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You are here: BAILII >> Databases >> First-tier Tribunal (Health Education and Social Care Chamber) >> Gedara v Secretary of State [2009] UKFTT 20 (HESC) (06 March 2009) URL: http://www.bailii.org/uk/cases/UKFTT/HESC/2009/20.html Cite as: [2009] UKFTT 20 (HESC)

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Gedara v Secretary of State [2009] UKFTT 20 (HESC) (06 March 2009)
Schedule 5 cases: Protection of Vulnerable Adults list - Inclusion on PoVA list

Sujith Wimalasena Maha Arambe GEDARA
-v-
Secretary of State
[2007] 1158.PVA [2007] 1159.PC
-Before-
Mr. Simon Oliver (Deputy President) Dr. S. Ariyanayagam Dr. E Walsh-Heggie
Decision

Heard on 16^th June 2008 at The Care Standards Tribunal, 18 Pocock Street, London, SE1 0BW

Representation

The Appellant did not appear and was not represented.

Mr S. Whale of counsel represented the Respondent.

Appeal

1. This is an appeal by Mr Gedara against the decision of the Secretary of State to place him on the Protection of Vulnerable Adults list (PoVA list) on 2^nd October 2007. As a result of that listing, the applicant was also placed on the Protection of Children Act list (PoCA list). The Appellant also appeals under section 144(1)(a) of the Education Act 2002 ("the Act") and Regulation 12 of the Education (Prohibition from Teaching or Working with Children) Regulations 2003 ("the 2003 Education Regulations") against the Respondent's decision of 2^nd October 2007 to prohibit him from working with children in schools or further education establishments. Mr Gedara was provisionally listed on 5^th February 2007.
2. Mr Gedara appealed against his listing to this tribunal on 26^th October 2007. A response was received from the Respondent and there was a directions hearing on 20^th February 2008 when directions were given to set this case down for hearing.

Preliminary Matters

3. Mr Gedara did not attend the hearing. We are aware that he was in Sri Lanka and was not able to return to the United Kingdom. We had his statement and decided to treat that statement as his evidence in the case. In those circumstances we only heard from the witness for the Secretary of State, Ms McDonough.
4. We were satisfied that Mr Gedara was aware of the date of the hearing and that he had an adequate opportunity to put forward his arguments. It would have been of help had we been able to hear from Mr Gedara in person so that we could have assessed his level of understanding but that was not possible so we used his statement. However, the Tribunal's findings and conclusions are based on the assumption that we have to start with the fact that English is not Mr Gedara's first language and that there needs to be some allowance made for his linguistic abilities and for the words and language he has used.

The Law

5. Appeals to this Tribunal against inclusion on the PoCA and PoVA lists are governed by section 4 of the Protection of Children Act 1999 and section 86 of the Care Standards Act 2000 respectively. Sections 4(3) and 86 (3) (combined) state that:

If on an appeal or determination under this section the Tribunal is not satisfied of either of the following, namely—

(a) that the individual was guilty of misconduct (whether or not in the course of his duties) which harmed (a child) or placed (a child) at risk of harm (a vulnerable adult); and

(b) that the individual is unsuitable to work with (children) (vulnerable adults),

the Tribunal shall allow the appeal or determine the issue in the individual's favour and (in either case) direct his removal from the list; otherwise it shall dismiss the appeal or direct the individual's inclusion in the list.

6. Thus there are two elements that the Tribunal panel needs to consider in relation to a PoVA and PoCA appeal. First, there is whether or not the applicant is guilty of misconduct. The second is whether the applicant is unsuitable to work with children or vulnerable adults. If the panel is not satisfied on one or other ground it allows the appeal. However, under section 4(3), if the two criteria are met the Tribunal must reject an appeal against listing: there is no discretion.
7. The onus of proving each of the two matters in section 4(3) lies upon the Respondent. The standard of proof is the civil standard of proof. The civil standard of proof is a single standard, namely the balance of probabilities. The civil standard of proof does not recognise or embody a moving standard according to the gravity of the allegation. Rather, the more unlikely it is that an incident of the kind alleged to have occurred would take place (based upon common experience), the stronger must be the evidence before a court or tribunal will find that on the balance of probabilities that occurrence did occur^[1]. It is for this Tribunal to use its own collective experience in assessing the inherent likelihood of the particularised misconduct. It is that likelihood against which the totality of evidence is to be measured.
8. Where an adult has been included on the List, that adult may at any time after 10 years apply to the Tribunal to be removed from it: sections 4A and 4B of the 1999 Act. Inclusion in the List does not prevent the listed person from securing any other form of employment. The List is not a public document. The List is not punitive. It is not disciplinary. Still less is it intended to shame or stigmatise a person. The objective of the List is to lessen the risk of harm to children or vulnerable adults from those working or having extended contact with them. It secures that objective by preventing a person who has been guilty of misconduct that harmed a child or vulnerable adult, or risked the same, and who is unsuitable to work with children or vulnerable adults, from being in a position having extended, unsupervised contact with children or vulnerable adults.
9. It is the Respondent's case that the misconduct identified in each of the 5 particulars set out in paragraph 17, below, placed a vulnerable adult at risk of harm.
10. Section 142(1) of the Act provides that the Secretary of State may direct that a person may not carry out work to which section 142 applies if one of the grounds set out in subsection (4) applies:

(a) On the grounds that the person is included in the list under section 1 of the Protection of Children Act 1999;

(b) On the grounds that the person is unsuitable to work with children;

(c) On grounds relating to the person's misconduct;

(d) On grounds relating to the person's health; or

(e) On grounds relating to the person's professional incompetence.

11. Section 144 of the Act and Regulation 12 of the 2003 Education Regulations provide a right of appeal against the making of a direction to the Care Standards Tribunal. When considering whether the direction is appropriate or not, Regulation 13 of the Education Regulations provides that the Tribunal shall not consider any information relevant to the decision to give a direction which the Secretary of State did not have at the time the decision was made, or any evidence of a material change of circumstances of the person concerned occurring since the decision was given. Furthermore, subsection (1) of Regulation 12 of the Education Regulations sets out the right to appeal against a direction. Subsection (2) prohibits an Appellant from basing his appeal on evidence that has not previously been brought to the attention of the Secretary of State. In the case of a person who is confirmed on the POVA and POCA list, being placed on the section 142 list creates no separate right of appeal. If an appellant succeeds in his appeal against confirmation on POVA or POCA, he will also be removed from the section 142 list.

Background

12. This case arose as the result of the death of JC in hospital on 31^st August 2006. JC had been a resident at Knights Court before his final admission to hospital.
13. Knights Court is a Nursing Home registered for elderly nursing care which, at the relevant time, was owned by Life Style Care plc. Life Style Care was taken over by Southern Cross in February 2007. The Appellant worked mainly in Excalibur Unit which has provision for twenty residents and he mainly worked as a day nurse, having started to work there on 18^th April 2006. The Appellant was in charge of the unit when he was on shift. Each resident in the home has an allocated named nurse. The allocated named nurse is responsible for reviewing and updating care plans. In their absence this may be handed over to another nurse. The Appellant was a named nurse for some but not all of the residents in the unit. He was not the named nurse for JC. There is always one nurse in charge of each shift, who is responsible for supervising a team of carers. The staffing levels in August 2006 would normally have been one nurse and three care assistants on each shift. At that time, day shifts for qualified staff would have been either 1.45 pm to 8 pm or 7.45 am to 2 pm or a long shift of 7.45 am to 8 pm. For care staff, day shifts would have been either 2 pm to 8 pm or 8 am to 2 pm or a long shift of 8 am to 8 pm.
14. While the Appellant was employed at Knights Court he was responsible and accountable for the care he deemed necessary for the residents. His role was to assess, plan and evaluate care documents and action as necessary. This included the physical and emotional needs of the residents. The Appellant was responsible for the supervision of care staff on duty which included monitoring, supervising and instructing care staff to implement the care plans for the individual residents and providing on the job training to correct/improve the care given.
15. During the day shift, the nurse on duty was responsible for liaising with family members, referring clients to GPs, psychiatrists, dieticians, attending case reviews etc. to ensure that full care was provided. The nurse on duty is not there primarily to carry out physical tasks, they are there to monitor and evaluate and the role is clinically orientated. From Ms McDonough's recollection, the care staff who were working with the Appellant at the time of the incident were experienced staff.
16. After JC's death in hospital a complaint was made to CSCI by a member of his family. This was passed to Valerie O'Brien, the manager of Knights Court at that time. Ms O'Brien held a meeting with the Appellant on 6^th September 2006 suspending him from duty in the light of the allegations.
17. A disciplinary meeting was held on 22^nd September 2006 to ascertain whether it would be necessary to implement disciplinary action against the Appellant in relation to the allegations that had been made. Ms McDonough's role was to ascertain what the facts were and she told us that she had to ask questions in order to do this. The Appellant communicated what he thought, but Ms McDonough did not consider that he realised the seriousness of the allegations against him. Ms McDonough said that what she considered emerged from the meeting was the Appellant's lack of ability to assess residents and action their needs. As a result of the meeting, the allegations against the Appellant all related to JC and were:

(a) Failure to complete Risk Assessments having identified a potential danger with regards to the control for the electric bed

(b) Failure to monitor a Diabetic's blood sugar levels appropriately

(c) Failure to review Nutrition care plan having identified potential malnutrition with regards to weight loss and reduced appetite

(d) Failure to implement appropriate monitoring tool in relation to Turn charts/Fluid charts

(e) Failure to update Tissue Viability Care plan having identified bruising/wound post return from hospital and implement appropriate action in relation to taking of photographs and wound charts.

18. After the meeting, the decision was taken to dismiss the Appellant. From Ms McDonough's recollection, this was on the same day as the meeting. Ms McDonough sent a letter dated 26^th September 2006 to the Appellant setting out the reasons for his dismissal, that the allegations were substantiated and that the Appellant was guilty of gross misconduct. The Appellant was considered to be guilty of gross misconduct as he had not understood the importance of risk assessments; in particular, he had failed to complete a risk assessment having identified a potential danger with regards to the control for the electric bed.
19. Ms McDonough told the Tribunal that further evidence of the Appellant's gross misconduct could be seen from the fact that she did not consider that the Appellant was competent to make appropriate assessments; in particular, with regard to not taking JC's blood sugar level. She said that the Appellant said that he was waiting for the GP to come on the line but he should have first eliminated the possibility of a diabetic coma and then he should have called 999. As a clinician he should have carried out observations and contacted the emergency services not the GP. He also failed to review the nutrition care plan and update the tissue viability care plan. He failed to implement appropriate monitoring tools in relation to turn charts and fluid charts.
20. In his statement Mr Gedara said that at 1.30 am on 26^th August 2006 the night nurse recorded that JC was complaining of chest pain. The following night duty was done by the same nurse. Mr Gedara said that, therefore, it is more relevant to question the that person who was on duty two consecutive nights about the care plan in relation to chest pain, rather than suspending him.
21. Mr Gedara's statement says that he recorded JC's physical condition before he was handed over to ambulance staff and that he did not think it was important to record JC's condition after he was handed over to the ambulance staff.
22. Mr Gedara also says in his statement that "nursing homes have no system in place to know what nurses do on a day-to-day basis. Managers, social workers, inspectors etc. are all very keen on checking records but nobody appreciates the time nurses spend taking blood, caring for residents, answering the telephones and answering relatives' questions, attending social works' review meetings, handing out medicine, helping other health visitors (doctors, chiropodists, hairdressers etc)."
23. In his statement Mr Gedara says that he does not think there is a fully completed residents' folder in Knights Court Nursing Home and also did not think that any day nurse can complete records up to the standard being expected. That is why, he says, when he was doing night duty in other homes, he had to work with the understanding of day nurses' workloads.
24. He continues to say: As a night nurse in other homes, he used to write care plans and risk assessments, receiving and disposing of medication, checking blood sugar levels, preparing residents for GP's rounds and so on.
25. The tribunal is aware that when any member of staff is dismissed it is part of Ms McDonough's role to consider whether the matter should be referred to the Secretary of State. In this particular instance it was decided that a referral should be made to the PoVA team and so she completed and sent the referral form to the Department of Health on 20^th November 2006. One of the reasons for the referral was that Ms McDonough did not consider that the Appellant had shown any insight into the consequences of his actions. Ms McDonough told us that If someone shows insight it indicated to her that there is the possibility of a matter being addressed. In addition to the referral to the PoVA team, Ms McDonough informed her line manager who took the decision to refer the Appellant to the NMC.
26. We intend to look at each allegation in turn, setting out the Secretary of State's case, the Appellant's case, our findings and conclusions in that order.
27. As above, we have set out as his evidence the information contained in Mr Gedara's statement.

