Mr David Graham Warren

: Social worker

: SW42524

: Final Hearing

Date and Time of hearing:10:00 30/01/2017 End: 17:00 31/01/2017

: Health and Care Professions Council, 405 Kennington Road, London, SE11 4PT

: Conduct and Competence Committee
: Suspended


Allegation (with agreed amendments):
During your employment as a Social Worker for Leicester City Council:


1. In relation to Service User A and Service User B, between approximately April 2012 and August 2012 you:

a)  Did not take appropriate action when you were made aware that the direct payments were being spent inappropriately;
b) Did not review the progress of the care package in place;
c) Provided your line manager with inaccurate information about the    progress of the care package;
d) Did not follow the correct case closure procedure when closing the case;
e) Did not complete a ‘short form’ assessment of Service User B’s finances.


2. In relation to Service User C you:
a) Between approximately February 2014 and March 2014, arranged a meeting with the service user’s residential provider to discuss the residential provider’s concerns about the service user’s sister but you did not inform and/or invite the sister;
b) In March 2014, undertook a reassessment of the service user without involving the service user’s sister;


3. In relation to Service User D, when the service user moved to a new residential placement in May 2014, you did not provide the new residential placement with:
a) An up-to-date Support Plan Supported Assessment Questioner (SAQ)
b) A copy of the service user’s Care Plan, otherwise known as a Support Plan
c) Information about the service user’s risk to children


4. In relation to Service User E you were made aware that the service user had been slapped by another resident in or around November 2013 but you:
a) Did not complete a Notification of Concern;
b) Did not investigate the incident and/or take any safeguarding action.


5. In relation to Service User F you were made aware that the service user had been pushed on two occasions by another resident in or around March 2014 but you:
a) Did not record the incidents on the system in a timely manner;
b) Did not complete a Notification of Concern;
c) Did not investigate the incident and/or take any safeguarding action.


6. In relation to Service User G you were made aware of an alleged assault on the service user in or around September 2013 but:
a) Did not sufficiently explore the incident;
b) Did not put a plan in place to safeguard against further allegations.


7. In relation to Service User H you were made aware that the service user had hit or been hit by other residents on more than one occasion in or around March 2014 but:
a) Did not complete a Notification of Concern;
b) Did not investigate the incidents and/or take any safeguarding action.


8. You did not consistently ensure that documents were uploaded on SmartSave.


9. The matters as described in paragraphs 1 - 8 constitute misconduct and/or lack of competence.


10. By reason of your misconduct and/or lack of competence your fitness to practise is impaired.




1. The Registrant commenced his employment with Leicester City Council (the Council) as a social worker on 23 May 2005. From 2011 and during the time of the allegation, he was working as a social worker within the Council’s Locality Team, working within adult services. His Line Manager was JB, Witness 2.


2. In September 2013, concerns were raised by the Council’s Finance Team in relation to inappropriate spending of Direct Payments on behalf of two service users, known in these proceedings as Service Users A and B, for whom the Registrant was the allocated social worker. Direct Payments are payments made by the Council for the social care of service users, where they arrange and pay for care themselves rather than receiving care from the Local Authority. There was not an exhaustive list of what Direct Payments can be used for but it should be set out clearly in the support plan and some use of payment may need additional authorisation.


3. An investigation within the Council led to the uncovering of additional concerns about the Registrant’s practice. The investigation was undertaken by RK, Witness 1, a Locality General Manager at the Council and the Investigating Officer for this matter.


4. The investigation uncovered a number of alleged failings by the Registrant, concerning management of cases and recording. The concerns included inappropriate action or inaction on cases, some of which involved harm or potential harm to service users.


5. The matter was referred to the HCPC by the Council.


Decision on Facts:


6. The Panel heard from RK and JB. The Panel also heard the Registrant’s evidence by telephone. The Panel read all the documents and accepted the Legal Assessor’s advice. In reaching its decisions, the Panel applied the civil standard of proof to its decisions on the facts and used its own judgement at the grounds and impairment stages. At the grounds stage, the Panel also referred to the HCPC’s Standards of conduct, performance and ethics (the Standards) and the Standards of proficiency for Social Workers in England (the Standards of proficiency).


