, particularly in the context of Registrant A’s support being

withdrawn.

Mr Harrison had numerous opportunities to investigate areas of concerns and

apparent discrepancies; for example, there was only one entry (dated 24 March

2010) in the Winterbourne View Complaints record log after 2009. This obvious

anomaly ought to have caused Mr Harrison, at the very least, to question

Registrant C.

In the exercise of his responsibilities, Mr Harrison appeared primarily to rely on

verbal feedback from his staff and placed a significant degree of trust in those

staff members to ‘get on with their job’.

Mr Harrison was in receipt of the monthly management reports completed by Unit

Managers in relation to areas of concerns in the Units including staffing, training,

risk management and supervision. There was limited evidence before the panel

that Mr Harrison formally escalated concerns raised to the Castlebeck Board.

A number of charges concerned documentation which was not available to the

CQC Compliance Inspectors during their visits of Winterbourne View in May

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2011. Some relevant documentation was later identified following the closure of

Winterbourne View, as evidenced in the material considered for the purpose of

the Serious Case Review. The documentation before the panel at this

substantive hearing was not likely, therefore, to have formed an accurate,

complete or global picture of Winterbourne View.

Charge 4.1

The Healthcare Commission inspection of Arden Vale took place on 18 October 2007.

Of the national minimum standards inspected, under the Care Standards Act 2000, only

two standards were ‘not met’. Nine standards were ‘almost met’ and five standards were

‘met’.

The panel was mindful of the evidence of Registrant A, Manager of Arden Vale at the

time. Registrant A told the panel that the outcome of the inspection “confirmed” what

she already knew, and that she was not given the opportunity to embed any significant

changes as she was constantly moved from one Unit to the next.

The panel was further mindful that it was not provided with any documentary evidence

in the form of previous Healthcare Commission/CQC reports against which it could

consider a comparison or assess what improvements, if any, had been made in the

Unit.

Having regard to the totality of the findings of the inspection carried out on 18 October

2007, in the context of the prevailing circumstances in Registrant A’s and Mr Harrison’s

case, the panel concluded that Mr Harrison’s failures were not sufficiently serious to

amount to misconduct.

Charges 1.1, 1.2, 2.1 and 4.2

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With regard to charge 1.1, the panel took account of the following:

Of the standards inspected, following the Healthcare Commission inspection of

Winterbourne View on 24 March 2009, six standards were ‘not met’ and two standards

were ‘met’.

Of the standards inspected, following the CQC inspection on 15 December 2009,

five standards were ‘almost met’ and 12 standards were ‘met’. There were no standards

inspected which were ‘not met’.

There was, evidently, a pattern of improvement. The panel also considered the

testimonies of both Registrant A and Mr Harrison who spoke of positive CQC

inspections which were not put before the panel. Having regard to the evidence before

it, the panel concluded that Mr Harrison’s failures were not sufficiently serious to amount

to misconduct.

With regard to charge 1.2, the panel took into account the following:

All 10 standards inspected, following the CQC inspection of Winterbourne View in

May/June 2011, were identified as ‘major concerns’.

Mr Harrison was the Responsible Individual for Winterbourne View. In that capacity, he

was responsible for ensuring the quality of the service provided by the Unit. As Regional

Operations Director, he was responsible for ensuring that all Units fully complied with all

appropriate statutory standards and requirements as regulated by the CQC.

Mr Harrison was acutely aware of the support that Registrant C required in the

operational management of the Unit. There was little evidence before the panel of any

steps taken by him to address the specific and identified deficiencies in the service

provided by Winterbourne View. The panel carefully considered the findings of this

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inspection against the findings in 2009; the deterioration in the quality of the service

provided was stark. As Regional Operations Director and Responsible Individual, Mr

Harrison was ultimately responsible and accountable for that deterioration.

The panel determined that Mr Harrison’s failures exposed patients to an unwarranted

risk of harm, particularly when considering that the standards inspected in May/June

2011 related to fundamental and essential nursing care, including ‘safeguarding people

who use services from abuse’, ‘care and welfare of people who use services’,

‘management of medicines’ and ‘records’.


Of the standards inspected, following the CQC inspection of Rose Villa in June and July

2011, three standards were identified as ‘major concerns’, two standards as ‘moderate

concerns’ and two standards as ‘minor concerns’.

The panel was mindful that it was not provided with any documentary evidence in the

form of previous Healthcare Commission/CQC reports against which it could consider a

comparison or assess what improvements, if any, had been made in the Unit.

On the basis of the limited evidence before it, the panel was not of the view that it could

safely conclude a finding of misconduct.


Mr Harrison was the Responsible Individual for Arden Vale from 2007. In that capacity,

he was responsible for ensuring the quality of the service provided by the Unit. As

Regional Operations Director, he was responsible for ensuring that all Units fully

complied with all appropriate statutory standards and requirements as regulated by the

CQC.

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The panel carefully considered the findings of the inspection in June 2011 against the

findings in October 2007; the deterioration in the quality of the service provided was

stark. There was an evident deterioration in the Unit’s compliance with essential

standards following the inspection in October 2007, to the extent that 11 standards were

identified as ‘major concerns’ and one standard as ‘moderate concerns’. As Regional

Operations Director and Responsible Individual, Mr Harrison was ultimately responsible

and accountable for that deterioration. Of concern to the panel was, according to the

notes of his disciplinary hearing on 7 March 2012, Mr Harrison’s apparent lack of

awareness of any issues in Arden Vale. This was, in the panel’s view, inexcusable and

unjustifiable, given his role and responsibilities at the time.

The panel determined that Mr Harrison’s failures exposed patients to an unwarranted

risk of harm, particularly when considering that the standards inspected in May/June

2011 related to fundamental and essential nursing care, including ‘safeguarding people

who use services from abuse’, ‘care and welfare of people who use services’,

‘management of medicines’ and ‘records’.

