Tunnicliff v A Professional Conduct Committee of the Nursing Council

Case

[2015] NZHC 1092

21 May 2015

No judgment structure available for this case.

IN THE HIGH COURT OF NEW ZEALAND WELLINGTON REGISTRY

CIV-2014-485-11295 [2015] NZHC 1092

UNDER

the Health Practitioners Competence

Assurance Act 2003

IN THE MATTER OF

an appeal to the High Court pursuant to section 106(2) of the Health Practitioners Competence Assurance Act 2003

BETWEEN

NANO CHRISTINA TUNNICLIFF Appellant

AND

A PROFESSIONAL CONDUCT COMMITTEE OF THE NURSING COUNCIL

Respondent

Hearing: 13 April 2015

Counsel:

J P Coates and K Rademacher for appellant
M F McClelland QC and H S de Montalk for respondent
D D Vincent for Health Practitioners Disciplinary Tribunal

Judgment:

21 May 2015

RESERVED JUDGMENT OF DOBSON J

Contents

Leave to appeal out of time............................................................................................................... [2] Ms Tunnicliff ’s relevant conduct...................................................................................................... [7] The disciplinary proceedings and the Tribunal’s decision ............................................................[11] The approach to an appeal on penalty .......................................................................................... [17] The grounds of appeal..................................................................................................................... [24]

The Tribunal incorrectly identified aggravating factors and/or gave too much weight to the

identified aggravating factors ...................................................................................................... [27] The penalty was unnecessary to protect the public, to deter others, and the Tribunal failed to adequately explain why a penalty less than suspension was not appropriate .............................. [36] The Tribunal failed to act consistently with its own decisions...................................................... [41] The Tribunal failed to take into account the prospects for Ms Tunnicliff ’s rehabilitation ............ [45]

The Tribunal made incorrect findings in relation to Patient 81 ................................................... [52]

The Tribunal’s decision was disproportionate, excessive and substantively unfair ...................... [58] Outcome ........................................................................................................................................... [68] Costs ................................................................................................................................................. [77]

TUNNICLIFF v A PROFESSIONAL CONDUCT COMMITTEE OF THE NURSING COUNCIL [2015] NZHC

1092 [21 May 2015]

[1]      The appellant (Ms Tunnicliff) has appealed against the penalty imposed by the Health Practitioners Disciplinary Tribunal (the Tribunal) in respect of a finding that she was guilty of professional misconduct.1

Leave to appeal out of time

[2]      Section  106(4)(b)  of  the  Health  Practitioners  Competence Assurance Act

2003 (the Act) provides that an appeal must be lodged within 20 working days after notice of the decision is communicated to an appellant, or within any further time that the Court allows.  Ms Tunnicliff’s notice of appeal was filed some 12 months after the statutory period had expired, and she accordingly sought leave to bring her appeal out of time.

[3]      In seeking leave to appeal, Ms Tunnicliff deposed that the legal advisers who represented  her  before  the Tribunal  were  not  optimistic  about  her  prospects  on appeal.  Subsequently she experienced serious difficulty in seeking employment in the health sector.   She attributed this difficulty to the conditions imposed by the Tribunal as an aspect of the penalty.  Ms Tunnicliff therefore reconsidered the need for pursuing an appeal.   Having obtained more optimistic legal advice on her prospects on appeal, she commenced the appeal and sought leave to do so out of time.

[4]      The respondent (the PCC) opposed leave, arguing that the extent of delay was significant and the reasons provided for it were not compelling.   The PCC argued that the overall interests of justice did not favour the grant of leave, that the merits of the proposed appeal were weak, and that there were no issues of public importance that would justify entertaining an appeal out of time.

[5]      The Court of Appeal in My Noodle Ltd v Queenstown Lakes District Council summarised the factors relevant to a decision on an extension of time as including “the reason for the delay, the length of the delay, the conduct of the parties and the

extent of any prejudice caused by the delay”.2

1      Re Tunnicliff HPDT 570-Nur13-248P, 12 September 2013.

2      My Noodle Ltd v Queenstown Lakes District Council [2009] NZCA 224, (2009) 19 PRNZ 518 at

[19].

[6]      Apart  from  the  delay  in  achieving  finality  with  this  disciplinary  matter, granting leave would cause no material prejudice.   The circumstances leading to Ms Tunnicliff not pursuing a timely appeal are understandable.  As appears from the reasoning that follows, I do not accept the PCC’s argument that the appeal is without merit.   Given the importance of the matter to  Ms Tunnicliff, and the long-term adverse consequences that she credibly claims have resulted from the conditions imposed as part of the penalty, the interests of justice do favour granting leave to appeal.  I accordingly do so.

Ms Tunnicliff ’s relevant conduct

[7]      From 2005 to 2012, Ms Tunnicliff was employed by the Nelson Marlborough District  Health  Board (DHB)  as  a specialty clinic nurse in  rheumatology.    The disciplinary charge related to her conduct between 2010 and 2012.  Throughout that period, there was an expectation that, during or after every patient consultation, a nurse in Ms Tunnicliff’s position would create an appropriate electronic record.  That record would be added to the clinical records maintained by the DHB in relation to every patient.

