disciplinary policy & procedure - West Hertfordshire Hospitals NHS ...

Disciplinary Policy / Version 4
Ratified by ISE
Date of Ratification: March 2011
Date of Review: March 2014
DISCIPLINARY POLICY & PROCEDURE
ID# 2011 045
Author’s Names
Laura Bevan and Caroline Lankshear
Author’s Job Title
Senior HR Manager and HR Manager
Division
Corporate
Department
Human Resources
Version number 4
Ratifying Committee
ISE
Ratified Date March 2011
Review Date March 2014
Manager responsible for review
Laura Bevan
Manager Job Title
Senior HR Manager
E-mail address of Manager
Laura.bevan@whht.nhs.uk
Source of Evidence (If applicable)
N/A
Level of Evidence indicated
N/A
Referenced (Yes/No)
Yes
Key Words (to aid searching) Disciplinary, investigation, warnings,
misconduct
User Group
All staff
The Trust is committed to promoting an environment that values diversity. All staff are responsible for
ensuring that all patients and their carers are treated equally and fairly and not discriminated against on the
grounds of race, sex, disability, religion, age, sexual orientation or any other unjustifiable reason in the
application of this policy, and recognising the need to work in partnership with and seek guidance from other
agencies and services to ensure that special needs are met.

Contents Page
1. Change History 3
2. Introduction 3
3. Scope of Policy 3
4. Equality & Diversity Statement 3
5. Manager Responsibilities 4
6. Employee Responsibilities 4
7. Human Resources Responsibilities 4
8. General Principles 5
9. Managing Employee Conduct Day to Day 5
10. Disciplinary Investigation Procedure 6
11. Disciplinary Hearing 10
12. Reasons for Disciplinary Action 11
13. Types of Disciplinary Action 13
14. Requirement for Professional Registration 14
15. Appeals Procedure 14
16. Keeping Records 15
17. Reference Requests for Employees under Investigation 15
18. Process For Monitoring Compliance And Effectiveness 15
19. Review of this Procedure 16
Appendices
Appendix 1 - Terms of Reference Template 17
Appendix 2 – Investigation Report Template 18
Appendix 3 – Disciplinary Hearing Schedule 20
Appendix 4 – Disciplinary Appeal Hearing Schedule 21
Appendix 5 – Guidelines on Writing a Statement 22
Appendix 6 – Disciplinary Process Flow Chart 25
Appendix 7 – Protocol for Dealing with Potential Cases of Fraud 26
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DISCIPLINARY POLICY & PROCEDURE
1. CHANGE HISTORY
Version Date Author Reason Ratification Required
Version 3 March 2010 Caroline
Addition of
Yes
Lankshear & Laura
Bevan
information relating
to fraud
Version 2 June 2009 Caroline
Out of date policy Yes
Lankshear & Laura
Bevan
Version 3 March 2011 Laura Bevan New legislation Yes
2. INTRODUCTION
The Trust is dedicated to being a fair and reasonable employer and is, therefore, committed to
promoting good and open employee relations. The Trust is concerned that all its employees should
be aware of their obligations with regard to conduct, including acts of neglect or omission and of
the likely consequences of failure to meet these obligations. Where instances of unsatisfactory
conduct arise the Trust after investigation will adopt the formal disciplinary procedure through
which the issues can be identified without delay and appropriate action taken in a consistent
manner. Where an act of misconduct occurs, disciplinary action, which is recognised in law, will
be the Trust’s response.
3. SCOPE OF POLICY
This policy and procedure applies to all Trust employees.
For Medical and Dental staff, a separate policy and procedure applies -“Maintaining High
Professional Standards in the NHS”, which should be used for cases involving professional
conduct and/or professional capability. This can be found on the intranet via:
http://wghintra01/uploads/out/Medical_Dental_Disciplinary_Procedures_sep09.pdf
Where alleged personal conduct issues arise, the matter will be dealt with in accordance with
“Maintaining High Professional Standards in the NHS”, but where the matter proceeds to a
disciplinary hearing, this will managed in accordance with the Trusts Disciplinary Policy and
Procedure.
When dealing with a clinical incident or near miss where patient safety is at risk, staff must also
refer to the Trust’s Incident Reporting and Investigation Policy. This can be found on the intranet
via http://wghintra01/uploads/out/Incident_SUI_Policy_V8.5.pdf
4. EQUALITY & DIVERSITY STATEMENT
It is the policy of the West Hertfordshire Hospitals NHS Trust to provide a Disciplinary Policy and
Procedure that ensures appropriate responses to alleged employee misconduct in an efficient and
fair manner. This document takes into account current employment legislation and must be
implemented in conjunction with the Trust’s Equalities Framework, The Trust’s Equal
Opportunities Policy and Procedure and equality and diversity legislation:
• Sex Discrimination Act 1975 (as amended)
• Race Relations Act 1976 & Amendment 2000
• Disability Discrimination Act 1995
• Rehabilitation of Offenders Act 1974
• Employment Rights Act 1996
• Equal Pay Act 1970 (as amended)
• Human Rights Act 1998
• EU Directives and Legislation
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Managers have a particular responsibility to ensure disciplinary processes do not discriminate in
the provision of their service or in the employment of staff. The Trust monitors and publishes
information on the profile of its workforce based on age, disability, ethnicity, gender and marital
status and appropriate actions will be taken by the Equality & Diversity Group to identify and
address any problems.
5. MANAGER RESPONSIBILITIES
• To ensure that employees are aware of the Disciplinary Policy and Procedure and inform
staff of the disciplinary rules and issues relating to misconduct and gross misconduct which
will result in disciplinary action
• To make clear to staff the rules, regulations and standards of conduct which they are
expected to observe / achieve
• To ensure that the informal stage is used wherever possible prior to any formal action being
taken
• To deal appropriately with employees whose conduct falls short of that required by the
Trust
• To involve the appropriate HR Adviser where potential misconduct has been identified
• To consult with a senior member of the HR department prior to taking a decision to
suspend an employee
• To keep appropriate written documentation relating to incidents of alleged misconduct
• To treat all employees fairly by applying the policy consistently and ensuring that any
personal information is kept in complete confidence
• To apply the incident decision tree process as set in the Incident Reporting and
Investigation Policy for any patient safety related incidents to decide on the appropriate
action to be taken
• Request statements in a timely way – see Appendix 5
6. EMPLOYEE RESPONSIBILITIES
• To read, understand and comply with the Disciplinary Policy and Procedure
• To attend investigation meetings as required
• To submit statements when requested in a timely way – see Appendix 5
7. HUMAN RESOURCES RESPONSIBILITIES
• To assist managers in the fair and consistent application of the policy
• To provide advice to employees and managers concerning individual conduct issues
• To provide training to managers on conducting investigations, to include how to collect
evidence and take witness statements, to ensure compliance with employment law
• To support the Investigating Officer in conducting the investigation and presenting the
management case at a disciplinary hearing where necessary
• To provide advice and guidance to the panel of a disciplinary hearing / appeal
• To record and monitor employee conduct cases and report on these with reference to equal
opportunities data
• To liaise with the Local Counter Fraud Service (LCFS) about allegations of potential fraud
as detailed in Appendix 7
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8. GENERAL PRINCIPLES
This policy and procedure is designed to help and encourage all employees to achieve and
maintain standards of conduct within the context of the following general principles:
• To help and encourage employees to improve behaviour rather than just as a way of
imposing a punishment
• To encourage employees to report clinical incidents and near misses that concern patient
safety without fear of disciplinary action
• To inform the employee of the allegation against them and to provide the opportunity to
state their case before any decision is made
• No disciplinary action will be taken against any employee until the case has been fully
investigated unless the offence is sufficiently serious to warrant immediate suspension,
which will be non-prejudicial
• An employee will not be dismissed for a first disciplinary offence, unless it is an act of
gross misconduct
• Employees will have the right to be accompanied by a trade union representative or work
colleague during a disciplinary investigation meeting, hearing or appeal
• Employees will have the right to appeal against any formal disciplinary action taken
including dismissal
• The procedure may be implemented at any stage if the employee’s alleged misconduct
warrants such action
NB: Issues relating to sickness absence will be managed in line with the Managing Sickness
Absence Policy. Concerns relating to employee job performance will be managed in line with the
Performance Management Policy
9. MANAGING EMPLOYEE CONDUCT DAY-TO-DAY
It is the responsibility of managers to set clear standards of expected behaviour and conduct and
to undertake a regular reviews with staff. This forms part of the normal management process and
does not form part of the disciplinary procedure. This is likely to mean less recourse to the formal
procedure if deficiencies in an employee’s conduct are brought to his/her attention at the earliest
possible stage by the line manager in the course of the employee’s normal duties.
Where a manager considers that action should be taken to encourage an employee to improve
their conduct, he or she should meet with the employee, although this may not be necessary for
every offence. This meeting will be used to bring to the employee’s attention the aspects of
conduct that are unsatisfactory, and to ascertain whether the employee recognises there is a
problem.
The manager and employee should agree acceptable standards of behaviour and a plan of action
that must be confirmed in writing. The manager should provide training (if necessary) and close
supervision, set targets and monitor the outcomes. The employee should commit him/herself to
achieving the necessary improvements in their conduct.
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10. DISCIPLINARY INVESTIGATION PROCEDURE
10.1 Preliminary Investigations into Clinical Incidents
When a clinical incident occurs, e.g. a drug error, the incident must first be investigated in
accordance with the Trust’s Incident Reporting and Investigation Policy. No disciplinary process
will be commenced as a result of a patient safety related incident until at least the initial report of
the investigation has been completed and agreed by the Head of Clinical Governance, Quality &
Risk. To ensure a robust and consistent approach to investigating patient safety related incidents,
the Trust must use the National Patient Safety Agency’s Incident Decision Tree (IDT). This can
be found at:
http://www.msnpsa.nhs.uk/idt2/(d5vvderjryty2f552oxkrr55)/index.aspx
The Incident Decision Tree helps NHS managers and senior clinicians decide initial action to take
with staff involved in a patient safety incident. It is intended to promote a consistent and fair
approach, avoiding unnecessary and costly suspensions and exclusions. This process can be
facilitated by the Head of Clinical Governance, Quality and Risk and / or Risk Manager in
conjunction with the Lead Investigation Officer and Head of Nursing / Divisional Director.
The view of the Trust is that disciplinary action should not form part of a response to an incident
except in cases where one or more of the following apply:
• Where in the view of the Trust, and / or any professional registration body, the actions
causing the incident / arising from the incident were far removed from acceptable practice
• Where there was intent to harm and / or criminal offence has taken place
• Where there is failure to report an incident in which the member of staff was either
involved or about which they were aware
It is important that managers undertaking a clinical investigation adhere to the timescales for this
process as set out in Appendix 6a on page 47 of the Incident Reporting and Investigation Policy to