The panel determined that Mr Harrison’s failures in respect of charges 1.2 and 4.2 were

sufficiently serious as to amount to misconduct. The panel further determined that his

failures were in breach of the following provisions of the Code:







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4 You must act as an advocate for those in your care, helping them to access relevant

health and social care, information and support.

12 You must share with people, in a way they can understand, the information they

want or need to know about their health.

15 You must uphold people’s rights to be fully involved in decisions about their care.

16 You must be aware of the legislation regarding mental capacity, ensuring that people

who lack capacity remain at the centre of decision making and are fully safeguarded.

22 You must work with colleagues to […] maintain the safety of those in your care.

30 You must confirm that the outcome of any delegated task meets required standards.

31 You must make sure that everyone you are responsible for is supervised and

supported.

33 You must inform someone in authority if you experience problems that prevent you

working within this code or other nationally agreed standards.

34 You must report your concerns in writing if problems in the environment of care are

putting people at risk.

35 You must deliver care based on the best available evidence or best practice.

61 You must uphold the reputation of your profession at all times.

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The panel was not minded to consider that the other instances (charges 1.1 and 2.1)

should be accumulated to find a further allegation of misconduct against Mr Harrison, as

the panel could not safely conclude on the evidence that there was any degree of

misconduct in respect of these charges on the part of Mr Harrison.

Charge 1.4

The panel took into account that the corresponding charge against Registrant A was

found, on the evidence before it, not proved. Notwithstanding Mr Harrison’s admission,

it cannot be said that there was a failure on his part and, therefore, no misconduct

arises.

Charge 1.5

Mr Harrison was the Regional Operations Director and Responsible Individual for

Winterbourne View at the material time. He had an obligation to ensure that

Winterbourne View fully complied with all appropriate statutory requirements as

regulated by the CQC; this encompassed the requirement to ensure that the Hospital’s

Manager was registered as such with the CQC. Registrant C, for whom Mr Harrison had

direct line management responsibility, did not apply to register as Manager of

Winterbourne View until April 2011.

Whilst Registrant A took steps to assist and prompt Registrant C to register with the

CQC as Registered Manager, it was Mr Harrison’s responsibility to ensure that this had

happened. As a result of Registrant C’s failure to register with the CQC, the lines of

management accountability were blurred by the time the BBC Panorama documentary

was aired. This had serious implications for Registrant A, who was still formally

registered with the CQC as Registered Manager.

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The panel determined that Mr Harrison’s failure to discharge his obligation as required

was sufficiently serious as to amount to misconduct. The panel further determined that

his failures were in breach of the following provisions of the Code:




Charge 1.6 in its entirety

Mr Harrison was aware of the whistle-blowing complaint raised by Witness 3. Whilst he

‘suggested’ to Registrant A that the matter be reported to the safeguarding team, and

having chased Registrant C on 22 October, he took few proactive steps to address what

were serious safeguarding allegations. Despite his overarching responsibility for

Winterbourne View, he was unable to explain why staff members were not suspended

or why a SUI was not reported until 4 May 2011, some seven months later. He said that

he made an assumption that staff members would have been suspended. It was

Witness 7’s evidence, the sentiment of which was echoed by the panel, that there was a

lack of urgency on Mr Harrison’s part, and a failure to grasp the seriousness of the

complaints which had been raised.

Whilst he acknowledged that his meeting with external agencies in relation to the

whistle-blowing concerns “took too long”, Mr Harrison sought to place blame on others.

According to Mr Harrison, the overall responsibility for taking control of this situation lay

with the Managing Director (Individual CC) and the HR Director (Witness 7).

Mr Harrison was the Responsible Individual, and Regional Operations Director, for

Winterbourne View at the material time, and Registrant C reported to him. He was

responsible for identifying all risks which had the potential to undermine the quality of

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care and the safety of patients and taking action to address and manage those risks. Mr

Harrison failed to discharge this obligation.

Mr Harrison was aware of the need to supervise and monitor Registrant C in the

circumstances. He was aware that Registrant A’s responsibility for Winterbourne View

had ceased by this point. In the panel’s view, Mr Harrison displayed a disregard for his

personal accountability in the circumstances. He failed to provide the appropriate level

of guidance, direction and supervision to Registrant C and failed to ensure that the

Whistle-blowing Policy was being complied with.

The panel was in no doubt, given the substance and severity of the concerns raised by

Witness 3, that Mr Harrison’s failures were significant and placed the patients at

Winterbourne View at serious and unwarranted risk of harm. The panel determined that

Mr Harrison’s failures were sufficiently serious as to amount to misconduct. The panel

further determined that his failures were in breach of the following provisions of the

Code:




supported.

32 You must act without delay if you believe that you, a colleague or anyone else may

be putting someone at risk.



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54 You must act immediately to put matters right if someone in your care has suffered

harm for any reason.


Charge 1.7

Despite Mr Harrison’s suggestion that he had “very little input on who was admitted” to

the Hospital, the panel was not so persuaded. Whilst the panel recognised and

acknowledged the pressure placed upon Units to admit patients in order to secure

maximum occupancy, Mr Harrison was in a position of considerable seniority and had

direct access to the Castlebeck Board. He was therefore in an influential position to

effect positive change and, ultimately, to ensure the safety of all patients, new and

existing, and staff members at the Hospital. He was aware of the patients’ high levels of

need and challenging behaviours. He was aware of the ongoing concerns in relation to

the adequacy of the training provided to staff to ensure the safe provision of care. He

was aware that the level of supervision of staff at the Hospital was “not always”

adequate. He was also aware of the concerns raised by Individual K and Witness 3, and

the increase in patient incidents and use of restraint following the admission of one

particular patient in December 2010.