[8]      In a rheumatology clinic consultation with Ms Tunnicliff in January 2012, a patient (Patient 81) had reported that she was experiencing “a funny feeling in her chest  and  pain  and  swelling  in  her  right  hand”.    She  recalled  Ms Tunnicliff explaining to her that Dr Porter, the rheumatologist, was away and would not be back for a further two weeks.   Patient 81 reported that Ms Tunnicliff told her she would talk to Dr Porter when he got back and, based on his advice, would be back in touch with Patient 81.  Ms Tunnicliff told Patient 81 that if she was concerned in the meantime, she should contact her general practitioner.  However, Ms Tunnicliff did not discuss Patient 81’s symptoms with any medical practitioner including Dr Porter after he had returned, and Ms Tunnicliff did not get back in touch with Patient 81.

[9]      As a result of the apparent omission in the records of Patient 81, the DHB conducted  an  investigation  that  revealed  an  absence  of  relevant  records  for  87 patients with whom Ms Tunnicliff had consulted.  The DHB discovered that in 2010 she had 42 patient appointments, 33 of which did not result in a clinical record being

made.  In 2011, she had 46 patient appointments and 35 were without an appropriate record.     In  2012,  up  to  late  March  when  the  investigation  was  undertaken, Ms Tunnicliff had 20 appointments, 19 of which were not appropriately recorded.

[10]     In late May 2012, Ms Tunnicliff was given informal notice of the preliminary decision by the DHB to terminate her employment, and she then resigned.  In June

2012, the DHB gave notice to the Nursing Council of Ms Tunnicliff’s resignation,

which it treated as being pre-emptive of termination on the ground of incompetence.

The disciplinary proceedings and the Tribunal’s decision

[11]     Thereafter, a PCC was appointed to investigate the conduct.  In July 2013, a disciplinary charge was laid by the PCC.   The charge was that Ms Tunnicliff had compromised patient safety by failing to document contacts with patients of the rheumatology service.   It cited 79 particulars of this having occurred after a consultation.   In addition, the charge alleged Ms Tunnicliff had compromised, or potentially compromised, the health and safety of Patient 81, as a patient in her care. This occurred when she failed to notify a medical practitioner of Patient 81’s advice that she was experiencing “a funny feeling in their chest and swelling and pain in their right hand”. The charge then contended that all the particulars, either separately or cumulatively, constituted professional misconduct.

[12]     The Tribunal hearing was conducted in August 2013, with the decision being delivered on 12 September 2013.  Having found Ms Tunnicliff guilty of professional misconduct,  the Tribunal  censured  Ms Tunnicliff  and  ordered  suspension  of  her registration as a nurse for nine months, ending on 20 May 2014.3

[13]     In addition, the Tribunal imposed the following conditions on her resumption to practice:4

·    she was to practice for a period of 12 months only under the supervision of a supervisor approved by the Nursing Council;

3      Re Tunnicliff, above n 1, at [86] and [88].

4 At [91].

·

that  supervision  was  to  include  at  least  monthly  meetings  with  the

supervisor, and was to focus on adequate note-taking and documentation

and compliance with her responsibilities as a nurse, with the supervisor to
report  to  the  Nursing  Council  on  the  supervision  that  had  been undertaken;

·

before resuming practice she was to complete a course approved by the

Nursing  Council  to  address  ethical  and  professional  obligations  of  a

registered nurse;

·

after resumption of practice, she was to practice for a period of three

years with personal supervision, with Ms Tunnicliff reporting annually to the Nursing Council;

·

Ms Tunnicliff was to meet the costs of all the supervision;

·

for a period of three years she was required to provide a copy of the

Tribunal’s decision to any existing or future employer;

·

for that three year period she was to advise the Nursing Council of the identity of her employer and any change in employer.

[14]

In

reaching  its  decision,  the  Tribunal  reviewed  various  considerations

affecting the relative seriousness of Ms Tunnicliff ’s conduct.  It listed what it treated

as the aggravating features in the following terms:

83.1     The period of time over which the offending occurred.

83.2     The number of patients affected by this offending.

83.3The risk that each patient was placed in and in particular, the risk that Patient 81 was placed in by a failure to report the concerns that were expressed.

83.4The fact that Ms Tunnicliff has sought to place responsibility for this offending on others such as her alleged unsupportive work environment, alleged inadequate training in the use of the electronic document management system and the other “workplace culture” matters  referred  to  in  her  letter  of  18 May  2012  to  the  Service

Manager, Specialist Services, Nelson Marlborough District Health

Board.

83.5Ms Tunnicliff’s  referral  in  that  letter  to  allowing  herself  to  be influenced by the medical professional in relation to documentation that did not meet best nursing practice.

83.6Ms Tunnicliff’s leadership role in NZNO and the standards that it tries to maintain, such as in the brochure “Documentation”, and Ms Tunnicliff’s knowledge of these.