avoid any unnecessary delays should a disciplinary investigation need to commence.
10.2 Disciplinary Investigations into Employee Misconduct
Where an employee’s conduct is called into question, the Commissioning Manager (usually
grandparent manager of the employee) will appoint a manager to act as Investigating Officer who
is independent to undertake a thorough investigation to establish the facts and to determine
whether or not there is a case to answer.
The Commissioning Manager will draft terms of reference for the investigation - see template in
Appendix 1.
The investigation should commence as soon as possible after the event and where practicable, be
completed within 8 weeks.
The Commissioning Manager will inform the employee in writing of the nature of the allegation and
their right to be represented by a trade union representative or work colleague.
The Investigating Officer will conduct the investigation and will normally interview the employee
and relevant witnesses as part of this process. The employee and witnesses are entitled support /
representation as detailed above.
All relevant facts should be gathered promptly before memories of events fade. Statements
should be taken from the employee and witnesses at the earliest opportunity, using Appendix 5.
All statements should be signed and dated. Where an employee does not provide a statement for
an investigation but is subsequently interviewed, the notes from the meeting will be used instead of
the statement. Any physical evidence should be retained if reasonable to do so. Information
provided by witnesses will be given in confidence and should be in good faith. As a result, the
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employee under investigation must not discuss the content of witness statements with the
individuals concerned, to avoid a breach of confidentiality.
At the end of the investigation, the Investigating Officer will produce an investigation report for the
Commissioning Manager, outlining the facts of the case and a chronology of the investigation. For
the report template, see Appendix 2. The investigation report will be factual and will contain
sufficient information for the Commissioning Manager to determine whether:
• There is a case of (gross) misconduct that should be considered at a disciplinary hearing;
• No further action is required
• There are concerns about the employee’s health that should be referred to Occupational
Health for further advice
• There are serious concerns that should be referred to the appropriate professional
registration body
• There are concerns about capability that should be under the Performance Management
Policy
• There are other recommendations that need to be considered
Based on the information contained in the investigation report, the Commissioning Manager will
decide whether it is appropriate to refer the case to a disciplinary hearing. If there is no case to
answer, the employee and their representative should be informed of this outcome immediately in
writing.
10.3 Suspension
If whilst the investigation is conducted, it is considered unwise to allow the employee to continue
working, they may be suspended from work for as short a period as possible. Suspension does not
constitute disciplinary action and does not imply guilt. The employee will receive full pay and will
lose no rights whilst the investigation proceeds apart from in exceptional circumstances.
Whilst suspending an employee is not disciplinary action and is action without prejudice, it may
have a detrimental effect on the employee being suspended. Suspended employees have been
known to experience symptoms of depression and their later rehabilitation to the workplace can be
exceptionally difficult. Suspension should therefore only be used as a last resort and where there
are alternatives to suspension, these should be considered. Alternatives include:
• restricting the employees access to certain areas of work
• temporary redeployment of the employee to a different work area
• changing the work pattern e.g. changing from nights onto days
• supervised practice
Whilst each potential case is different and it is not possible to be prescriptive, suspension will
usually be considered in the following cases:
• violence has occurred or is likely to occur if action is not taken
• extremely volatile situations
• there is believed to be a genuine risk to the safety of staff, patients or visitors
• allegations of assault
• the employee appears to be incapable of carrying out their duties
• other cases of potential gross misconduct
• other circumstances where the employee’s continued presence would seriously impede the
flow of work, or would prejudice an investigation
A decision to suspend an employee will be made by an appropriate senior manager in conjunction
with a senior member of the HR team and will be considered when determining the terms of
reference for the investigation. The decision may also be made during the investigation if
circumstances arise that indicate it is unwise to allow the employee to continue working.
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In normal circumstances an employee will only be suspended by a senior manager who has the
authority to suspend although a decision to suspend an employee must be made in consultation
with a senior member of the HR team.
The suspension must be carried out in private with a witness present, stating the content of the
allegation(s). The suspension will be confirmed in writing as soon as is reasonably practicable.
The suspension will be regularly reviewed and every effort will be made to minimise the period of
suspension. The employee should be allocated a designated person whom they can contact for
advice and support for the duration of the suspension.
During the suspension the employee should not undertake any paid work for the Trust or any other
employer. They should not attempt to enter any Trust property or make contact with colleagues
whilst suspended from work, unless for hospital treatment or to attend meetings associated with
the investigation. If the employee or their representative wishes to contact colleagues to request
their attendance at a hearing or to obtain information relevant to the case, prior consent should be
sought from the Commissioning Manager or an HR Manager.
The employee is required to make him / herself available for any meetings they are requested to
attend as part of the investigation.
10.4 Removal of Access to Buildings or Trust Property
There may be cases whereby in conjunction with an investigation it is necessary to remove an
employee’s access to Trust IT accounts / computers / buildings / mobile phones / laptops etc. A
decision about the necessity to undertake such action will be made by a Senior Manager in
conjunction with a senior member of the HR team. If the action to be taken is in respect of the
employee’s access to IT in some capacity, this will be made in conjunction with a senior member
of the Clinical informatics department and the employee will be informed as appropriate. In the
case of retaining 'personal items' a record should be made in case the Trust or the employee can
subsequently claim rightful possession to the item.
10.5 Involvement of Police & Criminal Offences
The Trust’s disciplinary procedure is separate from any police enquiries, legal proceedings or
convictions regarding a criminal offence relating to employment. Where police have been called to
make investigations and an employee’s action may be regarded as criminal, disciplinary action
may proceed on evidence obtained prior to the judgement of the courts. This may not, however,
always be appropriate and in some circumstances, suspension may be considered.
Where alleged misconduct concerns a potential criminal offence, it may be necessary to inform the
Police. In such cases, the line manager should contact the Police to inform them of the alleged
misconduct and notify the employee that the Police have been contacted. The manager should
also notify the appropriate HR Manager.
In most cases an internal Trust disciplinary investigation should not be delayed or depend on the
results of a police investigation. In exceptional circumstances it may be necessary to draw a
temporary halt to an internal investigation to ensure that it does not impede the criminal
investigation. The decision to temporarily halt an internal investigation should be made in
consultation with the Police and HR.
Criminal offences outside employment shall not be treated as automatic reasons for dismissal or
action short of dismissal. The main consideration shall be whether the offence has any relevance
to the individual’s duties as an employee is one which makes the individual unsuitable for their
work. Consideration should also be given as to whether other appropriate jobs are available.
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10.6 Investigations into Allegations of Fraud
If an allegation is made that has an element of suspected fraud, this should be reported to the
Director of Finance or the LCFS before any internal action is taken including suspension or
commissioning of an investigation.
In cases of fraud, there are a range of sanctions available including criminal, civil and disciplinary
sanctions. See Appendix 7 for further details of the process to be followed.
10.7 Investigations into Bribery and Acts of Corruption
The Bribery Act 2010, which repeals all existing corruption legislation, has introduced the offences
of offering and or receiving a bribe. It also places specific responsibility on organisations to have in
place sufficient and adequate procedures to prevent bribery and corruption taking place. Under
the Act, Bribery is defined as “Inducement for an action which is illegal, unethical or a breach of
trust. Inducements can take the form of gifts, loans, fees, rewards or other privileges". Corruption
is broadly defined as the offering or the acceptance of inducements, gifts or favours, payments or
benefit in kind which may influence the improper action of any person; corruption does not always
result in a loss. The corrupt person may not benefit directly from their deeds; however, they may
be unreasonably using their position to give an advantage to another. To demonstrate that the
organisation has sufficient and adequate procedures in place and to demonstrate openness and
transparency all staff are required to comply with the requirements of the this Policy. For a more
detailed explanation, please see the Anti-Bribery Policy. Should members of staff wish to report
any concerns or allegations they should contact their Local Counter Fraud Specialist.
Acts of bribery and corruption are potentially criminal offences and may therefore be passed to the
LCFS to investigate.
10.8 Staff Support
External Counselling Services
The Employee Assistance Helpline is a confidential support service, providing practical
information, legal advice, telephone and face-to-face counselling that can help employees cope
with a variety of personal, family or workplace issues. The service is free and available to all
Trust employees by telephoning 0800 328 1437. Further information regarding the counselling
services is available from Occupational Health or the Trust Intranet:
http://wghintra01/human_resources/staffsupport/documents/eah_leaflet.pdf
Trade Union Representatives
If employees are members of a trade union or professional association they may wish to contact
their representative for support.
Support Manager
In cases where an employee is suspended, they should be allocated a designated person whom
they can contact for advice and support for the duration of the suspension. Ideally, this should be
someone whom the employee being suspended feels comfortable with.
10.9 Right to be Accompanied
All employees have the right to be accompanied during investigation meetings, disciplinary
hearings and appeals by a trade union representative or work colleague. It is the responsibility of
the employee to arrange representation and this request must be ‘reasonable’ in that the
representative should not have a conflict of interest or be likely to disrupt the hearing. Any
representative or companion is entitled to paid time off for the period required.
Witnesses also have the right to be accompanied by a union representative or colleague during
meetings and disciplinary hearings, but their representative should not be a colleague who also
has direct involvement in the same investigation in the interest of avoiding bias.
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10.10 Accredited Representatives