7. The Panel’s impression of the witnesses was as follows:
The Panel considered that, on occasion, RK and JB lacked clarity within their own evidence and were also not consistent with each other’s evidence. This was exemplified, in the Panel’s view, by the following:
• RK stated that the authorisation of a computer and a holiday, the subject matter of particular 1(a) might each be appropriate depending on the needs of the service user, as a holiday, for example, could be viewed as respite. Each case was decided on its own merits. The Panel noted that JB was somewhat uncertain about these items, stating that, prior to the allegations arising a holiday, could be used for respite but by this time the practice had changed and it would no longer be authorized.
• Whereas JB was firm in her view that “batching” documentation was not a practice she was aware of or would support, and that the documents must be passed to the Council’s administration team immediately. RK in her oral evidence stated that she did not have a view on that matter, she was relaxed about the process.
• RK stated that KH was a support worker and had no role in the Direct Payments process, whereas, JB stated that KH had been involved in the Direct Payments process and was described by her as a Direct Payments “broker”, which compared similarly to the Registrant’s evidence on KH.
• RK continually referred to “custom and practice”, and asking colleagues, rather than referring to clear written guidance in relation to when a Notification of Concern was required and this made her evidence unclear. She had been clear that all safeguarding incidents should trigger a Notification of Concern, including “anything that makes you uncomfortable”. She referred to the decision-making process on this by a social worker as being a matter of “common sense”. The Notification of Concern guidance itself was unclear.
• However, the Panel noted that, for example, in the case involving Service User G, JB stated that this might not have been an “automatic safeguarding issue”, but, rather, was “an incident”. The Panel found this not to be helpful, as it left it unclear as to what was a ”safeguarding issue” as opposed to what was an “incident”, and what the difference between the two terms might be. Probing JB on that further did not take the matter forward for the Panel. JB finally stated that a Notification of Concern should be completed when a care home was not meeting the service user’s needs, particularly where there had been an incident. In her view, where there was a safeguarding issue, it was usual that a Notification of Concern was completed. This was not the impression that RK had given on this matter in her evidence.


8. The Panel concluded that the Registrant’s evidence was based on his honest belief that what he had done or not done was in the service users’ best interests and anything alleged had not been deliberate. The Panel considered that he was a committed social worker with the best interests of service users at heart. Where he recognised his failings, he admitted them, but saw these failings as minor administrative issues. The Panel’s view was that he did this without considering the wider implications. The Panel also concluded that his written and oral responses tended to try to lay the blame on others involved. He was inclined to be preoccupied with his view that RK had a vendetta against him, as well as the way that the Council investigated, rather than focusing on the allegations against him in this jurisdiction. The Registrant relied on having exercised his professional judgement on most occasions of the alleged failings, without considering the importance of discussing matters with his line manager or obtaining authorisation.


9. The Panel’s decisions on the Particulars of the Allegation, determined separately, are as follows:

1a: Proved.


10. The Registrant was the allocated social worker for Service Users A and B. As such, his duty was to challenge potentially inappropriate use of Direct Payments and to alert his line manager and the finance department about how the Direct Payments have been used.


11. The Panel heard that the Direct Payments for Service Users A and B fell within the “Right to Control” policy, and the guidance might not have been sufficiently detailed. However, both RK and JB stated that any use of Direct Payments not specified within a support plan would need to be authorised.


12. The Registrant stated in his oral evidence that the purchase of a computer was inappropriate use of Direct Payment monies. However, on receiving an email from the daughter which said that a computer had been purchased and a holiday to India was being considered using Direct Payment money, the Registrant chose to take no action.


13. The Panel considered that the Registrant’s reference, in his oral evidence, to laying the responsibility for inappropriate use of the Direct Payment money on the Council’s finance department, was not appropriate as in the Panel’s view the Registrant also had a responsibility to take action.

1b: Proved.


14. The Panel noted that the Registrant admitted in his oral evidence not recording a review and the Panel accepted the evidence of RK and JB that there was no review on the system.

1c: Not proved.


15. According to the daughter of Service Users A and B (daughter A), and the care agency, the care package was working well, as shown in the email from daughter A to the Registrant dated 22 June 2012. Furthermore, the Panel accepted that it was not a mandatory requirement that Service Users A and B should attend the Day Centre, as stated by the Registrant in his oral evidence. In the Panel’s judgement, the care package encompassed more than just the attendance at the Day Centre. As there had been an expression of satisfaction to the Registrant by daughter A, the Panel concluded that it was not proved that the Registrant had provided inaccurate information about the Care Plan’s progress.