[15]     As to the last of these matters, Ms Tunnicliff had been elected President of the  New Zealand  Nurses  Organisation  (NZNO)  in  2009.    In  explaining  to  the Tribunal the context in which her failures had occurred, she cited the extent of the commitment, which she put at around 20 hours per week, in discharging the responsibilities of the President of NZNO and that those responsibilities weighed heavily on her.   At the disciplinary hearing, the Tribunal invited both parties to comment  on  an  NZNO  brochure  entitled  “Documentation”.   The Tribunal  cited extracts from the brochure in its decision, including:

Accurate documentation is a critical element of nursing practice … Clinical records must be accurate, concise and include the care that has been given and/or is planned.  … When documenting in the clinical record many people may read the notes you have written. …

Counsel for Ms Tunnicliff had accepted that she was aware of the document.

[16]     The Tribunal then summarised the mitigating factors in the following terms:

84.1The fact that Ms Tunnicliff has acknowledged now, and to a large extent throughout, the inadequacies of her note-taking.

84.2The  (perhaps  fortuitous)  fact  that  there  have  been  no  adverse medical consequences for any of the patients in question including Patient 81.

84.3Ms Tunnicliff’s    cooperation    with    the    prosecution    process, acknowledgement of her acceptance of the Charge as made out and her agreement to the Statement of Facts which have all expedited the matter and confirmed her acceptance now of the situation.

The approach to an appeal on penalty

[17]     There has been a divergence of judicial opinion as to the correct approach in appeals from disciplinary tribunals that are by way of re-hearing.  The divergence

turns on a distinction between general appeals and appeals against an exercise of discretion.  Mr Coats urged me to prefer the approach applied in Austin, Nichols & Co Inc v Stichting Lodestar, where the Supreme Court approved the High Court reaching its own opinion on appeals from a tribunal.5   That approach was adopted by the Full Court of the High Court in Sisson v Standards Committee (2) of the Canterbury-Westland Branch of the New Zealand Law Society, which involved a challenge to the penalty imposed by a law society disciplinary body.6   If I took this approach,   it   would   be  incumbent   on   me  to  reach   my  own  view   on   the appropriateness of the remedy imposed.

[18]     In Sisson, the Full Court acknowledged that an earlier Full Court decision addressing solicitors’ disciplinary matters had favoured a bifurcated approach: professional misconduct findings were to be considered afresh, but penalty decisions were to be considered  on appeal by reference to the principles that  govern the

exercise of a discretion.7   However, it preferred the view taken in a more recent Full

Court decision that both misconduct findings and penalty decisions require an appellate court to reach its own view.8

[19]     For Ms Tunnicliff, Mr Coates fairly acknowledged the weight of recent High Court  authority  where  appeals  from  penalty  decisions  in  respect  of  health practitioners have adopted the approach from May v May.9     The High Court has treated penalty decisions in disciplinary proceedings as involving the exercise of a discretion, which means the appellate court must be satisfied that the Tribunal acted on  a wrong principle,  failed  to  take into  account  some  relevant  matter or took account of some irrelevant matter, or was plainly wrong.

[20]     In Roberts v A Professional Conduct Committee of the Nursing Council of

New Zealand, Collins J distinguished between the Court’s role in determining an appeal from a disciplinary finding, and the evaluative exercise involved in deciding

5      Austin, Nichols & Co Inc v Stichting Lodestar [2007] NZSC 103, [2008] 2 NZLR 141.

6      Sisson v Standards Committee (2) of the Canterbury-Westland Branch of the New Zealand Law

Society [2013] NZHC 349, [2013] NZAR 416.

7      At [14], citing Bhanabhai v Auckland District Law Society [2009] NZAR 282 (HC).

8      At [15], citing Hart v Auckland Standards Committee (1) of the New Zealand Law Society

[2013] NZHC 83.

9      May v May (1982) 1 NZFLR 165 (CA).

on penalty.10   The former would lend itself to a general appeal, but the latter is to be treated as an appeal from a discretion.  The approach adopted in Roberts has been followed in at least two more recent decisions in Joseph v Professional Conduct Committee and Katamat v Professional Conduct Committee.11

[21]     In Joseph, Ronald Young J summarised the approach that this involved in the following terms:12

(a)       to assess whether the Tribunal has correctly identified the relevant facts and other factors relevant to penalty.  This requires a de novo assessment by the appellate court.  If the appellate court differs from the Tribunal’s assessment of relevant factors, then it may itself assess the proper penalty;

(b)      if  the  appellate  court  is  satisfied  the  Tribunal’s  assessment  of

relevant factors is correct, then;

(c)       the appeal will only be allowed if the penalty is outside the range of penalties reasonably available to the Tribunal given the assessment undertaken. This recognises a proper element of discretion exercised by the Tribunal in setting a penalty.

[22]     By and large, judges are more likely to be comfortable placing themselves in the shoes of a law practitioners’ disciplinary tribunal when considering the appropriateness of penalty, because of their own experience as members of the legal profession.  Almost invariably judges will lack the same familiarity with the context in which penalty is assessed for medical practitioners.   However, the difference in approach between the cases cited cannot be rationalised on the basis that an appellate court forms its own view on penalty in the case of legal practitioners, but recognises that penalty is a matter of discretion for medical practitioners.

