Criminal Justice and Courts Bill

Earl Howe Excerpts

Monday 14th July 2014 Lords Chamber

[Lord Kennedy of Southwark]

My Lords, at Second Reading I made reference to this and other clauses in this section of the Bill. I said I believed that the Government were attempting to,

“close the loophole that Professor Don Berwick identified in his review of the events that took place at the Mid Staffordshire NHS Foundation Trust”,—[Official Report, 30/6/14; col. 1620.]

although of course these amendments have much wider implications for a wider group of employees looking after vulnerable people, as the noble Baroness, Lady Finlay, outlined. These clauses were added late to the Bill during its passage through the Commons and I do not believe that they were looked at in any great depth there. As I said at Second Reading, it seemed odd to me that volunteers were not also included in these clauses, so I hope the noble Earl can address that in his reply.

We have wonderful people working in the caring professions here in the UK and we have wonderful volunteers helping people, but we must be clear that an abuser who exploits people could easily be in either group. Look at the horror story of the actions committed by Jimmy Savile. He was a volunteer at numerous establishments that were caring for vulnerable people. He was never an employee at any of the hospitals he visited but it appears he had power, influence and keys, and the system in place failed his victims for decades.

There is always the risk of unintended consequences and we need to be very careful that these clauses do not create a culture where healthcare professionals would have their normal, everyday clinical decisions open to criminal investigation, as the noble Baroness, Lady Finlay, and my noble friend Lord Beecham outlined. I do not for one minute believe that that is the intention of the Government but we have to be very careful that that is not what is created or what people believe has been created. So the amendment moved by the noble Baroness, Lady Finlay, is very welcome as she attempts to bring clarity to the issues and talks about,

“a serious and substantial departure from the duty owed by the care worker to the individual in all circumstances”,

that,

“causes the avoidable death of, or serious harm to, that individual”.

For the same reasons, my noble friend Lord Beecham and I tabled Amendment 33, which makes it clear that clinical medical judgment exercised by a registered medical practitioner is excluded.

These are very serious matters. I hope that the Minister can address the points that I have made about volunteers and the whole question of the sanctions being applied only to the most serious cases, as well as those about harming transparency and improving excellence in care made so well by the noble Baroness, Lady Finlay, and my noble friend Lord Beecham.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, I am grateful to the noble Baroness, Lady Finlay, and both noble Lords for tabling these amendments, which give me the opportunity to explain the Government’s thinking behind these important new offences of ill treatment or wilful neglect.

The Government are clear that the ill treatment or wilful neglect of users of health or adult social care services by an individual paid to provide those services is never acceptable. It is for this reason that we accepted the recommendation of Professor Berwick and the National Advisory Group on the Safety of Patients in England to introduce a new, clear and specific criminal sanction for those guilty of ill treatment or wilful neglect. However, Professor Berwick’s original recommendation proposed that the offence should apply only in the most egregious cases, where the ill treatment or wilful neglect caused “serious harm or death”—in effect, a harm threshold. Amendment 30 would create a similar threshold by requiring both a “serious and substantial” departure from a care worker’s duty towards the victim and that the conduct must cause serious harm or avoidable death.

When we were developing these new offences, we gave careful consideration to these very issues. For us, it raised a number of difficulties. For example, if you set a harm threshold, you are effectively saying that any ill treatment or wilful neglect that fails to cause sufficient harm to meet that threshold can be tolerated. Similarly, a situation could arise where two people are subjected to the same behaviours by the same care worker with the same intent, but one is much more seriously harmed than the other. I cannot see how it can be fair that the lesser harmed victim cannot have the protection of the new offence simply because they have been fortunate enough not to suffer really serious harm.

We exposed these very concerns in our consultation on the formulation of the offence earlier this year. The overwhelming majority of those who responded supported our proposal that the offence should focus on the conduct of the care worker, not on the outcomes for the victim. The way in which the noble Baroness’s amendment is framed puts the focus of the offence back on to outcomes. Someone could be subjected to wholly unacceptable ill treatment or wilful neglect but the perpetrator could have a defence if they could show that their conduct did not meet the “serious and substantial departure” threshold of the noble Baroness’s amendment, that the harm suffered was not sufficiently serious or that the victim’s death was unavoidable.