1d: Proved.


16. The Panel accepted the evidence of RK and JB, as well as the oral evidence of the Registrant, that he had not followed the correct case closure procedure.

1e: Not proved.


17. The Registrant’s evidence was that he must have completed this document as Direct Payments funding is not calculated by the finance department without it. The HCPC did not produce to the Panel any written evidence in the records to demonstrate this alleged omission. The documentation (page 74 of the exhibits’ bundle) before the Panel showed that the Registrant had completed documentation in relation to Service User B and this did not highlight that any other documents or information were missing.

2a: Proved.


18. The Panel accepted the evidence of RK and, as well as that of the Registrant and the documentation, that the Registrant did not invite Service User C’s sister to the meeting between February and March 2014, or inform her of it. An entry in service user C’s records by the Registrant dated 9 April 2014 stated that the Support Assessment Questionnaire had been completed and that there had been a meeting “re issues presented by the involvement of the sister”.

2b: Proved.


19. The Panel accepted the evidence of RK and, as well as that of the Registrant and the documentation, that the Registrant did not involve Service User C’s sister in the reassessment in March 2014. An entry in Service User C’s records by the Registrant dated 9 April 2014 stated that the Support Assessment Questionnaire had been completed. Given the sister was a key person in the life of Service User C, and particularly as the sister had expressed to the care home some concerns, the Registrant should have obtained the sister’s views as part of the reassessment of Service User C’s needs. 

3a: Proved.


20. The Panel concluded that the documentation demonstrated that the Registrant did not provide Service User D’s new residential placement with an up to date Support Plan Support Assessment Questionnaire. In any event, the Registrant admitted that he did not, on the basis that there was no new information and that it was not needed.

3b: Not proved.


21. The Panel took into account that the case records for Service User D, dated 23 May 2014 as completed by the duty worker, stated that the care home manager had informed the duty worker that “all he has is a support plan”. Therefore, the Panel has concluded that the HCPC has not produced any specific evidence that it was not the Registrant who provided that support plan.

3c: Not proved.


22. The Panel concluded that there was insufficient evidence to demonstrate that the Council had been informed that Service User D had posed a risk to young children. Furthermore, there was no evidence that the Psychologist involved had discussed the case with the Registrant about that concern. The Panel accepted the Registrant’s evidence that he had knowledge of this service user over many years and that he had no history of involvement with young children.

4a: Proved.


23. The Panel noted that a Notification of Concern was not completed for Service User E. This was agreed by the Registrant, but he stated that he did not do so as he had made a professional judgement. Both HCPC witnesses confirmed that a Notification of Concern would have been appropriate in this case.

4b: Proved.


24. The Panel concluded that the evidence demonstrated that the Registrant, on receiving the incident report, did not investigate the incident of climbing onto and then slapping of Service User E by another resident or take any safeguarding action in relation to this. The Panel noted that the Registrant stated that he did not do so, using his professional judgement, as it was an isolated incident, the service user had not been intimidated and the assault had been insufficient to cause even a bruise on the service user. The Registrant did not make it clear on the records how he came to this conclusion. The Panel rejected the Registrant’s conclusions based on his professional judgement, as not being acceptable. The Panel considered that the Registrant, as an experienced social worker, should have known that such an incident required further investigation, with potential for this to lead to safeguarding action. 

5a: Proved.


25. The Panel noted the HCPC exhibits bundle showed that the incidents took place on 17 and 18 March 2014 and were not reported in the documentation by the Registrant until 4 April 2014. Furthermore, the Registrant admitted that he did not record them in a timely manner. The Panel accepted the HCPC’s evidence that acceptable practice was 3 - 4 days.

5b: Proved.


26. There was no Notification of Concern on this matter raised by the Registrant and he admitted that he had not done so, as he was using his professional judgement.

5c: Proved.


27. The Panel accepted the evidence of JB that no investigation was undertaken by the Registrant in relation to the two pushing incidents of Service User F. He also did not take any safeguarding action in respect of either incident. The Registrant accepted this but stated that he had used his professional judgement.

6a: Not proved.