It was incumbent upon Mr Harrison to ensure that the Hospital was able to meet the

needs of the patients sought to be admitted. He ought to have analysed the potential

adverse impact of unsuitable admissions on other patients in the Hospital as well on

staffing levels, and on staff members in general. His failure to discharge his

responsibilities in the circumstances would have had a direct impact on the safety of

newly admitted patients, existing patients and staff members, staffing numbers, and the

ability of staff members to provide the level of safe and effective care required.

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As a result of his significant failure, Mr Harrison placed patients and staff at serious and

unwarranted risk of harm. The panel determined that his failure was sufficiently serious

as to amount to misconduct. The panel further determined that his failure was in breach

of the following provisions of the Code:







supported.








Charges 1.8 and 1.9

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Training and supervision of staff are, individually and jointly, fundamental and critical to

the provision of safe, appropriate and effective care.

In light of the complexities and vulnerabilities of the patients at Winterbourne View, it

was crucial that staff members received the training required to provide proper and

appropriate care to patients. It was also crucial that staff members were supervised and

supported in their roles; effective supervision is, undoubtedly, key to the development of

good nursing skills and knowledge, reflective practice, confidence, competence and

morale.

Mr Harrison was the Responsible Individual for Winterbourne View. In that capacity, he

was responsible for ensuring the quality of the service provided by the Unit. As Regional

Operations Director, he was responsible for ensuring that all Units fully complied with all

appropriate statutory standards and requirements as regulated by the CQC. Moreover,

he was part of the corporate group established specifically in relation to training, of

which Witness 7, as HR Director, was also a member.

There was no evidence before the panel that the steps taken by Mr Harrison with regard

to training and supervision were sufficiently vigorous or reasonable. In light of his

responsibilities, and the direct access he had to the Castlebeck Board which placed him

in an advantageous and influential position to effect positive change, the panel found Mr

Harrison’s failures to be significant and had an impact on the overall quality of care

offered to, and received by, the patients at Winterbourne View. Additionally, Mr

Harrison, as the Responsible Individual for Winterbourne View, could and should have

raised any concerns that were not being addressed by the Castlebeck Board with the

CQC. The panel also had in mind Mr Harrison’s own failure to provide adequate

supervision to Registrant C to ensure that he was carrying out his role as Manager of

Winterbourne View to the standard required.

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The panel was satisfied that its findings in respect of the corresponding charges faced

by Registrant A can be distinguished by the identified actions taken by her in her

respective role as against Mr Harrison’s inaction/inadequacy of his actions and,

fundamentally, his overarching responsibility as Regional Operations Director and

Responsible Individual.

The panel determined that Mr Harrison’s failures were sufficiently serious as to amount

to misconduct. The panel further determined that his failures were in breach of the

following provisions of the Code:

23 You must facilitate students and others to develop their competence.

29 You must establish that anyone you delegate to is able to carry out your instructions.


supported.

Charge 1.10

As an experienced Manager of considerable seniority and authority, and in light of his

overarching responsibilities as Regional Operations Director and Responsible

Individual, Mr Harrison had a corporate responsibility to identify incidents at

Winterbourne View and ensure that such incidents were appropriately and adequately

analysed/reviewed. MDTs were, at the time, the prime mechanism used for reviewing

and analysing patient incidents. There was no evidence before the panel to suggest that

MDTs had been used effectively in this regard.

The panel took account of the evidence of Witness 5, who stated that

accidents/incidents in daily care notes did not correspond with accident/incident forms.

She further stated that forms were not always being completed after a patient restraint.

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It was her evidence that the accuracy and completion of such documents were

important in analysing and establishing trends and patterns. She said that “The

provider’s policy should set out the responsibilities for following up incidents, which is

usually a management responsibility. Follow up is necessary to consider trends/themes

and identify the learning and actions to prevent reoccurrence”. In addition, it was

reported in the Serious Case Review that “It is significant that the number of incident

forms do not tally with reference to incidents in the hospital’s nursing and medical

records… There were many incidents noted in the patient chronologies which were

based on the dispersed records of 20 former patients… The extent of such incidents

does not appear to have been shared during review meetings”. The panel was mindful

that Mr Harrison countersigned SUI forms completed by Unit/Deputy Managers and

would therefore have had considerable knowledge of patient incidents.

Mr Harrison’s failure in such a critical area of patient care was, in the panel’s judgement,

sufficiently serious to amount to misconduct. The panel was in no doubt that his failure

was such that it would be regarded as “deplorable” by fellow practitioners. The panel

further determined that his failure was in breach of the following provisions of the Code:









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Charges 1.11 and 1.12

Mr Harrison had an overarching responsibility to ensure the quality of the service

provided by Winterbourne View and ensure that it complied with all appropriate statutory

standards and requirements as regulated by the CQC. He had overall responsibility for

ensuring the Unit’s compliance with Castlebeck’s Physical Intervention Policy. He ought

to have taken steps to satisfy himself that there were adequate systems in place to

prevent the excessive use of restraint. This included, but was not limited to, his

responsibility to adequately review and scrutinise patient documentation; corporate

monitoring and identification of the number and nature of restraints; reviewing the

increasing level of staff turnover; and discussing all of these areas with Registrant C to

identify how any local issues could be properly addressed.

Mr Harrison’s failures related to fundamental and essential aspects of nursing care that

he was required to provide in a senior managerial capacity, including safeguarding the

health and wellbeing of vulnerable patients. His responsibilities were significant and the

interventions required of him were crucial. It is without doubt that the welfare of such a

vulnerable patient group was paramount. He was well placed to have identified and

acted upon the matters found proved in this case.