I also have some concerns about that phrase “serious and substantial”. Guaranteeing an objective and consistent interpretation seems to be fraught with difficulty. I fear that care workers could find themselves with less certainty about when the offence might bite, rather than more.

This brings me to the other point I want to make in respect of Amendment 30. It relates to the imaginary case study that the noble Baroness put before us. We recognise that it is important that there should be clarity around the types of behaviours which will be captured under this offence, and I understand the concern expressed by some that, without this, there is a risk that care workers could be less willing to be open and honest when things go wrong.

There are a number of issues to consider here. First, and most importantly, it must be remembered that the underlying premise on which the offence is predicated is that any neglect must be wilful; that is, deliberate, or else completely reckless as to whether the conduct will cause harm. In the case of ill-treatment, the courts have interpreted this as being ill-treatment that was intentional or reckless. I can assure the Committee that this is in practice a high bar to get over. Demonstrating that that is the case to the standard of proof required in criminal law will not be easy. Nor do we want it to be. We know that the vast majority of care workers would never dream of setting out to ill-treat or neglect those in their care. In the example given by the noble Baroness, a balancing of priorities is taking place. The offence would not cover that situation, but accidents and genuine mistakes do happen, and we have formulated the offence to make it clear that such situations will not be captured by it, no matter how serious the outcome may be for the patient or service user. Care workers need have no fear that being open and honest when such an accident or mistake occurs will place them at risk of prosecution under the offence.

Other safeguards will be in place, besides the fundamental protection given by the formulation of the offence itself. As with a whole range of criminal offences, the Code for Crown Prosecutors means that a public interest test will have to be met before a prosecution is brought. Moreover, even in the unusual event of an alleged victim or their family deciding to pursue a private prosecution, the care worker has protection. They can exercise their right to refer the case to the Director of Public Prosecutions for scrutiny, who will have discretion to take over the case and close it down.

With regard to Amendments 31 and 32, I am aware that in his remarks at Second Reading the noble Lord, Lord Kennedy, raised the issue of whether the ill-treatment or wilful neglect care worker offence should include volunteers. We considered that very carefully during the development of these offences. Indeed, we again addressed the issue directly in the consultation in March. We know, of course, that it is not only formally employed care workers who can ill-treat or wilfully neglect those in their care. Sadly, it can happen in many situations, as the noble Lord rightly pointed out, but his amendments would bring a vast number of people within scope of the offence because “volunteer” has a wide interpretation. Family carers; people who provide assistance to friends or neighbours by, for example, taking them shopping or to medical appointments; people who help out in nursing homes at meal times; volunteer patient transport drivers—all such people, and more, would be caught by the amendments.

Our view is that there is a significant difference between those employed to provide these services and those who do so voluntarily. Paid arrangements give rise to a formal obligation to provide services to a reasonable standard. That represents a significant and important difference from informal arrangements, where there is no element of prescribed obligation. I am sure that it is not the intention to make subject to the criminal law all those people who, from the goodness of their hearts, are willing to give of their time and effort to help others.

I would add that we do already have in place arrangements to provide safeguards in such situations. For example, the Care Act 2014 includes provisions explicitly relating to the powers and duties of local authorities to assess and meet the needs of informal carers, such as friends and family carers. Moreover, where an individual is volunteering in, for example, a day centre or nursing home, there are nowadays statutory duties on the operators of those facilities to carry out appropriate checks on the suitability of the individual to do that work and ensure that they receive training in health and safety, safeguarding and other procedures necessary to provide protection for the users of that service. It is no longer the case that someone could just walk in off the street, offer their services and come immediately into contact with vulnerable patients or service users.