Where an alleged act of misconduct is believed to have been committed by an employee who is an
accredited representative of a Trade Union or Professional Body, no action under the procedure,
other than suspension when serious misconduct is being investigated, will be taken until the case
has been discussed with a full-time official of that Union or Professional Body.
11. DISCIPLINARY HEARING
If it is decided that a complaint of misconduct is justified, a disciplinary hearing will be arranged.
This will comprise of the following:
11.1 Notice of the Hearing
The employee will be given notice of the disciplinary hearing a minimum of 7 working days before
the hearing is due to take place. This notice will include:
• Purpose of the hearing
• Nature of the alleged misconduct
• Names of panel members and witnesses
• 2 copies of the Investigation Report
• Invitation to attend with a trade union representative or work colleague
11.2 Right to State Case
At all stages, employees will be entitled to state their case before decisions are reached. If the
employee confirms with good reason that they are unable to attend on the date set for the hearing,
an alternative date will be convened. This will be arranged in conjunction with the employee,
taking into account the employee and their representatives availability. If, in exceptional
circumstances, the employee is unable to attend the hearing within a month of the time set and
agreed between the parties, it may proceed in their absence, but with their representative being
provided with an opportunity to present the employee’s case on their behalf. Hearings will not be
unreasonably delayed due to availability of the employee’s preferred representative.
11.3 Witnesses
It is the responsibility of the parties concerned to arrange for the attendance of their witnesses. In
the case of witnesses who are employees of the Trust, time off work with pay will be granted for
them to attend. Witnesses will only be present at the hearing whilst giving evidence.
It is recognised that in most disciplinary cases, it will be inappropriate or impracticable to involve
patients or relatives as witnesses.
11.4 Representation
Employees will have the right to appear personally before a panel, either alone or accompanied by
a colleague or representative of a trade union. Representation rights at a hearing do not extend to
professional legal advisers. If appropriate there may need to be a professional lead on the panel.
The trade union representative or colleague will be allowed to present the employee’s case and
question any witnesses called. The employee should however, respond personally to questions
posed by the investigating team or the panel.
11.5 Failure to Attend the Hearing
When an employee is notified of the date of the hearing, they will be required to confirm their
attendance. Correspondence will be hand delivered to the employee at work in person or sent
recorded delivery to the employee’s home address as detailed on the payroll system. Employees
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have a responsibility to ensure that their personal details are up to date and to notify the workforce
team via a change of circumstances form in respect of any change of address.
If the employee fails to confirm their attendance and subsequently does not attend the hearing, a
decision can be taken to continue with the hearing in the employee’s absence and the full range of
sanctions can still be applied.
11.6 Conduct of a Disciplinary Hearing
The hearing will normally be conducted by a disciplinary panel chaired by an appropriate senior
manager accompanied by one or more members of management, one of whom will always be a
member of the Human Resources Directorate. For the disciplinary hearing schedule, see
Appendix 3. If appropriate, a professional lead should also sit on the panel. In cases of personal
conduct involving medical staff, the disciplinary panel must include two employees of the Trust
who are medically qualified (in the case of doctors) or dentally qualified (in the case of dentists).
In exceptional circumstances an independent expert may be present to provide technical
information and advice at the request of any party present. The chair of the panel will outline the
reasons for the disciplinary hearing and ascertain the employee understands the allegations.
Both the employee and the investigating officer will be available for cross-examination by the panel
members and the employee or his/her representative. If witnesses are called in support of the
employee and/or the management case, they will also be available for cross-examination.
The hearing may be adjourned if further investigations prove necessary.
11.7 Findings of the Hearing Panel
On completion of the proceedings, both parties should return to hear the outcome where the chair
of the panel will announce the decision of the panel and the disciplinary action to be taken (if any),
where possible. He or she will also give an explanation for that action and will explain the
employee’s rights of appeal under this procedure. This will be confirmed in writing within 7 working
days.
In exceptional circumstances, if it is not possible to adhere to this timescale, the chair of the panel
will advise the employee and their representative of the reason for the delay and the expected
timescale for the decision to be communicated.
12. REASONS FOR DISCIPLINARY ACTION
Misconduct
Examples of misconduct where a form of warning may be issued or where cumulative or repeated
acts could lead to dismissal are as follows:
• Attendance and Time-keeping
- Continuing failure to comply with attendance and time-keeping requirements e.g.
lateness, regular failure to follow absence reporting procedures as specified in the
Management of Sickness Absence Policy
- Continuing failure to follow procedures for booking and returning from leave
- Absenteeism and unauthorised absence from the workplace including taking unauthorised
or excessive breaks
• Behaviour
- Refusal or failure to follow a legitimate management instruction
- Inappropriate behaviour or abuse of authority towards a colleague or member of the
public or person in the care of the Trust
- Insubordination
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- Failure to comply with the provisions of the Trust’s equal opportunities policy
- Conduct at work which is likely to offend decency
- Conduct which could bring the Trust into disrepute (including inappropriate or offensive
comments placed on social networking sites such as Facebook or Twitter)
- Negligence in the performance of duties
- Misuse of Trust’s facilities
- Abuse of Trust policies including refusal to comply with the Trust’s no-smoking policy
• Poor Working Practices
- Failure to maintain proper records
- Failure to comply with health and safety requirements
- Failure to follow Trust procedures e.g.
- Drug errors as a result of non compliance with appropriate Trust policy
- Failure to comply with Trust hand washing protocol
• General
- Misconduct in relation to official documents
• Any other act of misconduct of a similar gravity
Gross Misconduct
Gross misconduct is defined as misconduct of such a serious nature that the Trust is justified in no
longer tolerating the employee’s continued presence at the place of work. An allegation of gross
misconduct will normally lead to suspension, pending an investigation. Instances of gross
misconduct can lead to summary dismissal where the allegations are substantiated. Examples of
gross misconduct where a summary dismissal may be issued are:
• Theft or fraud in the course of employment, including fraudulent completion of expense claims /
time sheets or the falsification of records / qualifications (See Appendix 7 for further details
about fraud cases)
• Physical assault or threatening behaviour/language towards staff, patients or visitors
• Sexual offences / acts of indecency
• Breaches of the Trust’s equal opportunities policy, including serious acts of harassment,
discrimination or verbal abuse against employees, service users or the public on grounds of
race, sex, disability or religious belief or any other grounds
• Breach of confidentiality including deliberate misuse of data protection information and/or
deliberate interference with computerised information
• Deliberate and serious damage to Trust property
• Serious breaches of health and safety legislation
• Serious incapability at work bought on by alcohol or illegal drugs
• Intentional misuse of email or the internet and serious breaches of the Trust’s policies on
computer use
• Offences which seriously threaten the security of clients, members of the public, employees or
property or which seriously damages public confidence in the Trust
• Any act or omission reasonably judged to have resulted in a serious breakdown in trust and
confidence
• Serious breaches of the Trust’s Code of Conduct
• Serious insubordination
• Serious negligence / professional misconduct including ill treatment, neglect or abuse of
patients
• Continuous unauthorised absence from work without a valid reason and failure to communicate
with management regarding the ongoing absence (i.e. going awol)
• Failure to disclose any relevant criminal offences prior to employment or any criminal
convictions which occur during employment in a timely way
• Behaviour, including that outside of work, resulting in a criminal conviction, where the nature of
the conviction warrants dismissal because of its employment implications
• Failure to renew professional registration
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• Failure to comply with the Trust’s Scheme of Delegation for example by failing to declare
conflicts of interest, or acts of bribery or corruption, for example not declaring gifts or hospitality
– see the Trust’s Anti-Bribery Policy for more information
• Any other act of misconduct of a similar gravity
The above lists are neither exclusive nor exhaustive and there may be actions which do not
appear above but may nevertheless be the subject of disciplinary action.
In determining the seriousness of the misconduct, particular regard will be given to the
circumstances of the individual case. Factors, which can influence a decision as to the
seriousness of the offence, may include:
The type and degree of misconduct
The consequences arising from the misconduct
The frequency of the misconduct, and
The level of responsibility of the employee concerned
13. TYPES OF DISCIPLINARY ACTION
No Action
If the hearing results in a finding of ‘no action’, either because the case was found unsubstantiated,
or because of exceptional mitigating circumstances it was decided to take no action, all records of
the hearing and investigation will be removed from the employee’s personal file and destroyed.
Formal Oral Warning
For minor offences where an employee’s conduct does not meet acceptable standards, a formal
oral warning may be given making it clear that further misconduct may render the employee liable
to further disciplinary action involving more severe consequences. The issuing of a formal oral
warning should be confirmed in writing. The formal oral warning will remain on the employee’s
personal file for a period of 6 months.
First Written Warning
A first written warning may be given for a more serious offence, or where there has been a
repetition or no satisfactory improvement in the behaviour for which the employee received an oral
warning. This warning will remain on the employee’s personal file for a period of 12 months.
Final Written Warning
The final written warning will apply where there has been a failure to improve behaviour following
previous warnings, or repetition of the same offence. However, if misconduct is sufficiently
serious, it may be appropriate to enter the procedure at this stage. The final written warning will
remain on the employee’s personal file for 18 months. In exceptional cases this period may be
extended.
Dismissal
An employee’s contract of employment can be terminated as a result of dismissal in the following
instances:
• Where an employee has a current final written warning on file, and there has been a
repetition of the offence or a further incident at a similar level / similar seriousness but not
necessarily the same misconduct, dismissal will be the outcome, with required period of
notice (pay in lieu)
Or
• If the Disciplinary Hearing panel finds that an act of gross misconduct is established, the
final act will be summary dismissal without notice or pay in lieu of notice
Page 13 of 30