[23]     The Tribunal does have on-going disciplinary responsibilities for the conduct of health professionals, and has a responsibility to protect the public from conduct that is likely to be more life-threatening than comparably arises in disciplining legal practitioners.    That  difference  influences  the  appropriate  approach  to  an  appeal

where the Tribunal’s discretion on the terms for a penalty will be coloured by its

10     Roberts v A Professional Conduct Committee of the Nursing Council of New Zealand [2012] NZHC 3354.

11     Joseph v Professional Conduct Committee [2013] NZHC 1131; Katamat v Professional Conduct

Committee [2012] NZHC 1633.

12 At [39].

members’ experiences, and the Tribunal’s appreciation of context.   That expertise gives the Tribunal a real advantage over a judge on appeal.  For this reason, I will follow the approach set out at [21] to determine the appeal.

The grounds of appeal

[24]     The essence of Ms Tunnicliff’s appeal is that the conditions imposed were disproportionately harsh.  She has been unable to find any work in the health sector and has provided evidence of her unsuccessful attempts to do so.   She says the conditions imposed by the Tribunal have either discouraged potential employers, or precluded her employment in positions where the conditions for supervision could not be accommodated.   Mr Coates raised numerous more specific criticisms, all intended to support this general point.

[25]     For the PCC, Mr McClelland QC argued that the orders were proportionate, appropriate and reasonably open to the Tribunal.   He objected to  Ms Tunnicliff leading evidence of her unsuccessful attempts to find further work, arguing that the appropriateness of the orders was to be assessed by reference to matters as they were, and not with the benefit of hindsight.

[26]     Mr Coates cited eight grounds of appeal in challenging the penalty decision. Some of the criticisms can be grouped, and can be considered under six headings.

The Tribunal incorrectly identified aggravating factors and/or gave too much weight to the identified aggravating factors

[27]     Ms Tunnicliff sought to explain to the DHB the context in which she failed to make adequate clinical records of consultations.  She stated that she had significant difficulty adapting to the new electronic record-keeping system that the DHB had introduced in 2010.   She had hoped that a template would be designed for her by those responsible for information technology at the DHB, and that the pressure of her work might lessen to an extent that she could undertake training on how to dictate notes so that they were recorded in the correct way.  She also stated that a doctor  she  was  working  with  did  not  maintain  clinical  records  to  the  standard

contemplated by the electronic system, which lessened her own perception of the seriousness of her failures to complete the clinical records to the requisite standard.

[28]     The  Tribunal’s  decision  treated  these  explanations  by  Ms Tunnicliff  as aggravating the seriousness of her misconduct.

[29]     If, in the context of a criminal sentencing, a defendant attempted to explain offending conduct, it would be open to the sentencing court to reject the explanation as not constituting a valid mitigating factor.   Blaming others may signal a lack of remorse and failure to have insight into the circumstances of offending.  However, it would  generally  be  inappropriate  to  treat  such  explanations  as  rendering  the offending behaviour more serious.

[30]   The line between an ineffectual attempt to mitigate the seriousness of professional misconduct, and an explanation that suggests the misconduct is more serious, may be more difficult to draw.   In the disciplinary context, a subsequent acceptance of responsibility for misconduct could be taken into account as a mitigating factor.  It is understandable that the Tribunal might reject what it saw as Ms Tunnicliff’s attempts to share the blame for her omissions with others.  If such explanations are rejected, that could be weighed against any claim that she was contrite and regretted the omissions in an unqualified way.   In other words, her explanation might lessen the mitigating factor that might otherwise be taken into account in Ms Tunnicliff’s favour.

[31]     However, it is inappropriate to treat such an explanation as an aggravating factor when she has admitted the misconduct.

[32]     The   Tribunal   listed   Ms Tunnicliff’s   leadership   role   in   NZNO,   her involvement in maintaining standards, and her knowledge of the contents of the “Documentation” brochure as aggravating her misconduct.   It  is not possible to quantify the extent to which the Tribunal took these features into account.   Most likely, the Tribunal considered that because of Ms Tunnicliff ’s role with NZNO she could  be  expected  to  be  more  aware  than  other  nurses  of  the  importance  of adequately documenting clinical records.  Alternatively, in the negative sense, she

had less justification than nurses not involved in NZNO to be unaware of the relative importance of appropriately documenting clinical records.

[33]     Ms Tunnicliff had readily acknowledged that she was aware of the standards, so she did not argue she was unaware of what was expected of her.

[34]     Treating  a  heightened  level  of  awareness  of  the  importance  of  adequate record-keeping as an aggravating factor risks double-counting the criticisms legitimately made of the misconduct.  The starting premise is that the requirement to adequately document clinical records is both important and basic, so no competent nurse would be unaware of it.  A breach of the standard must therefore involve a conscious decision.  Awareness of the requirements is an aggravating factor inherent in any breach of the standard.  It double-counts that same factor if Ms Tunnicliff is treated as having committed more serious misconduct because she ought to be more aware than other nurses of how important the requisite record-keeping was.