Moreover, in the panel’s judgement, Mr Harrison had allowed the culture, subsequently

uncovered by BBC Panorama, to develop and persist in Winterbourne View. He was

aware of concerns surrounding the inappropriate admission of patients with challenging

and complex needs; he was aware of staffing issues including staffing shortages and

insufficient training provided to staff to provide appropriate care to patients; and he was

aware that Registrant C required ongoing support. He was, at the time, a very

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experienced senior Manager with direct access to the Castlebeck Board. There was no

doubt that he ought to have taken more robust and proactive steps to address the

above issues, in light of his primary responsibility to protect patients.

The panel concluded that Mr Harrison’s failure in his fundamental duty of care to the

patients was sufficiently serious to amount to misconduct, and was such that it would be

regarded as “deplorable” by fellow practitioners. The panel further determined that his

failures, with regard to both charges 1.11 and 1.12, were in breach of the following

provisions of the Code:








[…] uphold the reputation of your profession.

16 You must be aware of the legislation regarding mental capacity, ensuring that people

who lack capacity remain at the centre of decision making and are fully safeguarded.

26 You must consult and take advice from colleagues when appropriate.



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35 You must deliver care based on the best available evidence or best practice.

54 You must act immediately to put matters right if someone in your care has suffered

harm for any reason.


Charges 3.1, 5.1, 5.2, 6.1 and 7.1


Of the standards inspected, following the CQC inspection of Croxton Lodge on 8 March

2011, one standard was identified as ‘moderate concerns’, two standards as ‘minor

concerns’ and 13 were ‘compliant’.

Of the standards inspected, following the CQC inspection on 6 and 11 June 2011, three

standards were identified as ‘major concerns’, one standard as ‘moderate concerns’ and

one standard was ‘compliant’. The panel noted that only five standards were inspected

on this occasion compared to 16 in the inspection just a few months before.

Further, the panel was mindful that the most recent inspection took place soon after the

transmission of the BBC Panorama documentary and this may have had an impact on

the staff and the inspection process. On that basis, the panel determined that the

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evidence did not, in all likelihood, represent a sufficiently accurate picture of the Unit in

order to enable the panel to establish the seriousness, or otherwise, of Mr Harrison’s

admitted failure. It was not safe, therefore, to conclude that Mr Harrison had engaged in

misconduct in respect of this charge.

In respect of charges 5.1 and 5.2, the panel took account of the following:

Of the standards inspected, following the Healthcare Commission inspection of Cedar

Vale on 27 May 2008, four standards were ‘almost met’ and four standards were ‘met’.

Of the standards inspected, following the Healthcare Commission inspection on 13

January 2009, 12 standards were ‘not met’, three were ‘almost met’ and 10 were ‘met’.

Of the standards inspected, following the CQC inspection on 1 and 2 June 2009, eight

standards were ‘not met’, four were ‘almost met’ and seven were ‘met’.

Of the standards inspected, following the CQC inspection on 25 January 2010, one

standard was ‘not met’, three were ‘almost met’ and eight were ‘met’.

Of the standards inspected, following the CQC inspection on 7 June 2011, one standard

was identified as ‘major concerns’, four as ‘moderate concerns’ and one as ‘minor

concerns’.

There was, evidently, a pattern of improvement. Having regard to the evidence before it,

the panel concluded that Mr Harrison’s failures were not sufficiently serious to amount

to misconduct.


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Of the standards inspected, following the CQC inspection of Willow House on 8 June

2011, one standard was identified as ‘moderate concerns’ and one as ‘minor concerns’.

Notwithstanding Mr Harrison’s admission, the panel was not satisfied that the findings of

the CQC inspection were sufficiently serious to warrant a finding of misconduct.


Of the standards inspected, following the CQC inspection of The East Midlands Centre

for Neurobehavioural Rehabilitation on 23 June 2011, one standard was identified as

‘moderate concerns’ and two as ‘minor concerns’.

Notwithstanding Mr Harrison’s admission, the panel was not satisfied that the findings of

the CQC inspection were sufficiently serious to warrant a finding of misconduct.

In summary, the panel concluded that Mr Harrison’s failures as set out, and found

proved, in charges 1.2, 1.5, 1.6 in its entirety, 1.7, 1.8, 1.9, 1.10, 1.11, 1.12 and 4.2,

amounted to misconduct. The panel was not minded to consider that the other

instances where the panel had found elements of culpability falling short of misconduct

should be accumulated to find a further allegation of misconduct against Mr Harrison.

The panel then went on to consider the question of impairment. In considering Mr

Harrison’s fitness to practise the panel reminded itself of its duty to protect patients and

its wider duty to satisfy the public interest which includes declaring and upholding

proper standards of conduct and behaviour, and the maintenance of public confidence

in the profession and the regulatory process.

“Impairment of fitness to practise” has no statutory definition. However, the NMC has

defined “fitness to practise” as a registrant’s suitability to remain on the register without

restriction.

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The panel was assisted by the following observations of Mrs Justice Cox in the case of

Grant:

“In determining whether a practitioner’s fitness to practise is impaired by reason of

misconduct, the relevant panel should generally consider not only whether the

practitioner continues to present a risk to members of the public in his or her current

role, but also whether the need to uphold proper professional standards and public

confidence in the profession would be undermined if a finding of impairment were not

made in the particular circumstances.”

[Paragraph 74]

The panel further took into account the approach formulated by Dame Janet Smith in

her 5th report on Shipman, as outlined above in Mr Unwin’s submissions. In its

assessment of all the evidence, and in light of its determinations thus far, the panel

concluded that limbs a), b) and c) were engaged in this case. There could be no

question that Mr Harrison’s failures exposed patients to serious and unwarranted risk of

harm.