Following dismissal an employee will be required to return all property belonging to the Trust as
soon as is reasonably practicable.
14. REQUIREMENT FOR PROFESSIONAL REGISTRATION
Registration is a requirement of certain NHS employment, and where employees fail to renew their
registration, disciplinary action, including dismissal, may be considered. The onus is on the
employee to renew their registration, which should then be recorded by the employer. Mitigating
circumstances regarding the reason for non-renewal should always be considered. For further
information, please refer to the Policy for the Trust wide Management of Registration Verification
for Permanently Employed Nurses, Midwives and Operating Department Practitioners.
In all cases involving dismissal of professional staff, the Trust will inform the relevant professional
body. It will then be a matter for them to consider if further action is required.
Where disciplinary action by a professional body results in a member of staff's name being erased
by the appropriate professional register, then this will provide sufficient reason for termination of
his/her contract, irrespective of any previous disciplinary action or decision taken by the Trust.
15. APPEALS PROCEDURE
Every employee has the right to appeal against any disciplinary sanction reached at a hearing and
will be reminded of this right at the conclusion of the hearing. The person hearing the appeal will
not have been involved in the initial decision to take disciplinary action.
The appeal will normally constitute a re-hearing of the case, except where the appeal grounds
relate solely to the severity of the sanction.
Written notice of appeals must be sent to the Director of Workforce within 21 days of the date of
the letter confirming disciplinary action and clearly state the reason for the appeal.
The Director of Workforce will arrange for the appeal hearing to be set up and all parties to be
notified of the date, time and location. The appeal hearing should normally be heard within 8
weeks of the letter requesting the appeal being received.
A member of Human Resources will sit on the panel, and advise the panel on the application of
procedures and current legislation, which is pertinent to the case.
Before any appeal hearing the following documents should be sent to Human Resources no later
than 7 days before the hearing date. The HR representative will then arrange for copies to be
circulated to both sides involved in the appeal as well as the members of the Appeal Panel. No
material, which did not form part of the evidence at the disciplinary hearing, will be introduced at an
Appeal Hearing unless by joint agreement of the parties concerned:
Managers Statement -This statement should present the circumstances of the case and the
action taken to date, including reasons why the original sanction was given, and list the key
documents to be presented at the hearing as well as who will be called to give evidence to
the hearing as a witness.
Employee’s Statement - This statement may be prepared in conjunction with the
representative and will state the reasons why the appeal is being made. This should list
the key documents to be presented at the appeal as will as any persons who may be called
to give evidence at the hearing as witnesses.
Witnesses
It is the responsibility of the parties concerned to arrange for the attendance of their witnesses. In
the case of witnesses who are employees of the Trust, time off work with pay will be granted for
them to attend. Witnesses will only be present at the hearing whilst giving evidence.
Page 14 of 30

