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QUEENS BENCH DIVISION
ADMINISTRATIVE COURT
Strand, London, WC2A 2LL |
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B e f o r e :
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The Council for the Regulation of Healthcare Professionals |
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The Nursing and Midwifery Council |
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Smith Bernal Wordwave Limited, 190 Fleet Street
London EC4A 2AG
Tel No: 020 7421 4040, Fax No: 020 7831 8838
Official Shorthand Writers to the Court)
Mr Robert Lawson (instructed by Penningtons, Solicitors) for the First Respondent
Dr Karen Johnson(instructed by The Director of Legal Services for the Royal College of Nursing Legal Department ) for the Second Respondent
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Crown Copyright ©
Mr Justice Collins:
1. The appellant, whom I shall refer to as the CRHP, was established by Part 2 of the National Health Service Reform and Health Care Professions Act 2002 (the 2002 Act). Its general functions as set out in s.25(2) of the 2003 Act, are:-
"(a) to promote the interests of patients and other members of the public in relation to the performance of their functions by the bodies mentioned in subsection
(3) .. ( referred to as regulatory bodies), and
(b) to promote best practice in the performance of those functions,
(c) to formulate principles relating to good professional self-regulation, and to encourage regulatory bodies to conform to them, and
(d) to promote co-operation between regulatory bodies, and between them, or any of them, and other bodies performing corresponding functions".
2. The regulatory bodies cover most professionals who work in health care including nurses. Because of a reorganisation of the bodies responsible for the regulation of nurses, there are complicated transitional arrangements, but at the material time, the first respondent was the relevant regulatory body and is included in s.25(3) of the 2002 Act.
3. The CRHP was set up because of public concern that the arrangements for self regulation and the carrying out of their functions by the regulatory bodies did not always provide sufficient protection for the public. On occasions, it seemed that the interests of the professionals were put above those of the patients. The existence of the CRHP owes much to the recommendations of Professor Sir Ian Kennedy in his report on the inquiry into children's heart surgery at the Bristol Royal Infirmary.
"Subsection (3) does not prevent the Council from taking action, under section 29, but action may be taken only after the regulatory body's proceedings have ended".
4. Section 29 enables this appeal to be brought. It is headed 'Reference of disciplinary cases by Council to court'. So far as material, it provides as follows:-
"(1) This section applies to
[(a) to (h) then cover directions, orders, determinations and steps taken by the relevant disciplinary committees of the various regulatory bodies]
(i) any corresponding measure taken in relation to a nurse, midwife or health visitor.
(2) This section also applies to-
(a) a final decision of the relevant committee not to take any disciplinary measure under the provisions referred to in whichever of Paragraph (a) to (h) of subsection (1) applies,
(b) any corresponding decision taken in relation to a nurse and
(c) a decision to restore a person to the register following his removal from it in accordance with any of the measures referred to in subsection (1).
(3) The things to which this section applies are referred to below as 'relevant decisions'.
(4) if the Council considers that
(a) a relevant decision falling within subsection (1) has been unduly lenient, whether as to any finding of professional misconduct, or fitness to practise on the part of the practitioner concerned (or lack of such a finding), or as to any penalty imposed, or both, or
(b) a relevant decision falling within subsection (2) should not have been made,
and that it would be desirable for the protection of members of the public for the Council to take action under this section, the Council may refer the case to the relevant court
(7) If the Council does so refer a case
(a) the case is to be treated by the court as an appeal by the Council against the relevant decision (even though the Council was not a party to the proceedings resulting in the relevant decision), and
(b) the body which made the relevant decision is to be a respondent.
(8) The Court may
(a) dismiss the appeal,
(b) allow the appeal and quash the relevant decision,
(c) substitute for the relevant decision any other decision which could have been made by the committee or other person concerned, or
(d) remit the case to the committee or other person concerned to dispose of the case in accordance with the directions of the court
and may make such order as to costs as it thinks fit".