Registered Nurses are required to make the care of patients their first concern, work

with others to protect and promote the health and wellbeing of patients, and provide a

high standard of practice and care at all times; these are fundamental tenets of the

nursing profession. The public needs to have trust and confidence in Registered

Nurses, particularly those in a senior managerial capacity, to provide a high standard of

care to vulnerable patients by ensuring, fundamentally, that appropriate systems are in

place to safeguard the health and wellbeing of those patients. In the panel’s judgement,

as Regional Operations Director and Responsible Individual for Arden Vale and,

primarily, Winterbourne View, Mr Harrison failed to act in such a way as to justify the

trust and confidence which the patients in his care, his colleagues, and members of the

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public ought to have been able to place in him. As a result of his failures, Mr Harrison

significantly undermined the reputation of the nursing profession.

The panel therefore determined that Mr Harrison’s fitness to practise was, at the time,

impaired.

In considering whether Mr Harrison’s fitness to practise is currently impaired, the panel

had regard to the issues of future risk and public confidence. The panel has a duty not

only to protect patients, but also to safeguard the public interest. This includes the

declaring and upholding of proper standards of conduct and of behaviour, and the

maintenance of public confidence in the profession and the regulatory process.

With regard to future risk, the panel considered whether Mr Harrison’s misconduct was

easily remediable, whether it had been remedied and whether it was highly unlikely to

be repeated. In considering these questions, the panel had particular regard to the issue

of insight. The panel recognised that the level of insight shown by a practitioner is

central to a proper determination of that practitioner’s fitness to practise.

To effectively remediate past failings, Registered Nurses must demonstrate insight into

their behaviour and undertake sufficient remedial steps to address the concerns in

question.

Mr Harrison told the panel that when he attempted to pay his nursing registration fee in

2012, he was informed by an NMC member of staff that he was not permitted to renew

his nursing registration until the conclusion of these NMC proceedings. As a

consequence, he has not worked as a Registered Nurse since 2012.

In the absence of any information from the NMC to rebut Mr Harrison’s assertion, the

panel was concerned that this apparent misinformation would have had an adverse

impact on Mr Harrison’s ability to undertake full and meaningful remediation.

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Nevertheless, Mr Harrison did speak of reading journals to keep his general nursing

knowledge up to date, for which the panel afforded him some credit. However, of

concern to the panel was an apparent absence of sufficient awareness by him of the

considerable deficiencies in his practice as a senior Manager and Registered Nurse in a

care environment, and the crucial need, therefore, to address those deficiencies.

As to the matter of insight, the panel considered the following:

Mr Harrison has, to an extent, engaged in these proceedings and with the NMC. He

made admissions to the majority of the charges against him and admitted that his

current fitness to practise is impaired. He acknowledged the findings made by the panel,

describing them as well-established”. He accepted the seriousness of all the charges

and that “public trust in the profession is damaged because of the nature of what had

happened”.

Mr Harrison recognised some of the appropriate actions that were required of him at the

time, including the need for confident, robust and evidence-based challenge of the

decisions made by the Castlebeck Board; the need to conduct necessary checks to

ensure that delegated tasks were completed appropriately; spending more time in each

of the Units for which he was responsible and accountable; and providing support to his

staff members.

In respect of his current employment, Mr Harrison explained that he was privately

contracted to provide training to assist people in gaining their Level 4 National

Vocational Qualification. He described how his current working environment was a

positive change to that of Castlebeck; he said that working primarily in one location

made it easier for his staff to bring concerns directly to him, and allowed him to respond

“more robustly” and “follow through personally [to make] sure outcomes are achieved”.

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That being said, Mr Harrison had not, in the panel’s view, demonstrated sufficient and

meaningful acknowledgement and acceptance of his personal failures, as Regional

Operations Director and Responsible Individual. Nor had he demonstrated sufficient

understanding of the gravity and significance of the impact of his failures on the patients

and their families, junior colleagues for whom he was required to act as a role model,

senior colleagues who were frustrated and let down by his inaction, the profession, and

the wider public interest in terms of public confidence in him as a Registered Nurse and

the nursing profession generally. The panel was not entirely persuaded by his repeated

assertions that he was unable to provide the level of support and attention that was

required in each of the Units due to geographical difficulties; in light of his seniority, and

significant responsibilities and accountabilities, he would have been expected to take

appropriate steps to ensure that he discharged his obligations as required to the best of

his ability and to notify the appropriate individuals if he was unable to carry out these

obligations.

Whilst Mr Harrison told the panel that his remorse was “difficult to put into words”, he

went on to say that the events had had a “profound effect” on him personally, and on his

outlook. He then made reference to “the people who suffered the horrible abuse… and if

[Winterbourne View] was managed better, it could have been avoided”, but went into no

detail about how the patients actually suffered as a result of his own failures and at the

hands of those staff members for whom he, as Regional Operations Director and

Responsible Individual, had overall responsibility. There was insufficient evidence to

suggest that Mr Harrison had fully assessed the incidents in question objectively. There

was, furthermore, insufficient evidence of recognition by him as to what could and

should be done differently, by him, in the future to avoid a recurrence of similar issues.

There was no evidence of any references or testimonials to attest to his competence

and conduct as a Registered Nurse and/or Manager in a care environment.

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In the panel’s view, Mr Harrison’s evidence was demonstrative of a lack of sufficient

insight. He has not, in the panel’s judgement, demonstrated the depth of insight and

reflection necessary to embark effectively upon the process of remediation.

In the absence of sufficient evidence of remediation, remorse and insight, the panel was

unable to conclude that Mr Harrison’s misconduct had been remedied. He has provided

limited reassurance that his misconduct will not reoccur in the future. The panel,

therefore, concluded that there remains a real risk of repetition.