Representation
Employees will have the right to appear personally before an appeal panel, either alone or
accompanied by a colleague or representative of a trade union. Representation rights at a hearing
do not extend to professional legal advisers.
Findings of an Appeal Panel
On completion of the appeal process, the decision of the appeal panel will be final and there will be
no further right of appeal. The employee may apply to the Employment Tribunal for redress if they
so wish.
A record of the proceedings should be made and kept on file. The final decision will be notified to
the employee and trade union within 7 days and reported to the Trust Board. Where an employee
is reinstated, it will be have immediate effect and any loss of earnings as a result of the original
sanction will be reimbursed.
Where an Appeal Panel decides that the original disciplinary decision was not within the range of
reasonable responses by management, they have the right to either instruct management to
remove the disciplinary sanction imposed or to substitute a different form of disciplinary sanction.
This could be a more severe or lesser sanction.
16. KEEPING RECORDS
It is important to keep written records during the disciplinary process. Records should include:
• The allegation against the employee
• The employee’s defence
• Findings made and actions taken
• Reason for actions taken
• Whether an appeal was lodged
• The outcome of the appeal
• Any grievances raised during the procedure
Records should be treated as confidential and be kept no longer than necessary in accordance
with the Data Protection Act 1998, which gives individuals the right to request and have access to
certain personal data. Copies of investigation meeting records should be given to the employee
concerned although in certain circumstances, it may be appropriate to withhold certain information,
for example to protect a witness.
17. REFERENCE REQUESTS FOR EMPLOYEES UNDER INVESTIGATION OR WHERE A
CURRENT DISCPLINARY SANCTION APPLIES
In the event that a reference request is received for an employee who is currently the subject of a
disciplinary investigation or for whom there is a current disciplinary sanction on file, the manager
should contact HR for advice.
As references must lawfully be accurate and factual, information may be disclosed pertaining to a
current investigation or sanction, or where the employee has been dismissed in accordance with
this policy.
18. PROCESS FOR MONITORING COMPLIANCE AND EFFECTIVENESS OF THE POLICY
The HR Department will log all disciplinary cases including outcomes / appeals and ensure that
any disciplinary cases are dealt with as per the policy.
Page 15 of 30