No provision is made as to the position of the individual who was dealt with in the relevant decision. In this case, he has very sensibly been joined as a respondent. That course should be adopted in all appeals brought under s.29.
"The appellant considers that the decision was unduly lenient as to the penalty imposed in relation to the finding of misconduct made within the meaning of s.29(4)(a) of the [2002 Act] and that it would be desirable for the protection of members of the public for this case to be referred to the court".
The argument in support was contained in a document prepared by Mr de la Mare described as 'Appellant's outline submissions'. What was relied on was said to be a combination of superficial treatment of the evidence, mistaken appraisal of the seriousness of the evidence aggravated by a failure to consider or assess future risk and a failure to take that evidence in conjunction with previous misconduct. I shall deal with the facts of the case in due course, but it is to be noted that the grounds do not assert that any findings or lack of them were unduly lenient. This is of some importance since the Rules governing the conduct of disciplinary hearings for nurses require that, where the facts alleged in the charge are admitted, the prosecutor shall address the Committee as to the circumstances leading up to the facts and may call evidence. There is thus what in the criminal context would be termed a Newton hearing which enables the Committee to decide how serious the misconduct in issue was. Following the proof of facts, the Committee must consider whether misconduct is established even if it is admitted and the facts to which such misconduct relates. Finally, it will listen to mitigation and decide on the appropriate penalty: see Nurses, Midwives and health Visitors (Professional Conduct) Rules 1993 Approval Order 1993 (1993 No.893) as amended, paragraphs 17 and 18, which were in force at the material time.
9. It is important that the grounds of appeal specify clearly which of the provisions in s.29(4) are being relied on. If it is intended to argue that any finding was unduly lenient, whether or not in addition to the contention that the penalty was unduly lenient, the particular finding must be identified and the matters relied on in support of the argument specified. In cases where, because of under prosecution, relevant aggravating material was not put before the Committee, a finding made in the absence of such material is capable of being unduly lenient. In those circumstances, the material must be identified. If the appeal is based solely on a claim that the penalty was unduly lenient, the appellant can only rely on what was put before the Committee.
The charge read as follows:-
"That you, whilst employed by University College London Hospitals NHS Trust as a paediatric nurse on the Middlesex Adolescent Unit
1(a) used a computer located in the [Adolescent Unit] to access sexually explicit and/or offensive websites on the internet on or about
(i) 7th/8th March 2002
(ii) 8th/9th March 2002, excluding 1(a)(i) above
(iii) 9th/10th March 2002 excluding 1(a)(ii) above
(iv) 10th/11th March 2002, excluding 1(a)(iii) above
(v) 11th/12th March 2002, excluding 1(a)(iv) above
(vi) 14th/15th March 2002; and
(c) That, having so accessed explicit and/or offensive websites on the internet, you are guilty of misconduct".
"The Committee has reached its decision. This was serious misconduct, there was abuse of trust and you generated completely inappropriate material on a hospital ward. You have lost your job through the disciplinary hearing and we have considered whether we should remove your name from the register in order to protect the public. The case has not been put on the basis that your conduct demonstrates a risk to patients and there is no evidence of direct harm to patients. You have been working and such testimonials as we have are favourable. Furthermore, the police did not find reason to pursue prosecution in your case. We accept that there was an element of cascading but, nevertheless, we are of the view that you deliberately accessed pornographic sites and are not completely satisfied that you have shown full insight into the seriousness of your actions.
We therefore think it necessary to issue you with a caution on your behaviour. You should appreciate that this is a very serious matter to be found guilty of misconduct by the Council's Professional Conduct Committee. You must understand that the committee does not condone your actions in any way.
The Committee asks you to study the NMC's Code of Professional Conduct. The Code sets out the standards of conduct that the NMC requires of its registered practitioners. The Committee expects you to consider it carefully and to follow its standards in your future practise and conduct.