[35]     I accept that the Tribunal erred when it mischaracterised these aspects of Ms Tunnicliff’s misconduct.  It follows, in terms of the sequence of considerations proposed in Joseph, that I will embark on my own assessment of an appropriate penalty in light of the remaining grounds of appeal argued by Mr Coates.

The penalty was unnecessary to protect the public, to deter others, and the Tribunal failed to adequately explain why a penalty less than suspension was not appropriate

[36]     These criticisms require a view to be formed on the relative seriousness of Ms Tunnicliff’s  misconduct  in  not  maintaining  adequate  clinical  records  for  87 patients over some 27 months.  Mr McClelland argued that this constituted one of the  most  serious  breaches  of  the  required  standards  that  had  come  before  the Tribunal.  Patient safety and the standard of care that could be provided depended critically on an efficiently maintained and constantly available record of previous consultations and treatments.   Ms Tunnicliff persistently ignored this fundamental and important requirement for a period of at least 27 months, and it was a deficiency that was likely to have continued unless her omissions were discovered by others. He argued that it was purely fortuitous that the safety of any of the patients involved had not been compromised.

[37]     Mr Coates argued that Ms Tunnicliff ’s practice of keeping a hard copy of her own individual patient records, and the continuity of her contact with the patients, meant that the failure to note her consultations in the  electronic clinical record should not be seen as significantly serious misconduct.   Once the failing was disclosed, Ms Tunnicliff accepted the need to change her ways, and the Tribunal ought to have been assured that she would do so.  She had co-operated with the DHB and subsequently with the course of the prosecution.  No patient suffered as a result of the inadequate record-keeping.

[38]     Mr Coates argued that, in such circumstances, the penalties imposed did not need to protect the public.   Ms Tunnicliff’s omissions were not so serious as to require a deterrent signal to be sent to others in the nursing profession.

[39]     The  ranking  of  seriousness  is  not  addressed  explicitly  in  the  Tribunal’s decision.     It  is  apparent  that  the  Tribunal  treated  it  as  substantially  serious misconduct and I am not persuaded it erred in ranking it in that way.  It must have been apparent to Ms Tunnicliff that the quality of medical treatment in all cases, and patient safety in some cases, would be compromised unless all providers of medical services had access to complete and accurate records of consultations and treatment for each patient. A relatively substantial penalty was therefore justified.

[40]     The extent of Ms Tunnicliff’s failures, in terms of the number of inadequately recorded consultations and the period throughout which her failures continued, certainly justified the Tribunal imposing conditions that constrained Ms Tunnicliff’s future work as a nurse.   The Tribunal might be criticised for naiveté if it simply accepted her assurances that she had turned over a new leaf, and relied on that to allow her to practice again, without any monitoring.  The Tribunal recognised there was a need to protect the public, and to set appropriate standards.  Given the range of powers  open  to  it,  a  period  of  suspension,  and  some  form  of  supervision  of Ms Tunnicliff after she resumed work as a nurse, were justified and appropriate components.

The Tribunal failed to act consistently with its own decisions

[41]     In the Tribunal’s discussion on the appropriate penalty, no reference is made to other decisions to establish or  consider comparability.   In responding to this criticism, Mr McClelland submitted that was simply because there were no other penalty decisions of the Tribunal dealing with sufficiently similar misconduct.  He made  the  point  that  counsel  for  Ms Tunnicliff  at  the  disciplinary  hearing  had

accepted there were no penalty decisions of the Tribunal in comparable situations.13

[42]     In arguing the appeal, Mr Coates’ two sets of submissions referred to nine decisions in which inadequate record-keeping by a practitioner comprised a part of alleged misconduct.14     I am not persuaded that useful comparison can be drawn between  the  penalties  imposed  in  those  cases  and  the  appropriate  outcome  for Ms Tunnicliff.  They all involved misconduct in relation to one or a small number of patients, where the inadequacy of record-keeping appears to have been a relatively minor or incidental aspect of the misconduct of concern for disciplinary purposes.

[43]     Mr Coates  also  cited  cases  where  comparably  severe  penalties  had  been ordered, and which he characterised as involving far more serious misconduct than Ms Tunnicliff’s.15   Those cases had elements of serious dishonesty offending, and in one case criminal violence and inappropriate prescription of morphine for a patient with  whom  a  doctor  was  having  an  intimate  relationship.    Mr Coates  validly submitted that these other cases in which practitioners were suspended for nine

months reflected more serious misconduct than was involved in Ms Tunnicliff’s case.  Beyond that general point, it is not realistic to measure the extent of difference that might reasonably have been recognised between Ms Tunnicliff’s circumstances and those of the practitioners being dealt with in those other cases.  The comparison

makes out the point that the length of suspension imposed here was, in relative

13     Transcript of submissions on penalty at 29/20-27 and 33/3-16.

14     J v Director of Proceedings HC Auckland CIV-2006-404-2188, 17 October 2006; Re Dr D HPDT 6/Den05/05D, 4 April 2005; Re Dr N HPDT 553/Med-12/225D, 3 July 2013; Re Johri HPDT 54/Med06/33D, 25 July 2006; Re Stubbs HPDT 316/Med09/113D, 29 July 2010; Re P

