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You are here: BAILII >> Databases >> England and Wales High Court (Queen's Bench Division) Decisions >> Norfolk County Council v Durrant [2020] EWHC 3590 (QB) (30 December 2020) URL: http://www.bailii.org/ew/cases/EWHC/QB/2020/3590.html Cite as: [2020] EWHC 3590 (QB) |
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QUEEN'S BENCH DIVISION
Strand, London, WC2A 2LL |
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B e f o r e :
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NORFOLK COUNTY COUNCIL |
Appellant/ Defendant |
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- and – |
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SHARON DURRANT |
Respondent/Claimant |
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Mr Henry Mainwaring (instructed by Pabla & Pabla Solicitors) for the Respondent
Hearing dates: 24 June 2020
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Crown Copyright ©
Mrs Justice Foster :
INTRODUCTION
THIS APPEAL
a. That there were other relevant incidents or concerns at the time that were not recorded or reported, and this resulted in
b. A failure to provide an overall risk assessment
THE LEGAL FRAMEWORK
APPEALS
a. In a case in which credibility is in issue, an appellate court can hardly ever overturn primary fact findings where the trial Judge has seen the witnesses give evidence Cook v Thomas [2010] EWCA Civ 227 at [48].
b. As to evaluations and deductions from fact, in Re-Sprintroom [2019] EWCA Civ 932 (where the Judge's evaluation, rather than his findings of primary fact, was under appeal) the following was said:
"76. So, on a challenge to an evaluative decision of a first instance Judge, the appeal court does not carry out a balancing task afresh but must ask whether the decision of the Judge was wrong by reason of some identifiable flaw in the Judge's treatment of the question to be decided, "such as a gap in logic, a lack of consistency, or a failure to take account of some material factor, which undermines the cogency of the conclusion".
77. All this said, when assessing an evaluative decision of the facts found by a trial Judge, there can be no doubt that one must also bear in mind the well-known passage in the speech of Lord Hoffmann in Biogen Inc. v Medeva plc [1997] RPC 1, 45 where he said:
"…The need for appellate caution in reversing the Judge's evaluation of the facts is based upon much more solid grounds than professional courtesy. It is because specific findings of fact, even by the most meticulous Judge, are inherently an incomplete statement of the impression which was made upon him by the primary evidence. His expressed findings are always surrounded by a penumbra of imprecision as to emphasis, relative weight, minor qualification, and nuance (as Renan said, la vérité est dans une nuance), of which time and language do not permit exact expression, but which may play an important part in the Judge's overall evaluation. It would in my view be wrong to treat Benmax as authorising or requiring an appellate court to undertake a de novo evaluation of the facts in all cases in which no question of the credibility of witnesses is involved. Where the application of a legal standard such as negligence or obviousness involves no question of principle but is simply a matter of degree, an appellate court should be very cautious in differing from the Judge's evaluation."
"[114] Appellate courts have been repeatedly warned, by recent cases at the highest level, not to interfere with findings of fact by trial Judges, unless compelled to do so. This applies not only to findings of primary fact, but also to the evaluation of those facts and to inferences to be drawn from them. … They include:
"(i) The expertise of a trial Judge is in determining what facts are relevant to the legal issues to be decided, and what those facts are if they are disputed.
(ii) The trial is not a dress rehearsal. It is the first and last night of the show.
(iii) Duplication of the trial Judge's role on appeal is a disproportionate use of the limited resources of an appellate court, and will seldom lead to a different outcome in an individual case.
(iv) In making his decisions the trial Judge will have regard to the whole of the sea of evidence presented to him, whereas an appellate court will only be island hopping.
(v) The atmosphere of the courtroom cannot, in any event, be recreated by reference to documents (including transcripts of evidence).
(vi) Thus even if it were possible to duplicate the role of the trial Judge, it cannot in practice be done."
NEGLIGENCE
The inquiry into cause
5-01
A defendant who is in breach of a duty in tort cannot be held responsible for loss suffered by a claimant unless the defendant's conduct was a cause of that loss. As shortly stated, it might appear that there is a single inquiry into the cause of harm. However, the inquiry can conveniently be divided into three questions. First, it must be determined whether the defendant's conduct was a cause in fact of the plaintiff's loss. Normally this is a minimum requirement, although in certain special cases the proposition requires some qualification. Second, if a causal link in a strictly objective sense is shown, it is necessary to consider whether the conduct can be seen as a cause in law. It is not enough that the conduct provided the opportunity for the harm to happen: it must also be, in some sense, an effective cause of the harm. Formulating a test which captures this necessary link has proven to be difficult. Third, there is the question of the proximity between the cause and the damage or, in other words, of the remoteness of the damage. Assuming that the conduct was a cause, it must be sufficiently closely connected with the damage so as to justify the imposition of liability. While the test to apply in determining remoteness issues is clear, its application can often be a source of uncertainty.