The NMC will keep a record of the caution for five years. During this time anyone who enquires about your registration will be told that you have a caution on your record. If you are found guilty of further misconduct by the Preliminary Proceedings Committee or the Professional Conduct Committee within this five year period the Committee will be told about that caution on your record and may take it into consideration when deciding what action to take in future".
15. Over the nights in question, Mr. Truscott had spent in all a total of some 6 hours accessing pornographic sites. His misconduct was detected because access to those sites was blocked. The blocks were recorded and the extent of the access to the forbidden sites was noted. It was arranged that the matron in charge should go to the Unit if further access took place on the night of 14/15 March 2002 and that happened. Mr. Truscott was caught red-handed and on the desk beside him was a list in his writing setting out a number of sites. The cover of one of those which he had accessed that night and which was before the Committee, contains what is described as a 'disclaimer' in these terms:-
"Some people might find this web extremely offensive due to the content. We have sick pictures of death, raw gore, smashed up heads, disgusting disease, mutilation, general sick pictures and some other whacky shit! If you don't agree with the crap on this site do not enter.
By entering this web you agree that you are 18 or over prepared to see the most disgusting sickest pictures ever seen".
16. The extent of his accessing of the various sites was shown in a large bundle of over 200 pages which contained a detailed record of all the 'hits' on particular sites and coloured print outs of what appeared on them. This material was not given to the Committee in advance and so they were particularly dependent on the manner in which the prosecutor presented the case and the specific matters to which he referred. They had an opportunity to consider the material when they retired to consider the appropriate penalty. The transcript shows that they retired from 1.10pm until 3.15 p.m. During that time they had lunch.
18. In due course, he admitted deliberately accessing at least three pornographic sites. The main one, which was visited on 4 nights, contained a warning on its cover in these terms:-
"This web site contains sexually explicit adult orientated material that is intended only for individuals 18 years of age or older The material on these pages is ADULT ORIENTATED SEXUALLY EXPLICIT and related to XXX material. This site provides access to images of NUDE ADULTS possibly engaging in SEXUAL ACTS and other material of adult nature "
He also admitted visiting two other sites. One contained the name 'lolita'. This is said by CRHP to be of some importance since the word 'lolita' suggests images of underage girls. The cover of that site is copied. Under an illustration describing what is on offer, this is said:-
"ABSOLUTELY SHOCKING VIDEOS! Only on our site you will find really unique cases concerning loss of virginity. You must see this More than 2Gb of Hardcore teenagers video. More than 20,000 of high quality photos! Take a .. tour right now"
Below this appears the following:-
"All models appering (sic) on the website are 18 years or older".
The other website's cover has a number of photographs of naked models in various poses. It appears to be a Dutch based site. It boasts the 'hottest bookmarks' and 'more hot girls'.
" it is accepted that Steven Truscott may not have set out initially to deliberately access each and every one of these sites, to which we mean that there must be an element of some cascading but only some, the fact is that he did repeatedly and deliberately visit [some pornographic websites]. He, further, continued to go back, again and again, night after night, surfing the net accessing the images you see in your bundle at a time when he was supposed to be the nurse in charge of the Adolescent Unit. We say he was deliberately setting himself adrift on the sea of internet porn and that he did deliberately and repeatedly put himself into a position where he knew he was going to be accessing sexually explicit and offensive material".
Later, the prosecutor said this:-
"What one does not have evidence of in this case is evidence of downloading of images to a separate file. This is in no way a suggestion in relation to Mr. Truscott, the case is not put on this basis, but with a professional paedophile one would expect to find those images in specialist files on their computer away from prying eyes".
22. The director's report to the meeting held by CRHP to decide whether to make a reference under s.29 of the 2002 Act is in the bundle. After citing the passage from the Committee's reasons stating that the case had not been put on the basis that Mr. Truscott's conduct had posed a risk to patients and the reference to the failure of the police to prosecute, he says:-
"This seems to ignore the fundamental point that this was a Paediatric Nurse with professional access to adolescents in the course of his everyday work who while on duty was accessing pornography which it can be seen included what I would consider to be a significant proportion of explicit images of girls (many apparently but some obviously) under the age of puberty far less the age of consent .There are about twenty images [of naked female children] amongst those supplied to us. We and the PCC have only been provided with a sample of probably more than a thousand images that were on the computer used by Mr. Truscott. If the images of naked children have been intentionally accessed then this is obviously worrying".