19. REVIEW OF THIS PROCEDURE
This policy is expected to be reviewed within 3 years but if this is deemed unnecessary the policy
will remain in force until such time as it is reviewed.
Page 16 of 30

Appendix I
INVESTIGATION OUTLINE – TERMS OF REFERENCE
Hearing Panel Chair
Hearing Panel HR
Support
Investigating Officer
HR Support to
Investigating Officer
Name
Contact No
Was the employee suspended Yes
No
Please provide rationale for decision…………………………………………………………………….
……………………………………………………………………………………………………..…………
………………………………………………………………………………………………………………..
Background information …………….…………………………………………………………………..…
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
1.
2.
3.
STANDARDS
ISSUES TO BE INVESTIGATED
If found, whether the above allegations contravene the following documents / policies:
PROCESS
To interview/obtain statements from key individuals.
To review relevant documents and policies
OUTCOME
To produce a report for consideration by (name). Report content to include findings,
conclusions and recommendations.
Deadline for investigation
Terms of Reference
Completed by:
Date:
Page 17 of 30

Appendix 2
PRIVATE AND CONFIDENTIAL
DATE
INVESTIGATION REPORT
Allegation Against:
Name, Job Title
Investigating Officer and Report Author: Name, Job Title
Human Resources Support: Name, Job Title
Page 18 of 30

Section Headings:
1. Introduction
Explain why the investigation was requested and the background to the case.
2. Allegation
State the specific allegations being investigated
3. Methodology
Explain who was interviewed as part of the investigation and any other documentation that has
been reviewed.
4. Findings
A summary of the key findings and facts of the case. It is important for investigating officer to
separate fact from comment and personal perceptions. It may be appropriate to refer to
appendices such as notes of meetings with employees, extracts from policies here.
5. Conclusion
A summary statement of the report specifically detailing whether the alleged misconduct has been
substantiated or not
6. Recommendations
A list of recommendations should be included in the report for consideration by the commissioning
manager. These can include:
• Proceed to a disciplinary hearing without prejudice
• Additional training
• Appraisal and objective setting
• System reviews
Page 19 of 30

Appendix 3
Disciplinary Hearing Schedule
1. Chairperson to introduce all parties and explain the purpose of the hearing and procedure to
be followed
2. The employee/representative will be asked to state whether he/she admits or denies the
allegation(s)
A. If the employee admits the allegations:
• Employee and/or representative may present any mitigating circumstances
• Investigating Officer may ask questions about the mitigating circumstances
• Panel may ask questions about the mitigating circumstances
• Investigating Officer may provide a short summary of the management case
• Employee and/or representative may ask questions about the management case
• Both parties are given the opportunity to sum up
B. If the employee denies the allegations:
• Investigating Officer to present the management case
• Employee and/or representative, Chairperson and HR Support may ask questions
of the Investigating Officer
• Investigating Officer to call any witnesses who can be questioned by the parties as
above
• Employee and/or representative to present their case
• Investigating Officer, Chairperson and HR support to ask questions of the
employee
• Employee and/or representative may call witnesses who can be questioned by the
parties as above
• Investigating Officer to sum up their case
• Employee and/or representative to sum up their case
3. Parties to withdraw to enable the panel to deliberate in private. The chairperson must come
to a clear view about the facts, and if they have been disputed, decide on the balance of
probability as to which version of events the panel believes
4. Parties to be recalled to be informed of the panel’s decision if it is possible to make a
decision on the day
5. Letter to be sent to the employee advising or confirming the outcome within 7 working days.
Letter to confirm the reasons for the decision and advise of right of appeal
Page 20 of 30

Appendix 4
Disciplinary Appeal Hearing Schedule
1. Chairperson to introduce all parties and explain the purpose of the appeal hearing and
procedure to be followed:
2. The employee / representative will present their grounds for appeal
• If necessary, call and examine any witnesses
• The management representative will have the opportunity to cross examine the
employee and any witnesses
3. The management representative will present the management case
• If necessary, call and examine any witnesses
• The employee and/or representative will have the opportunity to cross examine the
management representative and any witnesses
Members of the panel may ask questions of both parties at any stage of the appeal hearing
4. The employee followed the management representative are given the opportunity to sum up
5. Parties to withdraw to enable the panel to deliberate in private. The chairperson must come
to a clear view about the facts, and if they have been disputed, decide on the balance of
probability as to which version of events the panel believes. If recall is necessary to clear
points of uncertainty, both parties will return.
6. Parties to be recalled to be informed of the panel’s decision if it is possible to make a
decision on the day
7. Letter to be sent to the employee advising or confirming the outcome within 7 working days.
Letter to confirm the reasons for the decision and advise that there is no further right of
appeal
• Where the appeal grounds relate solely to the severity of the sanction the above procedure in
sections 2, 3 and 4 will be followed. If the employee appeals for any other reason, the above
procedure will be reversed
Page 21 of 30