5-02
The three stages are analytically distinct, although the courts in their decisions do not always draw clear lines between them. The analysis is orthodox, and convenient, and assists in an understanding of the different aspects of the inquiry into cause.
The "but for" test
5-04
The "but for" rule is generally the starting point in proving a causal connection between negligent conduct and the damage suffered. The claimant seeks to show that but for the defendant's negligence the injury complained of would not have arisen. If he succeeds, there is no additional requirement to show that the defendant's negligence was the only, or the single, or even chronologically the last cause of injury. This threshold "but for" test is based on the presence or absence of one particular type of causal connection: whether the wrongful conduct was a necessary condition of the occurrence of the harm or loss. The test does not distinguish between legally relevant and other causes, yet it is not its function to do this. It identifies whether the conduct in question was a cause. At this stage we do not need to concern ourselves with all the other factors which combined to produce the total environment in which the damage could happen."
"It is obvious that the failure to carry out a proper assessment can never be the direct cause of an injury. There will, however, be some cases in which it can be shown that, on the facts, the failure to carry out a risk assessment has been indirectly causative of the injury. Where that is shown, liability will follow. Such a failure can only give rise to liability if a suitable and sufficient assessment would probably have resulted in a precaution being taken which would probably have avoided the injury. A decision of that kind would necessitate hypothetical consideration of what would have happened if there had been a proper assessment."
'' … the overall test is still the conduct of the reasonable and prudent employer, taking positive thought for the safety of his workers in the light of what he knows or ought to know; where there is a recognised and general practice which has been followed for a substantial period in similar circumstances without mishap, he is entitled to follow it, unless in the light of common sense or newer knowledge, it is clearly bad; but, where there is developing knowledge, he must keep reasonably abreast of it and not be too slow to apply it; and where he has in fact greater than average knowledge of the risks, he may be thereby obliged to take more than the average or standard precautions. He must weigh up the risk in terms of the likelihood of injury occurring and the potential consequences if it does; and he must balance against this the probable effectiveness of the precautions that can be taken to meet it and the expense and inconvenience they involve. If he is found to have fallen below the standard to be properly expected of a reasonable and prudent employer in these respects, he is negligent.
THE CASE BELOW
"
74. [Ms Hanwell] described J's behaviour in the Sunshine room as: "...aggressive, not continuous, he was not doing it maliciously. He could not control himself...I was not aware that he drew any blood on me or on the Claimant... I asked her (the Claimant) to leave... I did ask her on numerous times to leave ... I felt I had a good relationship with him, and I could de- escalate things when we left the room, he was calm with his legs crossed". … the aggression did not start until they had been in the room for some 5-10 minutes before physical violence began.
…
'The handle was behind her. There was no impediment to her leaving. She was not showing any physical signs of being unable to leave... I believe she had been trained in STEPS at her earlier school. She was not fainting nor appearing dizzy. I was concentrating on J ... He hit her in the stomach. I asked her if she was all right. "No." She would not get out. 'I would not leave you on you on you[r] own". In re-examination she said the aggression was not constant. "J was running back and forward quickly. He would run forward to us and wait for a reaction. He was at the other end of the room when we had our stomach conversation and I told her to leave again twice. I knew the holding techniques. I felt I could manage him, and I did …
After 5-10 minutes we finally persuaded J to calm down. ...the incident was unforeseeable and unprovoked"."
"75. I make it clear that where there was any conflict on the evidence as to what happened that day in the Sunshine room, I have no hesitation in preferring the evidence of Ms Hanwell to that of the Claimant, the lat[t]er having added to her own descriptions during the trial itself. The Claimant said she suffered "a frenzied attack", but I reject this. I find that the attack, which started after J and the two adults had been in the Sunshine room for about 5-10 minutes, was not continuous, and that the Claimant was invited to leave, that she could have done so, but cho[o]se] not to."
c. What was the history of J's behaviour?
d. What were the precise facts of the incident on 28 Sept 2015?
e. Had the Claimant shown that the Defendant had failed to take reasonable steps to provide a safe system of work – including
i) Training
ii) Management of the Claimant and of J
iii) Risk assessments and reporting
iv) Steps taken after events
v) Whether use of the Sunshine room (J plus 2 staff members) was in light of what was known, an unsafe system of work
f. If there were failings, did it/they cause or contribute to the injury
"Every incident of - of violence is considered by the senior leadership team. Every incident with J, I considered, as well as the senior leadership team. And that is why - when he got increasingly difficult within that, sort of, week period, why we made extra efforts to contact mum, why Sharon [Ms Durrant] then supported me more with him. From these incidents, we put actions into place straight away because that's what we do."