23. He accepts that there was an element of 'cascading' and that Mr. Truscott could not have deliberately sought out or taken account of all the images that were coming onto his screen. He concludes:-
"There is little, if any, direct evidence that Mr. Truscott deliberately sought out images of naked children. Some of the sites visited specialised in 'lolita', 'pre-teen' or 'apparently under age' naked female images and this would have been quite apparent to Truscott from the web addresses of the sites amongst other things. However, this was not addressed at all in the PCC hearing and it is to be expected that Mr. Truscott would put down the appearance of these sites to 'cascading'. You may consider there to be at least an element of truth in this as the vast majority of the sites using 'lolita' or similar in their website addresses were visited in a single seven minute period on just one night where a total of six pages of files were downloaded within the relevant period. Mr. Truscott did, however, admit to visiting one of these sites, 'videololita', though there is no evidence of how he came to do this or whether he knew what it would contain.
It is also not clear whether all the naked images of children (or women appearing to be children) originated from this one seven minute episode as it is not easy to associate the pictures with the web sites from which they emanated. There are a few other references at different times to web sites containing images of 'teens' though there is also no evidence as to whether these were visited intentionally.
In my view the significant aspect of this case is his apparent propensity to seek out pornographic images of girls many of them quite clearly under the age of consent (and in my view many under the age of puberty), while carrying out a profession with very direct access to very vulnerable children. This, in my view, should have given the PCC cause for concern as to the wider child protection issues presented by the misconduct rather than the specific issue of the likelihood of children on the ward inadvertently seeing the images.
It must be accepted that we cannot be sure that Mr. Truscott engaged in criminal activity. There is the issue about whether he intentionally sought out the images but there is also the fact that none of the images of naked children involve sexual activity, so it is possible that these would not be considered to break the law. The police decided not to seek prosecution though there is no detail on the nature of the police enquiry referred to and it surprises me that in his position of trust the matter was not pursued further by the police although there is no way of telling exactly what form the police involvement took whether he was formally reported to them in relation to an offence or whether advice was sought.
It is apparent that when Solicitor for the Council started to lead the committee through the process of relating the web addresses to the thumbnail images, the acceptance that this was unnecessary on the basis that Truscott had admitted the misconduct, seems to have resulted in the committee not fully considering the exact nature of some of the images also the explanation that the police had viewed the images and deemed them to be adult pornography from sites that were not illegal may have deflected attention from their content.
There is reference in the transcript of his actions not being that of a 'professional paedophile' in that he had not catalogued his images into some sort of file when later Truscott admits to basic understanding of accessing the internet but not having the skills to download or file anything".
24. At the meeting of the CRHP, legal advice was given that caution should be exercised in giving weight to allegations or arguments that had not been raised at the hearing before the PCC and on which Mr. Truscott had therefore not had the opportunity to make representations. Concern was expressed that the PCC had not considered whether the material accessed might show a proclivity for behaviour which would make it inappropriate for Mr. Truscott to work with children and adolescents. He had shown little insight into his misconduct and a lack of judgment in accessing the images when on duty in the Unit. The conclusion was expressed thus:-
"The meeting concluded that there was a risk that the images accessed by Mr. Truscott did evidence an unhealthy sexual interest in young people and that this might subsequently be reflected in Mr. Truscott's work since he remained free to work with children and adolescents. It was recalled in this regard, and separately, that Mr. Truscott had already shown himself to have poor judgment in the workplace and little insight into the wrongfulness of his own actions. The meeting could not safely reach any conclusion on whether or not Mr. Truscott had intentionally accessed the images of young people. It considered, however, that the material before it disclosed a real risk and that it would be desirable to take action to protect the public if it were agreed that the sanction imposed was unduly lenient.