28. The Panel was satisfied that the Registrant had sufficiently explored the incident. He had notified the Police of the alleged assault on Service User G by Service User G’s support worker and the Police had taken no further action, determining the accusation made by Service User G as being unfounded based on CCTV evidence. Furthermore, the Registrant had spoken about the incident to JB and the support worker’s manager.
6b: Not proved.


29. The Panel was satisfied that the Registrant had no duty to put a plan in place to safeguard against the potential for false allegations from Service User G. It would have been good practice to remind the care provider to put a plan in place to protect staff.
7a: Proved.


30. The Panel concluded that the HCPC witnesses demonstrated that there was a duty on the Registrant to complete a Notification of Concern for Service User H, as the Service User had been hit by other residents, or had hit other residents, on seven occasions in one month. The Registrant did not do so, and admitted that he relied on his professional judgement and the care home’s view that medication could have caused this type of behavior. The Panel’s view was that the Registrant should have considered implications for Service User H and others.
7b: Proved.


31. The Panel concluded that the HCPC witnesses demonstrated that there was a duty on the Registrant to investigate the incidents and to raise them as safeguarding issues. The service user had been hit by other residents, or had hit other residents, on seven occasions in one month. The Registrant did not investigate or take any safeguarding action. He relied on his professional judgement and information from the care home manager that the service user’s medication could have caused this type

of behaviour.

8: Not proved.


32. Although the HCPC produced some evidence that the Registrant should have been uploading information on SmartSave more frequently than he did, nevertheless, RK stated in her oral evidence that she did not think the Registrant’s practice in this area was of concern. In view of the conflict in the evidence produced by the HCPC on this issue, the Panel finds that it has not discharged the burden of proving this particular against the Registrant.


Decision on Grounds:


33. The Panel determined that the Registrant was a social worker of 16 years’ experience and who knew what was expected of him. He presented to the Panel in his oral evidence as a confident social worker exercising his professional judgement. Moreover, JB stated that she had no concerns about his performance in the past and no worries about the service users under his care. For these reasons, the Panel concluded that the facts found proved do not amount to a lack of competence.


34. When taken in the round, the Panel, in its judgement, concluded the following on the facts found proved:
i) By his actions and omissions, the Registrant put four vulnerable Service Users (E, F, G and H) and other vulnerable service users, who had been involved in the incidents in this case, at risk of further harm. Three of the service users lived at the same Care Home (E, F and H), which should have alerted the Registrant to a heightened need for a Notification of Concern on each occasion. In the cases of Service Users F and H, the physical assaults were on more than one occasion within a short space of time, which, again, in the case of the Registrant, should have alerted him to a heightened need for a Notification of Concern for each incident. Furthermore, in the case of Service User H, other residents were at risk of attack from him and this experienced Registrant should have realised this and completed a Notification of Concern on each occasion. In the case of Service User E, the Panel concluded that the Registrant’s oral evidence demonstrated that his professional judgement was not sound and did not protect the service user.
ii) He caused extra financial costs to the Council by his failings in relation to the inappropriate spending of Direct Payments for Service Users A and B;
iii)  He caused unnecessary anxiety to a service user’s sister by failing to involve her in a reassessment of the service user by directly contacting her, in that he should have known that her knowledge of her relative might have been useful.
iv) He caused a loss of continuity of information by poor recording practices, such as relying on the prior knowledge of a support worker, resulting in colleagues, such as the Psychologist and the care home manager, being unaware of the progress/deterioration of the service users. In the case of Service User F, the month’s delay in putting the incidents on the system put the service user at increased risk of physical harm, as the Registrant’s colleagues would have had no knowledge of the incidents in that month.  This inadequate practice also jeopardised the need to identify any patterns of behaviour at the care home, which, in the Panel’s judgement, was a vital component of assessing risk and safeguarding all service users in the future.


35. The Panel concluded that there was no misconduct in relation to particular 2a for the following reason. The Panel accepted the Registrant’s oral evidence that, on that day only, he thought he was attending a “pre-meeting” and, as such, he was not expected to coordinate a full meeting. He saw his role as a mediator and he was awaiting the care home manager to arrange another date.


36. In the Panel’s judgement, when taken in the round, the Registrant’s identified failings amount to a breach of several of the fundamental tenets of the profession. Specifically, the following paragraphs of the HCPC’s Standards and Standards of proficiency:


The Standards:

1: You must act in the best interests of service users.