And
"When J moved into my class, we did adapt how we were working with him to best support him. We stopped flashing a Red Card in front of that child and putting it on a chart in the classroom because we believe that would've exacerbated his emotions and he would - and that would've increased his anxiety. Every time he had a violent incident, I recorded it, and I record on the "Significant concerns and conversations" document, or I recorded it on an incident report."
75. Ms Chaplin also explained in evidence that she discussed the altered policy that was adopted for J with the Claimant "virtually every day and J improved with the Claimant's excellent work". She reflected that there were meetings to discuss J, which were noted down in their work diaries.
THE JUDGMENT
a. Paragraphs 1 to 7 are introduction
b. Paragraphs 8 to 9 give some history of employment including Ms Durrant's alleged complaints about J to the headteacher, and some history of J at school
c. Paragraphs 10 to 15 contain (some of) the Judge's comments with examples, on Ms Durrant's dishonesty in her application for the job contrasting her incapacity as reported to the DWP. These latter suggesting serious incapacity from regular unpredictable and frequent faints and requiring constant supervision with cooking, dressing, and mobility and the presence of Addison's disease. Her application to the school mentioned none of it.
d. At 15 to 16 the Judge states Ms Durrant's dishonesty prevented the school from doing a risk assessment as to her suitability; she finds "the school was grievously misled by the Claimant".
e. In paragraphs 17 to 23 the Judge comments on the system in operation at the school, and use of "the Base" and exclusion policy. The Judge observes that the circumstances triggering each of the steps were argued to be inconsistent - and that was partly justified:
"but those inconsistencies were altered by the teachers deciding how best an individual child could/should be dealt with".
In terms the Judge finds that the staff were extremely impressive, that their first concern was the child, and it was
"obvious they discussed and worried about getting the right strategies to work with a child rather than rigidly applying the framework",
Indeed, as she finds, J was the only child ever finally excluded from the school. The Judge finds as a fact that form filling was not followed to the letter and the system was convoluted and cumbersome and a
"shorthand practice had developed of a few words over coffee which resulted in the development of working strategies for the child which may or may not have been formally recorded".
She then expressly finds that if the records were not fully filled in and the apparent chain of command not followed, it was not because of idleness but because time was taken up with careful teaching and nurturing of pupils, and:
"they had professional trust in their own abilities… And were quite rightly proud of their own judgement and ability to provide working strategies for a particular child with needs".
f. The Judge returns in paragraphs 24 to 31 to the chronology of J at the school and his incidents with other children referring to evidence given on behalf of the Claimant that there had been a physical attack on a child on 28 January 2015, and there was a discussion as to what system could be offered to him. In February 2015 he was taken to the Sunshine Room. He moved to Ms Chaplin's class in March 2015 which appeared to work well, and he was integrated by April. On 30 June 2015 she notes one, possibly two incidents. In one he threw scissors. The Judge records that the emphasis in the notes is on what work would be suitable for J rather than any concern as to staff safety "which really does not seem to be an issue".
g. After the summer holidays, the Judge found, J appeared to work well with the new teacher. There was then a fight with another child on 22 September, throwing a chair and throwing a shoe at a light, on the Friday, 25 September 2015 throwing a chair and hiding under a table, he went to the Sunshine Room upset and then took his clothes off; eventually, following restorative conversation, J calmed down and returned to the class, although at break he ran to the school gate in an attempt to leave. Thereafter on Monday 28 September 2015 he ran into class and was violent and the index incident in the Sunshine Room took place in which he hit and injured the Claimant.
h. Importantly in paragraph 31 the Judge finds that after the events of 28 September 2015
"at a pastoral meeting the next day no one suggested anything different should have been done".