The panel had in mind that any approach to the issue of whether fitness to practise

should be regarded as impaired must take into account, not only the need to protect

members of the public, but also the collective need to maintain confidence in the

profession as well as declaring and upholding proper standards of conduct and

behaviour. The panel is well aware that these are particularly important considerations

given that there is no power under the NMC rules to issue a warning if there is a finding

of no impairment (Grant, paragraph 73).

The panel determined that this is a case where the firm declaration of professional

standards so as to promote public confidence in the profession is required. The panel

was of the view that reasonable members of the public in full possession of all the facts

would be appalled by the extent of Mr Harrison’s misconduct in light of the

vulnerabilities and complexities of the patients at Winterbourne View. The panel

determined that such a departure from the standards expected of Mr Harrison must

engage public interest considerations. The panel therefore concluded that a finding of

no impairment would fundamentally undermine proper professional standards and

public confidence in the profession, and significantly damage the regulatory process.

Accordingly, the panel determined that Mr Harrison’s fitness to practise is currently

impaired by reason of his misconduct, on both public protection and public interest

grounds.

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Determination on sanction – Thursday 6 July 2017

Following its determination on misconduct and impairment, the panel invited

submissions on the matter of sanction.

Mr Jeffs referred the panel to the NMC’s ‘Indicative sanctions guidance to panels’

(September 2016) (“ISG”). He reminded the panel that the overarching objective of the

NMC is the protection of the public, which involves the pursuit of the following

objectives: to protect, promote and maintain the health, safety and well-being of the

public; to promote and maintain public confidence in the professions; and to promote

and maintain proper professional standards and conduct for members of those

professions. He submitted that these objectives should be at the forefront of the panel’s

mind, particularly in the light of its finding that Mr Harrison continues to pose a risk of

harm to the public.

Mr Jeffs reminded the panel that the purpose of sanction is not to be punitive but to

protect the public interest. He submitted that the public interest may include the safe

return to practise of a Registered Nurse; however this must be balanced against other

public interest considerations.

Mr Jeffs further reminded the panel to consider all sanctions available in ascending

order, and to ensure that the sanction imposed meets the risk of harm identified in this

case.

Mr Jeffs submitted that any sanction imposed must be both appropriate and

proportionate. In that regard, he submitted that any interference with Mr Harrison’s

ability to practise must be no more than necessary to satisfy the public interest, which

includes the protection of the public.

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Mr Jeffs commended the prevailing circumstances identified by the panel, in detail, in its

determination on misconduct and current impairment. He acknowledged that the

prevailing circumstances accurately captured the mischief and seriousness of the

conduct found proved; the potential for harm to patients, colleagues and members of

the public; and the potential for harm to the profession. He therefore adopted the factors

identified by the panel as aggravating features in this case. In addition, he submitted

that as a result of Mr Harrison’s failures, Mr Harrison allowed the unacceptable culture

of abuse to develop and persist in Winterbourne View. Mr Jeffs invited the panel to have

regard to the lack of evidence of sufficient remediation and insight, and full

acknowledgement, on Mr Harrison’s part of the extent of his failures. Mr Jeffs reminded

the panel of Mr Harrison’s direct access to the Castlebeck Board and his ability

therefore to influence positive change. Mr Jeffs further reminded the panel of Mr

Harrison’s lack of proactive management.

Mr Jeffs contended that Mr Harrison placed patients at serious and unwarranted risk of

harm; Mr Harrison’s failures arose from basic, fundamental and essential elements of

nursing care. Mr Harrison was obliged to safeguard the very vulnerable patients in

Winterbourne View, who were entitled to receive a high level of care but did not do so.

Mr Jeffs further contended that Mr Harrison’s failures placed members of staff at

unwarranted risk of harm. Moreover, Mr Jeffs submitted that compliance with CQC

standards was “not an optional extra”; these essential standards were an important way

of assessing how Units were operating and to ensure safety and good governance.

As an aggravating feature, Mr Jeffs invited the panel to have in mind the fact that Mr

Harrison has not worked in a registered environment since the events in question. Mr

Jeffs acknowledged the panel’s reference to Mr Harrison being under a

misapprehension that he was not entitled to practise as a Registered Nurse. Mr Jeffs

submitted that whilst there was no evidence to demonstrate precisely the advice or

information given to Mr Harrison on that matter, Mr Harrison was, as a matter of fact,

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entitled to practise as a Registered Nurse and a ‘search’ of his PIN would have shown

that fact.

Mr Jeffs submitted that the harm caused to the patients at Winterbourne View were

brought to the fore “in the most public way”, which undoubtedly caused harm to the

reputation of the nursing profession.

As to mitigating features in this case, Mr Jeffs reminded the panel of Mr Harrison’s

engagement in these proceedings, although Mr Jeffs invited the panel to weigh this

against Mr Harrison’s obligation, as a Registered Nurse, to cooperate with regulatory

investigations. Mr Jeffs reminded the panel of Mr Harrison’s admissions to the majority

of the charges against him and to the matter of current fitness to practise. Mr Jeffs

reminded the panel of its finding that Mr Harrison had demonstrated some remorse and

had made attempts to keep his general nursing knowledge up to date. Mr Jeffs also

informed the panel that apart from the matters in this case, there is no evidence of any

previous or subsequent adverse disciplinary or regulatory findings against Mr Harrison.

In reaching its decision, the panel addressed the matter of sanction in the light of Mr

Harrison’s failures, as found proved, and in accordance with its determination on

misconduct and impairment. The panel noted that the question of sanction was a matter

for its own independent judgement.

The panel accepted the advice of the legal assessor, which included advice to disregard

Mr Jeff’s submission that Mr Harrison’s failure to work in a registered environment was

an aggravating feature. Further, the panel took account of the guidance set out in the

ISG. It had regard to the principle of proportionality, weighing Mr Harrison’s interests

against the public interest. The panel bore in mind that the purpose of a sanction was

not to be punitive, although it might have that effect; rather, it was intended to protect

patients and serve the wider public interest. The wider public interest included

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promoting and maintaining public confidence in the profession and the NMC as its

regulator, and promoting and maintaining proper standards of conduct and behaviour.