Appendix 5
Guidelines for Writing a Statement
There are circumstances where you may be called upon to provide a written statement. This will
occur when there has been an incident or complaint that needs to be investigated in line with
Trust policy and you were present at the time. Statements should be of a factual nature and
include a description of the events surrounding the incident or complaint.
These guidelines aim to provide you with some simple advice on preparing a statement, which
has been requested for an investigation into an untoward event or complaint that has occurred
during the course of your employment.
There is also a template attached following the guidance, which you may print off and use to write
a statement.
• Assume that the reader of your statement knows nothing of the facts of the case, of the
patient’s medical history or of hospital routines if appropriate. The statement will thus form
a story, which will tell the investigating officer the circumstances of the incident as you
remember them
• Use good quality A4 paper. Do not use scraps of paper, pages from notepads, medical
records sheets, or the backs of documents designed for other purposes
• Statements should ideally be typed but if this is not possible, you must write clearly and in
black ink
• Number the pages. If you use more than one page, ensure the pages are securely
fastened together
• Begin the statement with your name and job title – see template on page 3
• Be clear about the times you were on and off duty on the days in question and about what
you saw and heard. Put events in the order in which they happened, giving precise dates
and times (using am/pm or the 24 hour clock)
• State the location at the time of the incident and name any other witnesses who were
present. When referring to other people in your statement give their full names and job
titles
• Use your own words. Please note that staff are entitled to seek support from their Trade
Union Representative if they wish when writing a statement and should be given enough
time to do so
• Keep to the facts and avoid giving opinions or assumptions. Only include facts or
conversations you have actually witnessed or taken part in. Do not include things that
other people told you happened or conversations reported to you
• Write your statement in simple terms and avoid using jargon or abbreviations. Be as brief
as possible while covering all essential points. When using medical terminology always
explain the meaning
• If you include in your statement any information you have read in patient notes, you should
include references as to where it can be found, e.g. “It is recorded on the 3 rd February
2009 in Mrs Smith’s nursing notes that a request for a CT scan had been sent to
radiology”
Page 22 of 30

• Your statement should be written in the first person, i.e. “I was asked by Staff Nurse Jane
Smith to record Mr Green’s blood pressure”
• Any alterations to your statement should be made by drawing a single line through the
words you wish to change. This should then be initialled
• The final paragraph of your statement should read: “This statement is true to the best of
my knowledge and belief”
• Your statement should be signed and dated. You should also print you full name and job
title
• Keep a copy for your own records
Human Resources Dept
April 2010
Page 23 of 30

Name:........................................................ Job Title: ...................................................
Date and Time of Incident: ..........................................................................................
Location of Incident (ward / dept):...............................................................................
Other Witnesses that were present: ........................................................…...............
……………………………………………………………………………………………………
This section should be used to explain the facts of the incident but avoid giving opinions or
assumptions. Only include facts or conversations you have actually witnessed or taken part
in. Do not include things that other people told you happened or conversations reported to
you. Write your statement in simple terms and avoid using jargon or abbreviations.
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
Continue on another page if necessary
This statement is true to the best of my knowledge and belief.
Name: ............................................................................................................................
Signature: ......................................................................................................................
Date: ..............................................................................................................................
Page 24 of 30

Appendix 6
Disciplinary Process Flow Chart
Incident occurs
Commissioning Manager appoints
Investigating Officer to undertake
thorough investigation
Clinical incident
If incident relates to patient safety, use
the Incident Decision Tree before
progressing to disciplinary
investigation
Commissioning Manager to write Terms
of Reference
Investigation to commence with HR
support and be completed within 8
weeks where practicable
Investigation report is produced for the
Commissioning Manager
If no case to answer, employee is
notified in writing and process ends
Commissioning manager to decide if case is
referred to a disciplinary hearing
If yes, convene a disciplinary hearing
No action
Oral warning (6
months)
The chair of the panel will announce the
decision and action (if any) to be taken
First written warning
(12 months)
Final written warning
(18 months)
Decision is confirmed in writing within 7 working
days and employee given the right of appeal
Dismissal
If employee appeals, appeal hearing to be
convened and chaired by more senior manager.
There is no further right of appeal
Original decision upheld
Substitute sanction for a
different sanction
Page 25 of 30

Appendix 7
Protocol for dealing with potential cases of fraud
1 Introduction
1.1 This document has been established to enable effective interaction between the Local
Counter Fraud Specialist (LCFS) and the Human Resource Department (HR). It is
necessary that the co-operation between these two functions can be demonstrated; hence
this protocol has been established.
1.2 The protocol provides a framework for liaison between the LCFS and HR whenever a
potential fraud is highlighted. Applying the protocol will ensure that the full range of
sanctions available to the organisation can be considered at the earliest opportunity
(criminal, disciplinary and civil). To pursue these sanctions effectively there needs to be a
close and supportive liaison between the LCFS and the Human Resource functions. This
includes the sharing of information to avoid both duplication of effort and potentially
compromising the use of other sanctions by well-intentioned actions. The Director of
Finance should be consulted whenever there is any conflict between the two roles
regarding a course of action to be taken.
1.3 This protocol is not a definitive procedural document as this would not be possible as each
individual investigation may highlight specific issues requiring an adaptation to the
procedure outlined herein. However, despite any case-by-case adaptations that may be
required, the organisation should remain mindful of the need to conduct potential fraud
investigations in accordance with criminal and civil law and all relevant aspects of
employment law. Furthermore guidance outlined in the NHS Counter Fraud and
Corruption Manual and policy document ‘Applying Appropriate Sanctions Consistently’,
which includes specialist and legal advice on how to conduct investigations to ensure the
full range of sanctions are considered and can be applied in all fraud or corruption
investigations should be fully adhered to.
1.4 To maintain a high deterrent factor against NHS fraud, it is important to consider the full
range of sanctions available. This may result in criminal sanctions being applied at the
same time as any civil and/or disciplinary sanctions. Whenever sanctions are to be run
simultaneously (termed parallel sanctions) close liaison must exist between the LCFS and
HR, as findings from one investigation might be important to the success of another.
Generally, the criminal investigation will determine the actions and timing of other related
investigations, this is due to the higher burden of proof placed upon criminal investigations
and the resultant due process legislation that covers the gathering of evidence. However,
the fact that a criminal investigation is being conducted does not negate the fact that a
decision can be made on a disciplinary or civil matter, but rather this action should be
taken after consultation with the investigator leading on the criminal investigation.
2 HR Liaison Responsibilities
2.1 Meet regularly with the LCFS to discuss requirements and monitor the interaction
process ensuring it remains effective and fit for purpose.
2.2 Assist the LCFS, as appropriate, in any fraud reviews undertaken to detect and prevent
potential fraud from entering the organisations systems.
2.3 All referrals received that may have an element of suspected fraud MUST be reported
immediately to the LCFS or the Director of Finance. This can be verbally, in writing or e-
mail. If reported direct to the LCFS, then the LCFS will ensure that the Director of
Finance is notified at the earliest opportunity.
Page 26 of 30