The Judge emphasises that the chronology does not reflect the views of those teaching him who were at pains to stress how they could deal with him and how their thought-out strategies were working. The Judge makes no express findings on this evidence.
i. In paragraphs 32 to 33 the Judge recounts some of the evidence of C, her arrest for shoplifting, the death of her grandmother (recording that her evidence was unreliable as to the date of this). She describes how the Claimant "tried to exonerate herself" from apparently not understanding how the Red Card system worked although she did admit that she was aware of the 3 cards meaning a child would go to Base. The Judge makes no overall finding here.
j. Through paragraphs 34-80 the Judge describes the content of the evidence of each of the witnesses and recounts some of it, with some chronology again. Generally, as elsewhere the facts are set out only; occasionally the phrase "I find" is used and the recitation of the evidence is interspersed with the Judge's observations. Perhaps understandably, it is not always chronological. Of note are the following:
i) The Claimant complains that the policy of "3 Red Cards and then straight to Base" was not carried out in respect of J when it should have been. The Judge observed:
"This was right, but for pastoral reasons as explained by Ms Chaplin and others later."
ii) The Claimant had thought that J was a danger to himself on 22 September 2014
"she had been concerned that his breaking glass had made it unsafe for himself, but not for her".
and
"I was left with the distinct impression that the school was bending over backwards to help and assist at the disturbed child without actually fulfilling to the letter responses to every infraction of the school behaviour rules… He was being managed by competent and caring staff"
iii) the Claimant's evidence "at times was muddled and unclear"
iv) when the Claimant took J to the Sunshine room on the Friday before the index incident at the Judge observes
"I note she did not think it necessary to have assistance with this"
v) the Claimant's assertion of a "frenzied attack" is dismissed by the Judge who reiterates the disparity between what she told to the agencies and what to her doctors.
vi) the day after the index incident the school log was noted by Ms Durrant in respect of J as follows:
"the violence was on a scale she'd not seen before it was new and unexpected"
vii) the Judge also reminds herself particularly of the Claimant's evidence of the perceived improvements in J down to June 2015.
viii) She records that any member of staff could have asked for a risk assessment;
ix) Sue Painter was drafted in in January until she was removed in May at the request of J's mother (following her referral to social services) the Judge finds that the Claimant was "brilliant with J" she finds as a fact that she sees:
"a picture of a child who was beginning to settle down"
and the action plan that had been put in place was resulting in many improvements.
x) She notes Ms Sue Painter, giving evidence for the Claimant, had said she would have recorded it if J was an exceptional extensive risk. If he was not safe among staff and pupils, she would have recorded it, and she did not recall the Claimant mentioning that J made her feel unsafe. She also did not remember her saying she personally felt unsafe in September.
xi) The Judge thereafter says it was
"difficult for an overall analysis to be concluded when teachers use their own judgements as to what it was necessary to record".
She finds
"there was a more than regulated (sic) reporting system within the school to deal with disruptive children"
and
"…I find that the system no doubt devised with the best of intention to cover these problems had become overcomplicated and the varying groups were not clearly in liaison with each other this was made worse in that many including the Claimant did not record their concerns and report books available to them they just mentioned it verbally to others in the chain of command".
and
"they were without exception committed to doing their best in that each thought that how they were managing a child was for that child benefit …
"… nevertheless, the form filling in a busy school day was not as completely organised as it might have been."
xii) The Judge expressly found the school had endeavoured to adapt its usual system of discipline to the needs of J. She accepts that sometimes showing a red card to a child with attention disorder might actually disrupt that child and be counter-productive. She then states she considers the undressing incident is an example of the ordinary disciplinary machinery not being suitable or effective for "a grossly disturbed child".
"The difficulty appears to have arisen that not every teacher/assistant was applying the same analysis, and things (for may be perfectly good and understandable reasons) were not recorded in the various ways they could have been".
xiii) She says that there
"were options which could have been but were not taken such as sending the child to Base".
She does not here make observations on causation or other relevance.
xiv) The Judge then deals with the evidence of Ms Chaplin, a witness whom she commended as convincing and impressive and whose "professionalism and care shone out". At a different point [paragraph 66] she records:
"Ms Chaplin was adamant that for a child like J who had attachment difficulties one would just not send such a child to 'Base'. She said "we used other strategies like giving him support. She said the Claimant did not complain about these alterations from the school policy for J, which was adopted from that used with A … I discussed it virtually every day with the Claimant, and J improved with the Claimant's excellent work…""
xv) Ms Chaplin's evidence is recorded as being adamant there were meetings to discuss what to do with J and the outcome was entered into personal work diaries of those involved. There were no injuries by J to any staff before the instance complained of. Ms Chaplin was of the opinion the school was managing J even when it got worse and did not agree that J had reached a crisis point on Friday, 25 September such that they should have been intervention or a central incident report. In Ms Chaplin's view J was being managed effectively. Nowhere does the Judge say other than that she found Ms Chaplin to be convincing and impressive, impliedly accepting her evidence.
xvi) The Judge then says, quoting Ms Chaplin
"he was a child in crisis… A red card to J would not have helped him… the policy would not have been right for him. We did not follow the policy.… At no point did the Claimant ever complain to me that she was not safe, at no point did she say she was in danger….