HPDT  30/Med05/11D), 12 April  2006;  E  v  Director  of  Proceedings  (2008)  PRNZ  1003;

Director of Proceedings v Vatsyayann [2012] NZHC 2588; Re Mistry HPDT 269/Nur09/123D,

10 December 2009.

15     Re  Dr D  HPDT  220/Med08/102P, 27  April  2009;  Re  Winefield  HPDT  83/Phar06/30P),  5

February 2007; Re Marchand HPDT 280/Med09/133P), 5  March 2010; Re Petcher HPDT
99/Nur07/54P, 10 May 2007.

terms, harsh.   However, that does not of itself make out an entitlement to have it varied.

[44]     Mr Coates also criticised the Tribunal for not taking into account the period during which Ms Tunnicliff had voluntarily removed herself from work in the health sector.   She had not sought re-employment between resigning and the disciplinary hearing substantially more than a year later.   I agree that the Tribunal could have given her some credit for that when assessing the appropriate length of suspension. That consideration would also need to take into account how modest the prospects of re-employment would have been while this matter was hanging over Ms Tunnicliff.

The   Tribunal   failed   to   take   into   account   the   prospects   for   Ms Tunnicliff ’s

rehabilitation

[45]     Mr Coates criticised the primacy that the Tribunal had given to protection of the public, and urged an interpretation of the statutory provisions that allowed the Tribunal to also have regard to the prospects for Ms Tunnicliff ’s rehabilitation.  He characterised the Act as balancing the need to protect the public with the promotion of an environment for competent health professionals, who are fit to carry out their jobs, to do so.  In a resourcing sense, Mr Coates suggested that it was contrary to the public interest for “over-regulation” to prevent health practitioners from attaining the required standards and being available to provide health services.

[46]     He cited from the explanatory note to the Bill which became the Act.  That stated the Bill was seeking “to create a supportive environment in which health practitioners can practice, maintain their competence throughout their careers, and learn from their experiences and the experiences of their colleagues”.

[47]     Mr McClelland rejected the idea that the Tribunal should be distracted by rehabilitative concerns.  He relied on s 3 of the Act which specifies that its principal purpose:

… is to protect the health and safety of members of the public by providing for mechanisms to ensure that health practitioners are competent and fit to practice their profession.

[48]     He submitted that any concern to have professionals return to work is of secondary importance.  Part 3 of the Act has relatively detailed provisions in relation to competence, fitness to practice and quality assurance.  The potential relevance of rehabilitating or restoring the competence of health professionals involved in disciplinary proceedings has previously been recognised.  For instance, Collins J in

Roberts:16

… where it is appropriate, the Tribunal must give consideration to rehabilitating health professionals.  This point was made by Blanchard J in B v B.  A reason why rehabilitation may be an important consideration is that health professionals and society as a whole make considerable investments in the training and development of health practitioners.  Where appropriate, the Tribunal should endeavour to ensure these investments are not permanently lost, provided  of course the practitioner is truly capable of being rehabilitated and reintegrated into the profession.

[49]     The  extent  to  which  the  Tribunal  can  accommodate  concerns  for  a practitioner’s rehabilitation at the same time as addressing the concern to protect the public in appropriate measure will depend on the circumstances of the case. As with the imposition of any penalty, the Tribunal ought to identify the least restrictive form of penalty that addresses the purposes for which the penalty is to be imposed.  The Tribunal would err if it preferred a rehabilitative approach and thereby failed to protect the health and safety of the public.  The penalty would be too harsh if the penalty constrains the practitioner’s ability to practice for longer than necessary, or in respects that are unnecessary to provide reasonable protection for the health and safety of the public.

[50]     Here,   Ms Tunnicliff’s   misconduct   reflected   a   persistent   practice   of inadequately documenting consultations for the clinical record.   There is no suggestion  that  this  material  blind-spot  in  her  practice  adversely  affected  the qualities she otherwise displayed.  The materials in support of her from others that were before the Tribunal tend to confirm her competence in other respects.

[51]     It accordingly presents as a serious, but curable, deficiency.  I incline to the view that the totality of the conditions imposed was more protective of the public

16     Roberts v A Professional Conduct Committee of the Nursing Council of New Zealand, above n 10, at [47] (citations omitted).

than  was  necessary,  and  correspondingly  failed  to  optimise  the  prospects  of

Ms Tunnicliff’s rehabilitation.

The Tribunal made incorrect findings in relation to Patient 81

[52]     In reviewing Ms Tunnicliff’s conduct relevant to the charge, the Tribunal characterised her communication with Patient 81 as a “promise” that she would report Patient 81’s concerns to Dr Porter on his return.  That characterisation elevates the  only  source  of  evidence  available  to  the  Tribunal,  which  was  the  agreed statement of facts. The relevant extract of that states:

[Ms Tunnicliff] stated that she would talk to Dr Porter when he got back and based on his advice, she would get in touch with Patient 81.