The meeting considered whether the sanction imposed by the PCC was unduly lenient. It noted that a more severe sanction was available and that Mr. Truscott remained eligible to practise. Indeed, Mr. Truscott had continued to practise in the field of paediatrics and this caused the meeting considerable concern in the circumstances of this case. Mr. Truscott had not shown any or sufficient insight into his admitted misconduct.
Attention was drawn to the fact that the web pages accessed by Mr. Truscott included a number that used the descriptions 'teens', 'pre-teens', 'lolita' or 'barely legal'. Looking at the transcript, Mr. Truscott had also apparently admitted to visiting a site called 'videololita'. There was no evidence as to whether Mr. Truscott had intentionally visited these sites and it was accepted that most of the sites with these descriptions were visited in one short period and that these visits might be explained by the concept of 'cascading' that Mr. Truscott had relied on at the PCC hearing. The meeting considered, however, that the PCC should have specifically addressed its mind to the risk implied by the presence of these web pages in the list supplied and to the existence of images of naked children or young people. In the circumstances where it was not clear precisely how and why Mr. Truscott came to access these images and where the PCC had not addressed itself to the risk that an interest in such images on the part of a paediatric nurse implied, it could not be said that the caution imposed afforded adequate protection to the public. Mr. Truscott remains free to work with children (and did so pending his disciplinary hearing before the PCC) and it could not be assumed that future employers would learn of the caution or of the facts underlying it".
25. Emphasis has been placed on the images of under age naked girls and the concern that must follow that this may show a dangerous trend in a paediatric nurse. It may well be that an unhealthy attraction to hardcore pornography coupled with the circumstances in which the visits to the sites took place and the previous history of taking drugs from the hospital shows that the public may be at risk and that, at least until he does something positive to address his problem, Mr. Truscott should not be able to work as a paediatric nurse. He did not seek to get out of the sites when the images were 'cascading' and, in the knowledge of what had happened, he went back to the sites night after night and, if he had not been caught, he was likely to have continued.
26. I fully recognise the force of these considerations. However, the evidence before the PCC, whether or not their attention was specifically drawn to it, would have justified a conclusion that, as he contended, Mr. Truscott had not deliberately accessed sites which produced images of naked under age girls. Suggestions of paedophilia were not put forward. Although a caution may seem a somewhat light penalty, it is regarded in the profession as a serious matter and its existence and the reasons for it will be disclosed whenever Mr. Truscott seeks employment as a nurse during the period of 5 years while it remains in force.
27. I do not doubt that the penalty was lenient. I am sure that if the PCC had decided that he should be removed from the register, an appeal against sentence would have been unlikely to succeed. But that is not the test and the adverb 'unduly' must be given its proper weight. Accessing adult pornography is not criminal and the circumstances in which Mr. Truscott accessed it demonstrates poor judgement but is perhaps more material to whether he could remain in his employment. It fully justified his dismissal.
28. This is very much a borderline case and I am satisfied that the CRHP was correct to refer it. However, the lack of deliberate accessing of what can be termed child pornography persuades me that undue leniency has not been established.
29. The burden rests on the CRHP to establish that the action in question was unduly lenient. There is an element of double jeopardy of which account must be taken. It is of less importance in the context of s.29 of the 2002 Act because the emphasis is on the protection of the public rather than punishment of the individual concerned.
30. I have been pressed by Mr. Lawson and Dr. Johnson with authorities which show that the court has been reluctant to interfere with penalties imposed by professional bodies since the members will have been chosen for their knowledge and experience of their professions and what is needed to protect their integrity. Those considerations are subsumed in the need for it to be shown that the penalty is unduly lenient and knowledge and experience is not likely to be so relevant in dealing with issues of fact. I would only add that the provisions of s.29(4) mean it is important for PCCs to make findings on matters which may be in issue in mitigation or aggravation of penalty.
31. In the result this appeal is dismissed.