The specific allegations

Use of Bed Controls

28. The Appellant was accused of failure to complete risk assessments having identified a potential danger with regards to the control of the Vulnerable Adult's (JC's) bed. The Appellant confirmed in the investigation meeting on 6^th September 2006 that he had identified that JC's behaviour, with regard to use of the bed control, was a risk. In his role he was expected to complete a risk assessment and implement the actions from the risk assessment into JC's care plan. He was expected to complete a risk assessment to minimise any potential risk of harm to JC. It is the Secretary of State's case that this should have been done as soon as the risk was identified because if a risk had been identified and no action plan was prepared then this increased the risk of harm to JC. JC was a vulnerable adult whose mental capacity was impaired. The Appellant did not seem to think that it was important to carry out a risk assessment and this in itself was of concern because it called into question the Appellant's ability to risk assess, appropriately, for any client. Ms McDonough said that because the Appellant had noted that the bed was high and he had hidden the controls from JC, she had assumed that he would not have hidden the controls if he did not consider there was a risk to JC. Ms McDonough did not consider that the Appellant had the necessary good judgement to ensure JC was protected.
29. Mr Gedara's statement says that on 30^th August 2006 the night nurse has recorded: "JC is playing with bed control, moving bed up and down." He says that she should have written a risk assessment and care plan as well.
30. In relation to the use of bed controls, we find that Mr Gedara failed to take appropriate action. The Nursing Standard stipulated that there needed to be a risk assessment and Mr. Gedara appeared to accept that in the meeting on 6^th September 2006. Whilst we accept that there were others who could just as easily have undertaken the risk assessment that does not excuse Mr Gedara from doing so. We do feel, however, that if a risk assessment had been carried out it would have concluded that there was no risk involved. Just because the outcome may have been that there was no risk, we do not accept that this would mean that there should be no assessment. Our conclusion is that whilst we accept that this was a failing by Mr Gedara, given that there was actually no risk we do not regard this as evidence of poor or unsatisfactory performance. The failure to undertake the assessment was not a serious lapse which would lead us to conclude that he was guilty of misconduct.

Monitoring of Blood Sugar Levels

31. In relation to the failure to monitor properly the blood sugar levels of JC it is the Secretary of State's case that it is the responsibility of the nurse on duty to ensure that all charts and care documentation are completed accurately. The Appellant knew that JC had been losing weight and that he was not eating and drinking properly, he was also aware that JC was a diabetic. At his disciplinary hearing, the Appellant said that he did not rely on the chart for that day but he was accountable for the information that was put on them. The condition of JC should have meant that the Appellant had monitored JC more closely and that blood sugar levels should have been checked on a regular basis. The care plans set out how often blood sugar levels should be checked but this is on the basis that the Vulnerable Adult is eating and drinking appropriately. Given that this was not the case with JC at this time, the Appellant should have evaluated the care plan, used his clinical judgement and taken action. The Appellant, knowing that JC was diabetic should have checked JC's blood sugar to eliminate one way or another whether there was a problem. He then should have determined what action needed to be taken.
32. Mr Gedara's statement says that on 26^th August 2006 JC's blood sugar level was checked. The system was that, unless he had any signs of hyper/hypo glycaemia, his blood sugar level had to be checked once in a week. Further, says Mr Gedara, at 3.00 pm on 31^st August 2006 JC did not show any signs of hypoglycaemia. That's why without being treated (by a 5% Dextrose IV infusion) JC woke up and talked and was smiling with ambulance staff. Mr Gedara thought that JC had experienced a neurogenic attack as he was supposed to be referred to neurologist. If ever he was found with hypoglycaemia in the hospital it was after more than an hour and this must have been due to actions taken by the ambulance staff. Mr Gedara says that JC had his blood sugar levels taken regularly but most of the time he did not allow the nurses to take it and his notes recorded that he was uncooperative.
33. The Tribunal's findings are that in this instance Mr Gedara acted appropriately. He followed the care plan. On 31^st August the Blood Sugar Monitoring would have been no use to JC and would have delayed the transfer to hospital. Whether or not the blood sugar monitoring should have been done between 26^th and 31^st August is a moot point but given that there was no evidence that JC had low blood/sugar levels and we are aware that JC was in and out of hospital, it does not seem to us that on 26^th August 2006 that there was any reason to deviate from the weekly testing.
34. In an ideal world we accept that one would test blood/sugar levels twice a day but given that the system was a weekly check unless there was cause for concern and JC often refused to have it taken anyway, we conclude that Mr Gedara was entitled to take the view he did – that JC did not look hypoglycaemic. It was an appropriate response and did not place JC at risk.
35. The Tribunal's conclusion is that there was no error or misconduct by Mr Gedara in relation to blood/sugar.