[53]     Mr Coates  was  understandably  uneasy  that  the  Tribunal’s  criticism  of Ms Tunnicliff’s conduct had an additional measure of condemnation because she was perceived to have broken a promise, when her failing was a somewhat lesser one in not carrying through on an assurance that she would speak to the doctor.

[54]     Ms Tunnicliff made a separate statement that she did not recall Patient 81 telling her that she had pain or swelling in her right hand.  The Tribunal treated that statement as a contradiction of the relevant part of the summary of facts to which she had agreed.   That criticism is misconceived.   The relevant sentence in the agreed statement of facts was entirely consistent in recording Ms Tunnicliff’s not recalling Patient 81 as mentioning pain and swelling in her right hand.

[55]     Mr McClelland submitted that nothing turned on the language used by the Tribunal, and that Ms Tunnicliff’s evidence contradicted the charge as admitted in the summary of facts.  In any event, this inconsistency did not form the basis of the Tribunal’s findings in respect of Patient 81.

[56]     Mr Coates accepted that it is impossible to define the extent to which the Tribunal relied on these particular findings in respect of the components of the charge relating to Patient 81.  However, it is clear the Tribunal considered this aspect of the misconduct to be particularly serious.   Further, it is reasonable to infer the Tribunal may have increased its perception of the gravity of the misconduct as a

result of an error.  It wrongly perceived her to have breached a promise made to the patient, and to be advancing inconsistent recollections in response to this aspect of the charge.

[57]     I would not be persuaded that this reflected a material error, if assessed on its own.  However, it does add somewhat to the criticisms of the penalty as more severe than was reasonably justified.

The Tribunal’s decision was disproportionate, excessive and substantively unfair

[58]     This final group of criticisms is to be assessed in light of my findings on the extent to which the other criticisms are justified.

[59]     A significant component of Ms Tunnicliff’s unfairness argument relied on her evidence of the extensive difficulties she has encountered in attempting to obtain further employment since the period of suspension had expired.   That  evidence certainly suggests that she has made numerous attempts to find employment, and that the apparent difficulties in complying with the requirements for supervision have been the reason, or among the reasons, given for her not being employed.

[60]     Mr Coates  described  Ms Tunnicliff  as  passionate  about  her  career  and desperate  to  re-establish  herself.    However,  the  impracticality  of  the  extent  of required supervision has thwarted all her endeavours.

[61]     Mr McClelland opposed the admission of evidence of subsequent events on the ground that it could not have had a bearing on the Tribunal’s decision.  Grounds for the appeal had to be made out on the state of affairs as presented to the Tribunal at the time of its decision.   He pointed out that if a timely appeal is pursued, the appellant will not have the advantage of reviewing such a lengthy period of post- decision conduct.

[62]     Subject   to   minor   exceptions,   I   accept   Mr McClelland’s   objection. Ms Tunnicliff bears an onus to challenge the penalty decision as a wrong exercise of discretion.  The classic grounds for doing so do not admit of criticisms that depend on subsequent events.

[63]     However, in assessing whether the Tribunal was wrong to impose the extent of constraints on subsequent practice that it did, it is possible for Ms Tunnicliff to argue that the Tribunal ought to have appreciated the extent of difficulties it would be creating by imposing those conditions.   If her subsequent experience ought reasonably to have been anticipated, then evidence of it is indirectly relevant in establishing what the Tribunal ought reasonably to have appreciated would follow from the conditions it imposed.

[64]     Mr McClelland also objected to the quality of the evidence.   He disputed whether Ms Tunnicliff could establish that it was the existence of the conditions and their terms that has precluded her being employed.  He argued that it was equally likely that Ms Tunnicliff was in fact not offered jobs because prospective employers considered the misconduct involved in the charge was too serious for them to assume the risk that her subsequent conduct would be sufficiently different.

[65]     Mr McClelland also disagreed with the extent of supervision that would be necessary to comply with the conditions imposed.  He suggested that the concerns raised in the course of Ms Tunnicliff attempting to find employment related to a greater degree of on-going supervision than the Tribunal’s conditions would require.

[66]     Mr McClelland’s   oral   submissions   included   an   explanation   that   the supervision  required  by  the  conditions  could  be  indirect,  so  not  necessarily  by another employee of the employer with whom she found work.   Certainly in the period  after  the  initial  12  months,  the  periodic  contact  with  a  supervisor  was intended to afford Ms Tunnicliff an opportunity of discussing with a mentor any difficulties she was continuing to have in practising competently.

[67]     Notwithstanding those being Mr McClelland’s instructions from the PCC, it is not immediately apparent from the terms of the Tribunal’s decision that the degree of supervision contemplated in the terms of the conditions imposed was as indirect as Mr McClelland described them.  I note that three years was the maximum period

for which the Tribunal could order on-going supervision.17

17     Health Practitioners Competence Assurance Act 2003, s 101(1)(c).

Outcome

[68]     Having regard to all these considerations, I am satisfied that the Tribunal’s decision on penalty was wrong.   Mr McClelland submitted that if I reached this point, I ought to direct the matter of penalty back to the Tribunal for reconsideration of   Ms Tunnicliff ’s   case   in   light   of   any   errors   that   had   been   made   out. Mr McClelland urged that  the Court respect the expertise of the Tribunal in its on-going supervisory role of those medical practitioners required to appear before it.