The panel acknowledged that any sanction imposed must be no more than would be

necessary to protect the public and satisfy the public interest.

In keeping with its detailed decision on current impairment, the panel considered that

the following aggravating features applied in this case:

The patients at Winterbourne View were highly vulnerable and were entitled to

expect a Registered Nurse in a senior managerial capacity to protect and

safeguard their health and wellbeing.

Mr Harrison was an experienced Registered Nurse with considerable experience

of Castlebeck and was therefore familiar with its working practices. Whilst he was

the most senior Manager at an operational level, as a Registered Nurse he was

at all times bound to abide by the primary and fundamental principles of good,

safe and effective nursing care. This included his obligation to escalate matters

which place patients at risk of unwarranted harm; in this case, Mr Harrison

should have reported concerns to, at least, the CQC and he failed to do so.

In light of his knowledge and awareness of the significant and persistent

concerns in Winterbourne View including staffing, training, supervision, patient

incidents and patient admissions, Mr Harrison’s material failure to provide

proactive management and support in general, and with particular regard to

Registrant C, undoubtedly contributed to the poor practices, standards of care

and abuse that continued at the Hospital.

Mr Harrison’s lack of awareness of the ongoing status of his Units’ CQC

compliance was inexcusable and unjustifiable.

Mr Harrison has not accepted full accountability and responsibility for his failures.

He sought, at times, to place blame on others and on the company.

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The systemic abuse of patients at Winterbourne View, as uncovered publicly by

the BBC Panorama documentary, significantly damaged the reputation of the

nursing profession.

The panel rejected Mr Jeff’s submission that the fact that Mr Harrison has not since

worked in a registered environment should be regarded as an aggravating feature (in

fairness to Mr Jeffs, he accepted, after hearing the advice of the legal assessor, that this

fact should more appropriately have been referred to as a ‘relevant feature’). Mr

Harrison had told the panel that he was informed by an NMC member of staff that he

was not permitted to renew his nursing registration until the conclusion of these

proceedings, and he therefore laboured under the misapprehension that he was not

entitled to practise as a Registered Nurse. No evidence was presented by the NMC to

rebut Mr Harrison’s assertion. If a Registered Nurse is informed, directly or indirectly, by

their regulator that they are not permitted to practise as a Registered Nurse, it is

unreasonable to place the responsibility on the individual to seek information to the

contrary. The panel also acknowledged that Mr Harrison is entitled not to work in a

registered capacity.

As to the mitigating features in this case, the panel considered that the following

applied:

Mr Harrison was not afforded the level of support he ought to have received from

the Castlebeck Board and there was undoubtedly a degree of pressure placed

upon him to prioritise the company’s financial interests.

Apart from the matters in this case, there is no evidence of any previous or

subsequent adverse disciplinary or regulatory findings against Mr Harrison.

Mr Harrison has taken some steps to keep his general nursing knowledge up to

date.

Mr Harrison had engaged, to an extent, in these proceedings.

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Mr Harrison had made admissions to the majority of the charges against him,

including the more serious allegations, and admitted that his current fitness to

practise is impaired.

Mr Harrison demonstrated some remorse.

Mr Harrison demonstrated some insight and reflection.

Mr Harrison demonstrated some learning from his experiences at Castlebeck.

Under Article 29 of the Nursing and Midwifery Council Order 2001, the panel, when

considering sanction, can consider the following courses of action in ascending order,

beginning with the least restrictive sanction: take no action, make a caution order for

one to five years, make a conditions of practice order for no more than three years,

make a suspension order for a maximum of one year, or make a striking-off order.

The panel concluded that there were no exceptional circumstances in this case which

would justify taking no action. The panel considered that to take no action would be

manifestly inappropriate given the seriousness and extent of the misconduct found.

Furthermore, the panel considered that taking no action would be wholly insufficient for

the purpose of upholding public confidence in the nursing profession and in the NMC as

its regulator.

The panel then considered whether to make a caution order. The panel bore in mind

that such an order would not restrict Mr Harrison’s ability to practise. As above, the

panel concluded that a caution order would be wholly inappropriate. Such an order

would not properly mark the seriousness of the misconduct found, nor would it be

sufficient to protect the public or satisfy the wider public interest. This is not a case at

the lower end of the spectrum of impaired fitness to practise.

The panel next considered the imposition of a conditions of practice order. The panel

noted that this sanction primarily focuses on remedying identifiable areas of concern

within a registrant’s clinical practice or skills that may require retraining, assessment

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and supervision. In addition, it requires the potential and willingness of a registrant to

respond positively to any conditions imposed.

The wide-ranging misconduct established in this case concerned fundamentally Mr

Harrison’s failures in a managerial capacity. Whilst elements of his misconduct may, in

principle, be capable of being addressed by appropriate conditions of practice, there

was evidence before the panel which suggested that his overall misconduct was

compounded by an attitudinal problem. Mr Harrison’s management was passive,

apathetic and, despite his knowledge and awareness of matters that placed patients at

unwarranted risk of harm, lacked the urgency that was required of him.

The panel was mindful of its earlier finding that Mr Harrison had not demonstrated

sufficient insight into his misconduct and had not taken full responsibility for his failures.

The panel took account of the absence of sufficient recognition and acknowledgement

by Mr Harrison of the significant impact of his failings on the patients and their families

and the profession.