The Judge then says:
"I accept without hesitation the evidence of this witness".
She records that Ms Chaplin decided to put strategies in place to deal with J after his flareups and those strategies were going well, then J had a wobble and Ms Chaplin had to "up her strategies". By the week of 21st September, she agreed the strategies were not working but
"we thought we had the skills to cope. No one expected his outburst…". [68]
xvii) the Judge comments on Ms Chaplin's evidence:
"she agreed that pupils risk assessment was not completed for J: "because we were managing the risks… If we had completed that risk assessment, we would have been covering ourselves. However, we were doing everything that was on that form"".…the Judge then held "the reality from her evidence appears to be at they would apply the red card policy to children who would benefit from it being applied to them" [68]
"[the Claimant] was always very positive about J she never said that his behaviour was too extreme to be dealt with. No other staff raised it."
She records that Ms Chaplin never felt every part of the school policy had been exhausted or that J's behaviour was so extreme he would have to be moved to Base. It was not a "dramatic escalation" rather "we are used to this kind of behaviour and worse". It is at this point the Judge comments again on how convincing and impressive Ms Chaplin was.
"I make it clear that where there was any conflict on the evidence as to what happened that day in the Sunshine Room, I have no hesitation in preferring the evidence of Ms Hanwell to that of the Claimant, the latter having added to her own descriptions during the trial itself.…"
a. The Deputy Headmistress Ms Gooch had said J's behaviour was challenging and aggressive but not extreme.
b. There was uncertainty as to the frequency and formality of the Leadership Team meetings but any teachers who were present recorded their own notes/minutes in their own words and their diaries were shredded after 3 years.
c. The Judge said
"I am concerned that these overlapping layers of reporting had become cumbersome and bureaucratic [for] the busy staff to use".
d. The Judge then deals with evidence from the Deputy Head Ms Gooch who
"was adamant that stage E exclusion had not been reached for J… "We found alternative ways of dealing with him".
The Judge records how Ms Gooch was firm that the package of strategies was working, and that J was more of a risk to himself and to other children and anyone else; they had not foreseen what had happened on the Monday.
"The witness was certain that although J might need more physical intervention, it was not foreseeable that he would injure himself or others."
e. The Judge then states
"Details of what might have happened if protocol had been followed can be seen from this witness's evidence "–
she refers to February 2015 and says [with emphasis added]
"they might have come to a decision that other forms of referral would have been better";
And
"Tiffany Howard could have done an observation which could then have gone on to advise the Pastoral Team…
and
"following the June incidents Ms Gooch could have triggered this if necessary (but she was adamant that even the slap face incident would not have triggered this) although the after-school incident was reported to the Pastoral Team."
"83. But what really happened was that the teachers on the spot did not think it would have helped this child. They could manage him with inter-teacher discussions: "he was safe within the school and the staff were safe within the school", said this witness.
84. The tragedy here is that by not invoking the somewhat cumbersome machinery of checks and balances, a wider overview about J and his problems did not take place. It was, bluntly, negligent. I remind myself that the Claimant herself could have invoked this system in writing, and not just with a word to another teacher over coffee.
85. By September 2015, Ms Gooch considered that the events of 22 September 2015 which involved J fighting with another child, was a common occurrence between children, which did not merit any upward reporting as J had accepted the consequence of his actions, and his mother came into school the next day. The 23rd and 24 September 2015 had both been good days. "He was doing really well, and our restorative actions were working". She did not know of the two events on 25th September. Even if these had merited exclusion, the Deputy's range of actions on that Friday were limited. She explained "to stop him being in the school was not a clear option. There had been no opportunity to speak to his mother. Tiffany was not on the site she was at Base with another child". This witness thought that to have put J in Base at that point would increase the risk for a child with an attachment disorder. The witness thought that the Claimant was dealing very well with J's initial outburst. The other children were on their break and were not with J. She was rocking him, and he was in a calm place, and appearing to enjoy the physical contact. I note nowhere that, even with her experience of J, the Claimant was willing to treat him thus, and did not appear to object to her own physical contact with this disturbed child. When asked about the later events in the Sunshine room this witness said "I could not have foreseen that assault. We did not wait until something happened. I do care about our duty of care…" When asked about the Claimant's evidence that she said that she had had complained to Ms Painter [sic) and to Ms Gooch, her reply was: "she never said that to me. I had taken it on board. I have a duty of care." She was pressed on this but was adamant that the Claimant had never complained to her, I have to say that I by far prefer the evidence of this witness to that of the Claimant."