6: You must act within the limits of your knowledge, skills and experience and, if necessary, refer the matter to another practitioner.

7: You must communicate properly and effectively with service users and other practitioners.

10: You must keep accurate records.

The Standards of proficiency:

1.1: Know the limits of their practice and when to seek advice or refer to another professional;

1.3: Be able to undertake assessments of risk, need and capacity and respond appropriately;

1.5: Be able to recognise signs of harm, abuse and neglect and how to respond appropriately;

2.2: Understand the need to promote the best interests of service users and carers at all times;

2.3: Understand the need to protect, safeguard and promote the wellbeing of children, young people and vulnerable adults;

2.4: Understand the need to address practices which present a risk to or from service users and carers or others;

4.2: Be able to initiate resolution of issues and be able to exercise personal initiative;

4.4: Be able to make informed judgements on complex issues using the information available;

4.5: Be able to make and receive referrals appropriately;

10.1: Be able to keep accurate, comprehensive and comprehensible records in    accordance with applicable legislation, protocols and guidelines;

10.2: Recognise the need to manage records and all other information in accordance with applicable legislation, protocols and guidelines;
11.2: Recognise the value of supervision, case reviews and other methods of reflection and review;

14.3: Be able to prepare, implement, review, evaluate, revise conclude plans to meet needs and circumstances in conjunction with service users and carers.


37. The Panel determined that the accumulation of the identified failings in the Registrant’s practice reflect conduct that falls far short of what would have been proper in the circumstances of the case and is a serious departure from acceptable practice. The conduct posed a risk, both at the time and in the future, to service users, colleagues, relatives and the Council. For these reasons, the Panel has concluded that the facts found proved are so serious as to amount to misconduct.


Decision on Impairment:


38. The Panel considered that the Registrant had been impaired at the time of the events as he had fallen far below the standards expected of him, putting the health and safety of the service users at risk. Furthermore, in the Panel’s opinion, his conduct at the time undermined public confidence in the profession of social work, as the public would be entitled to rely on the ability of a social worker to provide a consistent and safe service, which he failed to do.


39. The Panel next considered whether there had been any remediation in the intervening period and concluded that the Registrant had not provided any evidence that he had commenced such remediation. In the Panel’s judgement, the Registrant had demonstrated little insight into his failings in his written or oral evidence. The Panel determined that the Registrant’s tendency to blame others was unacceptable in a professional of his standing and experience. The Panel also concluded that the Registrant has not demonstrated any regret or remorse or shown how he had reflected and/or might have understood how the effects of his actions and omissions might have impacted on the service users concerned, their respective relatives, his work colleagues, his former employer and the profession as a whole. In the Panel’s opinion, the Registrant’s misconduct found proved has brought the profession of social work into disrepute.


40. In the Panel’s judgement, the Registrant’s lack of insight outweighed the fact that he has had a blemish free 16 year career as a social worker, these were not isolated incidents. Without appropriate insight and acceptance that his actions and omissions were unprofessional and unacceptable, and without remediation in these identified failings, the risk of repetition is high. For these reasons, the Panel concluded that the Registrant remains a risk to service users. In the Panel’s judgement, were the Registrant be declared not to be impaired, this would put the public at risk of harm and would undermine public confidence in the profession and in the regulatory process.


41. For these reasons, the Panel has determined that the Registrant’s fitness to practise is impaired on the grounds of misconduct.

Decision on Sanction:


42. After the Panel reached its decision on the facts, grounds and impairment the written determination was at the same time handed to the Presenting Officer and emailed to the Registrant. After some initial difficulty in accessing the attachment containing the written determination, the Registrant was able to read it.


43. The Panel subsequently convened in open session for the purposes of receiving submissions on the issue of sanction. The Registrant participated by telephone during this stage of the case.


44. The Presenting Officer urged the Panel to have regard to the HCPC’s Indicative Sanctions Policy.  She identified aggravating factors identified by the Panel’s decision on the allegations, in particular that the failings were not isolated but repeated over a period of time, that there was lack of insight, an absence of remediation and a significant risk of recurrence.  She also drew attention to the evidence of JB, the Registrant’s Line Manager, that before the events with which the Panel has been concerned in this case, she had not received complaints about the Registrant’s work.