Nutrition Care plan and Turn Charts/Fluid Charts

36. It is the Secretary of State's case that Mr Gedara failed to review the nutrition care plan of JC, having identified potential malnutrition with regards to weight loss and reduced appetite, and failed to implement appropriate monitoring tools in relation to the turn charts and food/fluid charts of the vulnerable Adult. There was only one fluid chart available for JC, which was for the day of the incident, i.e. 31^st August 2006, yet the Appellant knew that JC was not eating and drinking properly as he noted this in JC's care plan on 27^th August 2006. He should have ensured that fluid charts were being completed every day. It is the duty of the nurse to evaluate and assess matters such as residents losing weight which may happen for a number of reasons, such as difficulty in swallowing. Ms McDonough told us that she understood there was a care plan in place stating that there was potential for weight loss. The Appellant did clarify that JC had not been eating and drinking properly as evidenced on the fluid chart. Given this, he should have put an action plan in place. Failure to do so could have resulted in JC becoming very ill.
37. The Appellant's case is that other nurses, including night nurses, are also responsible for updating care plans. He says in his statement that JC had lost weight when he was in hospital. On 27^th August 2006 he was weighed and was supposed to be weighed again on 30^th August 2006 to see whether he was gaining or losing weight. Mr Gedara's statement actually refers to this latter date as 3^rd August 2006 but we believe that this is an error given the context of the dates.
38. JC lost weight when he was in hospital. After coming back from hospital, he had sandwiches, milk, supplementary drinks. Just because he refused food and drinks during meal times, he had not been fasting. The reason that JC was supposed to be weighed again on 30th August 2006 to see if he was losing or gaining weight because, if he was still losing his weight in the nursing home, a short term care plan should have been in place.
39. The Tribunal's findings are that this matter has not been proved to our satisfaction at all. JC's weight was all over the place. He had just come back from hospital. The Tribunal's conclusion is that there was no specific failure by Mr Gedara in relation to the nutrition charts. There was a record of what JC ate and if he refused food.
40. Mr Gedara also states that JC did not like to be on his lateral sides. It was recorded. When staff turned him from supine position to lateral positions, he turned himself back to the supine position. By doing so, JC showed his ability to roll over on bed by himself. It is Mr Gedara's belief that if somebody can turn by themselves on bed, there is no need to have turning charts in place.
41. As for the turn charts and fluid charts, we accept the points made by Mr Gedara about the fact that JC was able to turn himself. You cannot have and do not need turn charts if an individual is able to turn himself. The records show that JC did not want to turn, that although he sat up he preferred to be on his back and that even if he was turned he could and would turn back.
42. We conclude that Mr Gedara did fail to keep fluid chart charts. However, these are far more important from a cardiovascular point of view. In an ideal world it would have been the nutritionist's task to keep the fluid charts. We also note that no one else kept fluid charts for JC and so, once again, it is unfair to blame an individual for a collective failure.
43. We have come to the conclusion that there was no misconduct on the part of Mr Gedara in respect of the nutrition care plan, or the turn and fluid charts.