In the light of the panel’s finding that there remains a real risk of repetition and,

therefore, a risk of serious harm to patients (for all the reasons set out above), the panel

determined that conditions of practice could not be devised which would satisfactorily

address Mr Harrison’s misconduct. In all the circumstances the panel concluded that,

given the seriousness and extent of his misconduct, a conditions of practice order would

not be sufficient to protect the public, nor would it satisfy the wider public interest. The

panel therefore determined that a conditions of practice order would be an insufficient

sanction in all the circumstances of this case.

The panel next considered imposing a suspension order. A suspension order is

intended to convey a message to the registrant, the profession and the wider public as

to the gravity of the unacceptable and inappropriate behaviour, but which, in the

particular circumstances of a case, falls short of being fundamentally incompatible with

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continued registration. A period of suspension can also serve to provide a practitioner

with an opportunity to reflect on their misconduct and to take action to commence or

complete the process of remediation.

The misconduct in this case was not limited to a single incident. It comprised a pattern

and history of failures on Mr Harrison’s part to act in the best interests of the patients in

his care, over a considerable period of time. In respect of each of the matters found to

amount to misconduct, Mr Harrison’s failure was accompanied by an identifiable risk of

serious harm.

In its preceding determination, the panel concluded that Mr Harrison failed to

demonstrate and deliver safe nursing care. He was in a position to influence positive

change for the benefit of the patients and staff for whom he had overall accountability,

and did not do so. As a result, he placed patients at serious and unwarranted risk of

harm and the consequences of his failures were significant, given the particular

vulnerabilities and complexities of the patients for whom he was responsible. By virtue

of his misconduct, Mr Harrison failed in his overriding duty as a Registered Nurse to

safeguard and maintain the health and wellbeing of patients.

The public would be protected temporarily by the imposition of a suspension order. The

panel also took into account Mr Harrison’s extensive and otherwise unblemished

nursing career. However, in the particular circumstances of this case, the panel

concluded that such an order, even for the maximum period of 12 months, would not

satisfy the wider public interest, in declaring and upholding standards of behaviour and

maintaining public confidence in the profession. The panel therefore determined that a

suspension order would not be a sufficient sanction.

Mr Harrison’s misconduct represented a significant and serious departure from the

standards expected of him as a Registered Nurse in a managerial capacity. His

overarching duty was to safeguard the vulnerable patients in his care. In this case, he

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failed to discharge that duty. He acted in such a way that could foreseeably have

resulted in harm. Given the particular vulnerability of this patient group, Mr Harrison was

in a crucial position, and was depended upon, to protect the patients in his care. His

failure to act on a significant number of occasions was a breach of the trust incumbent

upon him as a Registered Nurse.

For all those reasons, the panel concluded that Mr Harrison’s misconduct is

fundamentally incompatible with him continuing to be a Registered Nurse.

Mr Harrison’s failures, in the context of his position as Regional Operations Director and

Responsible Individual, fundamentally undermine public trust and confidence in the

nursing profession. He failed to use his privileged position to protect and promote the

health and wellbeing of vulnerable patients. His failures are unequivocally serious.

The panel therefore determined that a striking-off order is the proportionate and

appropriate sanction. A lesser sanction would not be sufficient to satisfy the wider public

interest in maintaining confidence in the profession and its regulator and in declaring

and upholding proper standards of conduct and performance.

The panel was mindful that such an order could have a financial and professional

impact on Mr Harrison. Nevertheless, the panel concluded that his interests were

outweighed by the public interest in this matter.

Accordingly, the panel has determined to direct the Registrar to strike Mr Harrison’s

name from the Register.

Mr Harrison will be advised that his name will be removed from the NMC register. He

may not apply for restoration until five years after the date that this decision takes effect.

Anyone who enquires about his registration will be advised of this.

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Determination on interim order – Thursday 6 July 2017

The striking off order will take effect 28 days from the date when notice of it is deemed

to have been served upon Mr Harrison.

The panel considered whether it was appropriate to impose an interim order to cover

the appeal period before the substantive order takes effect, or to cover any time

required for an appeal of the substantive decision in this case to be heard.

Article 31 of the Order outlines the criteria for the imposition of an interim order. The

panel may make an interim order on one or more of three grounds:

Where it is satisfied that it is necessary for the protection of members of the

public;

Where it is satisfied that such an order is otherwise in the public interest;

Where it is satisfied that such an order is in the interests of the registrant.

The panel may make an interim conditions of practice order or an interim suspension

order for a maximum period of 18 months.

Mr Jeffs made an application for the imposition of an interim suspension order for a

period of 18 months on the grounds that it was necessary for public protection and that

it was otherwise in the public interest. He submitted that an interim suspension order

was appropriate and proportionate, in light of the panel’s determinations thus far. He

further submitted that an 18 month interim order was necessary to allow for any appeal

process.

In reaching its decision, the panel had regard to the submissions made by Mr Jeffs and

it accepted the advice of the legal assessor.

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For all the reasons set out in the panel’s determination thus far, and in all the

circumstances of this case, the panel decided to impose an interim suspension order on

the grounds that it was necessary for public protection and that it was otherwise in the

public interest. The panel first considered an interim conditions of practice order but

determined that, for the reasons set out in its determination on sanction, such an order

would not be appropriate.

The panel considered that, in the light of the reasons set out above for imposing a

striking off order, members of the public would be put at risk of harm, and confidence in

the NMC’s regulatory process would be damaged if, pending an appeal, there was no

interim order preventing Mr Harrison from working as a Registered Nurse before the

substantive order takes effect.

The panel determined that the order should run for a period of 18 months to allow for

any appeal process. The panel considered this to be an appropriate and proportionate

period.

If at the end of the appeal period of 28 days Mr Harrison has not lodged an appeal, the

interim order will lapse and will be replaced by the substantive order. On the other hand,

if he does lodge an appeal, the interim order will continue to run until the conclusion of

the appeal.

That concludes these proceedings.

Harrison, Peter - The Nursing and Midwifery Council

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