45. The Registrant confirmed that he had been aware of, and had had access to the Indicative Sanctions Policy document.  He told the Panel that he had retired over two years ago and had no intention of returning to practise as a social worker.  He indicated that he was content for the Panel to make any sanction decision they are empowered to make.


46. The Panel approached the issue of sanction on the basis that a sanction is not to be imposed to punish a registrant against whom a finding has been made.  Rather, a sanction is only to be imposed to the extent that it is required to protect the public and to maintain a proper degree of confidence in the registered profession and in the regulation of it.  As a finding that an allegation is well founded does not require the imposition of a sanction, the first decision to be made in any case is whether the particular findings require a sanction. If a sanction is required, the available sanctions must be considered in an ascending order of seriousness.  In the present case the finding is one of misconduct which means that the whole sanction range up to, and including, the making of a striking off order is available. The Panel confirms that it has applied this approach in reaching the decision.


47. The view of the Panel is that the Registrant’s misconduct in this case is serious. The Panel does not propose to repeat what has already been said in the determination on the allegations, but it should be recorded that the failings were numerous, concerned a number of different service users and continued over a significant period of time. Although they were failings of a type that are capable of being remedied, in fact they have not been remedied.  The Registrant has little insight into his shortcomings and of the actual and potential consequences of them. Against this, the Panel acknowledges the Registrant’s earlier good record which indicates that he is capable of practising safely and effectively.


48. The Panel is of the view that the findings made require the imposition of a sanction. Further, a caution order would not sufficiently reflect the seriousness of the findings. 


49. The Panel next considered a conditions of practice order. Even if the Registrant had a current intention to practise, a conditions of practice order would not be appropriate as there are no workable conditions that could be formulated that would sufficiently protect Service Users. 


50. It follows that the Panel has been left to consider the sanction outcomes of suspension and striking-off.  That these are the realistic options accords with the Panel’s view that without significant steps being taken towards remediation, the risk to service users by the Registrant is unacceptably high. The Panel’s view is that there is a continuing need to protect the public as well as consider the reputation of the profession, upholding proper standards of a registered social worker and maintaining confidence in the regulatory process. The Panel noted the Registrant’s position that he has no intention of returning to practise as a social worker. Notwithstanding his position in this regard the Panel is only too aware that such a view may well change after a period of reflection by the Registrant. It has already been recorded that the Registrant is a social worker who is capable of safe and effective practice.  Despite what he has said today about not wishing to return to practise as a social worker, the Panel would not wish to remove from him the opportunity of reconsidering that view by making a striking off order.  Accordingly, in the judgement of the Panel the appropriate sanction today is the making of a suspension order.  In the judgement of the Panel the appropriate length of the period of suspension is 12 months, the maximum period permissible.


51. The Registrant should be aware that the suspension made today will be reviewed before it expires.  When it is reviewed, the reviewing Panel will have the opportunity to make any sanction decision that could have been made today.  This will include the making of a striking-off order.  If the Registrant wishes to avail himself of the opportunity of addressing the shortcomings identified by the present Panel, then he should present clear evidence of steps taken towards remediation to the reviewing Panel. He should also demonstrate how he has gained insight. The order to be made by the reviewing Panel will, of course, be a matter for that Panel to determine, but the Registrant would be well advised to approach the review on the basis that if he does not wish to avail himself of the opportunity to remediate the findings made, there is real prospect that the reviewing Panel will make a striking off order on the basis that no lesser sanction than further suspension would be appropriate, and a further period of suspension would serve no useful purpose.



That the Registrar is directed to suspend the registration of Mr David Graham Warren for a period 12 months from the date this order comes into effect.

The order imposed today will apply from 27 February 2017. 

This order will be reviewed again before its expiry on 27 February 2018.


This Final hearing of the Conduct and Competence Committee was originally scheduled to take place from 7 to 10 March 2016 but adjourned with no evidence heard.

The reconvened Final hearing took place from Monday 22 August 2016 to Thursday 25 August 2016, and adjourned due to lack of time. 

This hearing reconvened on Monday 30 January 2017.

Hearing history

History of Hearings for Mr David Graham Warren

Date Panel Hearing type Outcomes / Status
24/01/2018 Conduct and Competence Committee Review Hearing Struck off
30/01/2017 Conduct and Competence Committee Final Hearing Suspended