It is the Government’s view that these arrangements provide adequate safeguards in these specific circumstances in a far more proportionate way than applying this offence would do. The latter would also risk putting people off volunteering for fear of prosecution, however unlikely that prosecution might be in practice.

I turn finally to Amendment 33. Although I can readily understand the motive behind it, I have to say that I cannot agree that it is necessary, even on the “for the avoidance of doubt” basis which the amendment adopts. We have been clear from the outset that matters involving the exercise of informed clinical judgment by any healthcare professional, not just registered medical practitioners, should be outside the scope of these ill-treatment or wilful neglect offences. We addressed this explicitly during the consultation exercise and the offences have been formulated to ensure that this is the case. I reiterate my earlier remarks about the key element being that of wilfulness. There has to be intent to ill treat or neglect, or recklessness as to whether the perpetrator’s actions or omissions will cause ill treatment or neglect, for the offence to bite. For a surgeon making decisions about the relative priorities of two patients or the best course of treatment for a particular condition, the implications and effects of their decisions will be uppermost in their minds. They will be all too aware that their decision may cause further delay or discomfort in the short term, even though the longer-term outcome may be better, but in taking these sorts of decisions healthcare professionals are not deciding deliberately to ill treat or neglect. They are taking decisions in what they believe to be the best interests of the patient, taking into account other priorities. I cannot see how a doctor who can demonstrate that they have followed appropriate clinical practice and professional standards in exercising their clinical judgment would fall prey to this offence.

[Lord Beecham]

I can quite understand the Minister saying that he cannot see that. However, is there not a danger that members of the public will not see it that way? If this amendment were to be adopted, it would send a clear message to the public that clinical judgment is outside the scope of the general provision. Is that not something worth achieving? I cannot see that it costs anything in terms of the Government’s policy and its implementation. However, it sends a clearer signal not just to the profession but to those who might feel that they should have recourse to the law when it has resulted from clinical judgment. It would be better to make that clear from the outset in the legislation.

[Earl Howe]

I come back to my earlier point: the bar is set high here because wilful neglect has to involve ill treatment that was intentional or reckless. The courts have traditionally interpreted that in a very narrow way, which is as it should be. I say this again and on advice: we do not believe that a doctor exercising his or her clinical judgment would fall within the scope of that offence.

I should make a couple of other points here. Amendment 33 refers only to “a registered medical practitioner”. The implication of that would be that other types of healthcare professionals exercising clinical judgement would not be excluded because they are not specified. So, for example, a triage nurse working in an A&E department would have very reasonable cause for concern about the kind of clinical judgments that they have to make perhaps not being outside the scope of the offence, because they are not explicitly mentioned in the Bill. Clearly, I would not want to create that kind of confusion and I am sure that the noble Lord would not either.

I hope that I have been able to demonstrate that the Government have worked hard to ensure that a whole range of issues and concerns were properly considered in the formulation of the new offence of ill treatment or wilful neglect. In particular, I hope that I have been able to reassure the noble Baroness and the noble Lords on their specific concerns and that she will now feel able to withdraw her amendment.

[Baroness Finlay of Llandaff]

I am grateful to the Minister for such a full response to the amendment that I moved and to the other amendments. For the record, I make it absolutely clear that ill treatment or neglect is never, ever acceptable by anybody. I am certainly not trying to make wriggle room for anybody. It is clear in the way that this debate has gone that it is about the intention of the worker, and if they were badly intended—if they had mal-intent—then they should duly be picked up and indeed suffer the consequences of the harm that they may have inflicted.

I hope, though, that the Minister will consider that the guidance that goes with this needs to set out clearly the issues that we have debated today, as well as the point raised just now by the noble Lord, Lord Beecham, which relates to all the clinical professionals. As the Minister has just said, it is not just doctors; it will be nurses, physiotherapists and lots of others who will be exercising clinical judgment. There is something important about being clear that clinical judgment has an important role because of the message that it gives to the public, who may feel vexatious against the outcome of a well intentioned clinical judgment that, for whatever reason, just did not go right—not even that a mistake was made but just that the disease process, their expectations and the way that they interpreted the communication have perhaps been mismatched.