Tissue Viability Care Plan

44. Failure to update the Vulnerable Adult's tissue viability care plan having identified bruising and a wound on the Vulnerable Adult's return from hospital and failure to implement appropriate actions in relation to his wound chart. The Appellant had a duty to update the tissue viability care plan and put in place a treatment/care plan. On JC's return from hospital, on 25^th August 2006, the Appellant recorded the breakdown of JC's skin in the progress and evaluation record. He failed, though, to put in place a treatment or care plan to deal with this so staff would know what action to put in place. Failure to do this could have led to further deterioration and breakdown of skin integrity.
45. Mr Gedara's case is that he took photographs of JC's bruises and rashes on 25^th August 2006 and handed them over to night staff so that they could proceed with the other procedures. On 26^th August 2006, he was off duty and believes that other nurses could have implemented appropriate actions.
46. Mr Gedara says that JC was particularly vulnerable as can be seen from his care plans and assessments. These documents set out that JC had bilateral above-knee amputation, which he had had after cardiac surgery due to a clot; he was diabetic and suffered previously from an inferior Myocardial infarction. He suffered from a mild depressive illness, faecal incontinence and had an urethral indwelling catheter in situ. JC had prosthesis but needed hoisting for all transfers and he required pressure relieving equipment to ensure he did not suffer from pressure sores. JC also had some behavioural problems and could be verbally aggressive.
47. The Tribunal's findings are that Mr Gedara did not do what was expected in that he did not put in place a tissue viability care plan. However, we also find that this was a long-term condition and that there was collective responsibility for JC. We find that there was no mention of these problems in the hospital notes – again surprising considering that this was not a new problem. For example, the hospital notes do not mention the return of the pressure sore.
48. The Tribunal's conclusions are that although there was no care plan put in place by him, what Mr Gedara did was reasonable – he had recorded and photographed the bruises and rashes. Further, given that Mr Gedara was not solely responsible for JC and because this was a long-term condition, whilst Mr Gedara did not do what was required, the same can be said of all other staff. To expect someone to get out grids and charts was surprising. Given that the hospital staff failed to record the return of the pressure sore it is unfair to put all the responsibility on Mr Gedara for a collective failure to properly document.
49. Once again, we conclude that there was no misconduct by Mr Gedara in relation to this matter.

Conclusions

50. As can be seen from paragraph 46 above, JC was a complex case. It could be argued that there was a multiple pathology and so JC was at greater risk than others and therefore required more attention than others. We do consider, however, that JC was appropriately cared for. In an ordinary situation in a nursing home many of the desired procedures do not happen. Whilst we have identified matters where we are satisfied that Mr Gedara should have acted and he did not, we regard these, proportionately speaking, as trivial. Whilst Mr Gedara's conduct was not perfect, the degree of imperfection there was does not equate to misconduct. We also bear in mind that, as Mr Gedara records, between 18^th August 2006 and his death at the end of August 2006 JC had been looked after and treated by more than five nurses and a GP in the nursing home as well as the nurses, doctors and specialists in the hospital. To suggest that out of all of the professionals involved in JC's care Mr Gedara was the only one who had placed JC at risk of harm is both unfair and impossible to suggest with certainty given that there was no investigation into what others had, or had not, done.
51. We note that the CSCI reports show that the management in the home was poor and that, overall, the care in the home was only just adequate. We regard it as relevant that there was no improvement of the care/management plans over 6 months seen in the CSCI reports and that there were on-going concerns about staffing levels. It is easy in retrospect to say that things were wrong and, on the death of a resident, to blame an individual for failures to complete the paperwork properly. Others are as, if not more, responsible.
52. To have a protocol and then find failings by one person when someone died is unfair. If there were gaps in the system it should have been the manager who identified what was missing. If the system was robust the manager should have checked that the routines were properly in place and being done correctly. From what we can see no-one else at the home was using the system properly. It seems to us that once JC had died and his family had complained because they were unhappy, the home needed to find someone responsible. It is wrong and unfair to make Mr Gedara the scapegoat as it is clear to us that others could have been equally responsible.
53. Bearing all the above in mind, whilst we conclude that there were some errors in the way Mr Gedara did things, we do not come to the conclusion that he was guilty of misconduct, let alone gross misconduct. Having reached that conclusion, we are not required to consider the question of suitability. The reason for this is that, as set out in paragraph 6 above, if we are not satisfied on one of the two matters set out in Section 4(3) and 86(3) of the Acts, we must allow the appeal.

Concluding Remarks

54. This decision should have been produced many months ago. The panel chair apologises to the parties for the very considerable delay in producing this.

Accordingly, our decision is:

APPEAL ALLOWED, and DIRECT that he be removed from the POCA and POVA lists. In consequence his name is automatically removed from the list under the Education Act 2002.

Mr. Simon Oliver

(Deputy President)

Dr. S. Ariyanayagam

Dr. E Walsh-Heggie

Date: 6^th March 2009

Note 1   See both Re: H and R (Child sexual abuse : Standard of Proof ) [1996] 1 FLR 80, per Lord Nicholls and R (N) v. Mental Health Review Tribunal (Northern 3 Region) & ors [2006] QB 468 at [60]-[64]. These principles have been confirmed recently by the House of Lords in Re B (Care Proceedings: Standard of proof) [2007] EWHC 2395; [2008] 2 FLR 141     [Back]