[69]     For Ms Tunnicliff, Mr Coates urged the Court to substitute its own view of the less onerous conditions which he argued should have applied.  He opposed any reference back to the Tribunal on grounds of the lapse of time since the relevant events, and the additional cost that would be incurred for Ms Tunnicliff.

[70]     I agree with Mr Coates that a final resolution of the matter ought to  be achieved without any further delay.  I intend no disrespect to the Tribunal in coming to that view, with the assistance of the competing contentions that were thoroughly aired in the submissions for the parties, and in light of the length of time that has passed since the relevant misconduct.

[71]     I consider that the penalty decision was expressed in harsher terms in respect of Ms Tunnicliff than were warranted.   I am satisfied that it was an unduly harsh component of the penalty to require Ms Tunnicliff to disclose the full terms of the decision to any prospective employer, especially given that I have found it expresses criticisms of her in harsher terms than were warranted.   Henceforth she will be required to disclose the fact of the decision and the extent of penalties, as amended by this judgment, but she will not be required to produce the full terms of the Tribunal’s decision.

[72]     I  am  also  satisfied  that  the  period  of  suspension  was  longer  than  was necessary  to  reflect  the  seriousness  of  the  misconduct.    In  that  finding,  I  am influenced  by Ms Tunnicliff’s  self-imposed  exclusion  from  the  health  sector  for more than a year between her resignation and the Tribunal’s determination. A period of six months’ suspension would have been adequate to reflect the seriousness of the conduct and to protect the public.  I substitute an order for length of time.

[73]     Given that the longer period of suspension has now been completed, any reduction in the period of suspension is to adjust the perception of seriousness, without being able to provide any positive relief for Ms Tunnicliff.

[74]     The conditions requiring her to be supervised also need to be re-defined, particularly in light of Mr McClelland’s view that they have been interpreted as requiring closer supervision than the PCC considers the Tribunal intended.

[75]     “Supervision” is defined in s 5 of the Act as meaning “… the monitoring of, and reporting on, the performance of a health practitioner by a professional peer”.  A “professional peer” is defined as a person who is registered with the same authority with which the health practitioner is registered”.   In this case, that is clearly the authority  responsible  for  registering  nurses.    It  follows  that  Mr McClelland  is correct,  in  terms  of  the  statutory  provisions,  in  suggesting  that  supervision  of Ms Tunnicliff could be achieved by someone other than an employee of any new employer.

[76]     I substitute the conditions governing Ms Tunnicliff’s resumption of practice with   amended   conditions   that   reduce  the  period   contemplated  for   personal supervision from 12 to six months, and the longer period of personal supervision from three to two years.   The original conditions are to be clarified by an acknowledgement  that  the  supervision  can  be  indirect,  so  as  not  to  require  a co-employee at the same site to conduct the supervision.   From the date of this judgment, the conditions are:

(a)      She  is  to  practice  for  a  period  of  six  months  only  under  the supervision of a supervisor approved by the Nursing Council.

(b)The supervision is to include at least monthly meetings with the supervisor, and is to focus on adequate note-taking and documentation and compliance with her responsibilities as a nurse. At the conclusion of the six month period the supervisor is to report to the Nursing Council on the supervision that has been undertaken.

(c)      Before resuming practice she is to complete a course approved by the Nursing Council to address ethical and professional obligations of a registered nurse.

(d)After resumption of practice, she is to practice for a period of two years   with   personal   supervision,   with   Ms Tunnicliff   reporting annually to the Nursing Council.

(e)      Neither  the  six  month  nor  the  two  year  period  of  supervision necessarily requires a supervisor employed by the same employer as Ms Tunnicliff.  The supervisor is to have a sufficient relationship with Ms Tunnicliff and her working environment to enable, for the first six month period, effective review of the quality of note-taking and documentation.   The supervision for the second period (that is, for

18 months after the first six month period has expired) is in the nature of mentoring for Ms Tunnicliff’s support.  Ms Tunnicliff is to meet the costs of all the supervision.

(f)      For the two year period she is to advise the Nursing Council of the identity of her employer and any change in employer.

Costs

[77]     My  provisional  view  is  that  costs  should  follow  the  event,  and  that Ms Tunnicliff  is  entitled  to  costs  on  a  2B  basis,  together  with  reasonable disbursements as approved by the Registrar.   If the parties do not accept this indication, I will receive submissions.   These are to be filed, first, on behalf of Ms Tunnicliff, not later than 35 days after delivery of this judgment, and thereafter on behalf of the PCC within 10 working days of the service on its solicitors of submissions on behalf of Ms Tunnicliff.

Dobson J

Solicitors:

Claro Law, Wellington for appellant

Thomas Dewar Sziranyi Letts, Lower Hutt for Health Practitioners Disciplinary Tribunal

Counsel:

M F McClelland QC for respondent