I hope that we might be able to have further discussion with the Minister about the issues around this. I beg leave to withdraw the amendment.

--- Later in debate ---

[Lord Kennedy of Southwark]

My Lords, I will be brief. This amendment was tabled by me and my noble friend Lord Beecham. It seeks to close what we thought was a loophole in the clauses that the Government introduced here. It seeks to introduce a criminal liability on a director of a corporate body or an incorporated association for failing to sack employees who have committed an offence of ill treating or wilfully neglecting an individual in their care. That seemed to us to be a serious omission on the part of the Government. As I said in my contribution on the previous group, these clauses did not get a huge amount of scrutiny in the other place; they were added very late. We think that this is a serious omission and that the Government should look at it very carefully. The amendment is a probing one, designed to get a response from Government at this stage. We may want to come back to it on Report, but I would be grateful if the Minister could give us his views on this. I beg to move.

[Earl Howe]

My Lords, I am grateful to the noble Lord for giving me the opportunity to deal with this important issue of individual liability, where a care provider offence has been committed. Professor Don Berwick was very clear, in his recommendation on the creation of the offence, that it should apply to organisations providing care as well as to individual care workers. We completely agree with that principle; however, we have deliberately formulated the offence in respect of care provider organisations somewhat differently from the care worker offence, for two reasons. First, we wanted to try to ensure that the care provider offence could be applied to an organisation as an entity in its own right, without the need to first identify and convict an individual of sufficient seniority within the organisation’s management hierarchy so that they could be seen as the controlling mind of the organisation. That is why Clause 18 is modelled on the corporate manslaughter offence. Secondly, we wanted to ensure that the focus of the care provider offence was unequivocally on the provider organisation as a whole. We deliberately chose not to create a situation where attention could be deflected on to an individual such as a director when the offence had been committed by the organisation’s board acting as an entity, not as individuals. The intention is that the care worker offence will apply in respect of individuals, with the care provider offence capturing organisational failings that have allowed ill treatment or wilful neglect to occur.

It seems to me that this amendment would risk creating exactly that possibility of deflection away from the organisation by specifying that in certain circumstances an individual director of a care provider organisation is to be treated as a care provider in their own right, irrespective of the activities of the remainder of the board. Moreover, given the way the care provider offence is structured, I have to say that I think there would be some difficulties in making out the elements of it in relation to an individual director. For example, I fear that the historical difficulties in extrapolating the existence of a relevant duty of care from the organisation as a whole to an individual director could also arise here, and if that duty cannot be demonstrated then the offence cannot apply in any circumstances.

Nevertheless, I reassure the noble Lord that it is the Government’s policy to strengthen corporate accountability in health and social care and to hold individuals to account where they are responsible for failings in care. It is for this reason that we are introducing a fit and proper person test for directors of care providers. Directors will also be liable for the care worker offence when committed by them. Also, Clause 22(2) to (5) clarifies that a conviction for the care provider offence would not preclude an organisation being convicted for a breach of the proposed new fundamental standards for health and social care or a health and safety offence on the same facts, if this were in the interests of justice. It would therefore also be possible to convict an individual on a secondary basis for such an offence under provisions such as Sections 91 and 92 of the Health and Social Care Act 2008 or Section 37 of the Health and Safety at Work etc. Act 1974. This ensures that existing liabilities are not reduced as an unintended consequence of the new offence.

I am afraid that it seems to me that the noble Lord’s amendment would be in direct contradiction of the Government’s position on how the care provider offence should be applied. I am therefore unable to accept it. I hope that the explanation I have given will enable the noble Lord to withdraw the amendment.

[Lord Kennedy of Southwark]

I thank the Minister for his explanation. I shall reflect on it. My only intention is to protect people and staff and that, where people or companies have done wrong, we deal with them properly. The points that he outlined may provide sufficient protection and guarantees. I beg leave to withdraw the amendment.