"88. I am constrained to find that the rather convoluted system for recording children's' behaviour was not fully, nor carefully, implemented. Forms were ignored and reporting up the chain of command to the Headmistress was not rigorously carried through. However, I make it clear that the teachers who were dealing with J were by far more concerned was trying to help him, calm him and settle him. I was very impressed by their professionalism, involvement, and concern to keep J within the mainstream school system. They had little or no support from his mother. I acknowledge that Ms Durrant was regarded as someone who could deal with J, but she too failed to take advantage of the in-house reporting system. With regret I must find that the gaps on reporting results (and the summer holidays may also have disrupted J) meant that an overall view of any risk J might be posing to himself, other children and to staff was not as carefully considered within the apparently rigorous reporting system, which was supposed to provide a platform for just this kind of developing situation, as it should have been. This was negligent.
89. Because of the failure to record and report, there was no proper overall assessment of how to treat J, or as to what risks/measures were advisable to have due regard to staff safety. No risk assessment to staff and to the Claimant was carried out, as all the information was not recorded, or any overall assessment made, let alone any blueprint for action. This amounted to a negligent failure to have due regard for the safety of staff, which has caused injury to the Claimant."
"… because we were managing the risks… If we had completed that risk assessment, we would have been covering ourselves. However, we were doing everything that was on that form".
In other words, there was no material reason for the completion of the form, except protecting themselves with "process" by filling it in. Further, what would have been written down was just what happened in any event: it would have changed nothing about what in fact they did. Furthermore, other evidence apparently accepted by the Judge was all to the effect that no staff- including the Claimant- perceived J to be a risk to staff whether in the past or just before the incident.
DISCUSSION AND CONCLUSIONS
a. There had been an unjustified, unreasonable, and undocumented departure from policy and departures are prima facie negligent
b. The departures were not, as stated in evidence, positive, but rather a simple failure of enforcement
c. The school consistently failed to recognise the seriousness of J's behaviour and at least 4 Red Cards ought to have been issued in the September week before the incident
d. Although accepted that a record was made of incidents [the evidence was, it was put in individual diaries which are destroyed after 3 years], this was not sufficient
e. The evidence from Ms Chaplin was "most unsatisfactory"; it was not accepted that there was any actual discussion of J in Senior Leadership meetings nor with the Inclusion Manager as Ms Chaplin had said in evidence
f. By early July J should have reached level E – exclusion from Clover Hill
g. Alternatively, referral to an external agency should have taken place
h. Nothing turns on the differences in accounts between the Claimant and Ms Hanwell of the incident – it is not in dispute she suffered injury
a. the Judge did not find Ms Durrant was inadequately trained or prepared by the school;
b. the Judge did not find the Claimant was inadequately managed;
c. The Judge did not find that steps taken following any of the J incidents, or the reflections after those events were wrongly or poorly made;
d. the Judge did not find that the use of the Sunshine Room, in particular, in the circumstances of what was known at the time, constituted an unsafe system of work;
e. the Judge did not say that the system of reporting behaviour was negligent in itself although she describes it as convoluted and cumbersome;
f. the Judge nowhere sets out the counterfactual as to what would have happened differently on the balance of probabilities, had a risk assessment form being completed, or a different system been in place; and
g. the evidence reported and accepted by the Judge does not support a finding that, but for the flawed system of reporting, the incident that injured Ms Durrant would not have happened. Indeed, to the contrary, there is no witness who was able to say anything would have been done differently. That was so whether the processes and protocols had been followed to the letter or not.
SUMMARY
UPON the APPELLANT'S APPEAL
1. The Appellant's appeal is allowed for the reasons given in the judgment previously circulated to the parties and handed down on 30 December 2020.
2. The question of costs and any consequential matters arising be adjourned for representations in writing (if so advised) by 4pm 6 January 2021.
3. The time for appealing this judgment does not begin to run until 6 January 2021.
4. Liberty to either party to set aside or vary this Order on 48 hours' notice in writing by email to the other side and to the Court.
Dated this 30 Day of December 2020