2.4 Inform the LCFS of any possible system weaknesses, which could allow fraud or
corruption to occur. This includes weaknesses discovered as part of any HR
investigation that did not warrant the commencement of a fraud investigation.
2.5 Meet regularly with the LCFS for updates on investigations whenever parallel sanctions
are being conducted to ensure a flow of information and avoid potential duplication of
effort.
2.6 Inform the LCFS whenever Health and Safety risks (i.e. not holding appropriate clinical
qualifications) or allegations relating to vulnerable clients, must take precedence over
any potential fraud investigation that may be undertaken.
2.7 Allow the LCFS, whenever possible, to interview the suspect under caution before a
disciplinary investigation / process takes place. In this way first reactions to the
allegations are taped which can then be used for both in both criminal and disciplinary
investigations. Please note that while information can be shared it does not negate the
need for a correct and proper investigation for each sanction being considered, for
example information might be shared from an interview under caution but this
information should be discussed with the person at a separate disciplinary interview,
which is bound by its own rules of conduct.
2.8 When appropriate to do so, and in liaison with the LCFS, undertake disciplinary
sanctions even if a criminal sanction may still be ongoing. Feedback to the LCFS the
outcome of such disciplinary hearing as this may have an impact on the criminal
sanction investigation.
2.9 Where necessary, and available, provide sufficient evidence to the LCFS in order that a
fraud investigation and criminal sanctions can be pursued.
2.10 Liaise with the Director of Finance and LCFS whenever a decision has been made to
suspend an employee who is subject to a fraud investigation. The decision to suspend
will rest with an appropriate Executive Director / Senior Manager with the support of a
Senior HR Colleague, but any decision should not be taken without consultation with the
LCFS as HR action may adversely affect the success of a criminal investigation, for
example it may warn the suspected person and allow them time to cover up the fraud or
corruption.
2.11 It is important that HR inform the LCFS of all decisions taken in disciplinary cases where
the LCFS has considered ‘parallel sanctions’. The LCFS is required to provide brief
details of the outcome of such cases on the NHS CFS Compound Indicator selfassessment
made by the health body at the end of the financial year.
3 LCFS Liaison Responsibilities
3.1 Meet at agreed regular intervals with the Deputy Director of Workforce to discuss liaison
requirements.
3.2 Provide a bespoke presentation to HR staff explaining the role of the LCFS and the
interaction between the counter fraud and HR.
3.3 Acknowledge receipt of HR referrals and arrange to meet with an appropriate HR
representative to discuss. The LCFS will then undertake an initial and timely review to
establish the validity or otherwise of the allegation.
3.4 Meet at regular intervals with HR for updates on investigations whenever parallel
sanctions are being conducted to ensure a flow of information and avoid potential
duplication of effort.
Page 27 of 30

3.5 Liaison with the relevant NHS CFS Operational Service Team throughout the
investigation passing relevant advice onto HR for consideration.
3.6 Where necessary, and appropriate to do so, the LCFS will provide sufficient evidence to
HR in order that a disciplinary investigation can be taken forward as appropriate.
3.7 Concluding reports will be issued at the closure of any investigation undertaken by the
LCFS in accordance with the requirements outlined in the NHS Counter Fraud and
Corruption Manual.
4 Outline of Investigation Process
4.1 From the initial review undertaken by the LCFS, the following will be considered (see
Appendix A):
• No evidence of fraud found (4.2)
• No evidence of fraud found but system controls need to be strengthened (4.3)
• No evidence of fraud found but matter needs to be referred back to HR for potential
disciplinary sanction to be considered (4.4)
• Reasonably held suspicion/information/evidence of suspected fraud received
requiring criminal investigation (4.5).
4.2 No case to answer or no evidence of fraud found
The LCFS will inform the Director of Finance that no fraudulent action has been
identified. Human Resources will also be notified of this decision. A concluding report will
be written by the LCFS and issued accordingly.
4.3 No evidence of fraud found but system controls need to be strengthened
The LCFS will inform the Director of Finance and HR of this decision.
A concluding report will be issued with recommendations to strengthen controls in
identified areas of weakness. This report will be distributed in accordance with the
requirements outlined in Directions. The recommendations will be followed up by the
LCFS as part of future fraud prevention work.
4.4 No evidence of fraud found but the referral is returned to HR for potential disciplinary
sanction to be considered
The LCFS will inform the Director of Finance and HR of this decision.
If the LCFS does not find evidence of fraud but a breach of policy/procedures may have
occurred, then the LCFS will meet with a member of HR to discuss the findings and pass
on the file of evidence gathered to date as disclosure allows. HR should use this file of
evidence to establish if further consideration/action is required.
The LCFS will take no further part in any additional investigation undertaken by HR
regarding a suspected breach of procedures. However, the LCFS may be called to a
disciplinary hearing as a witness if required.
A concluding report will be issued with recommendations to strengthen controls in
identified areas of weakness. This report will be distributed in accordance with the
requirements outlined in Directions. The recommendations will be followed up by the
LCFS as part of future fraud prevention work
4.5 Case to answer criminal investigation undertaken and appropriate sanction considered
Page 28 of 30

The LCFS will liaise with the Director of Finance and conduct an investigation in
accordance with investigative legislation such as the Police and Criminal Evidence Act
1984 (PACE) and the Criminal Procedure and Investigations Act (CPIA). Instruction
outlined in the NHS Counter Fraud and Corruption Manual must be followed.
Confidentiality will be respected during the course of the investigation.
Criminal investigations will be undertaken in a timely and professional manner so that
the pursuit of other potential sanctions is not compromised.
Regular case meetings will be held so that the LCFS can keep the Director of Finance
and the designated HR Manager updated as the investigation progresses and discuss
any potential sanctions that may be pursued.
If parallel sanctions are being undertaken, the LCFS will meet regularly with the HR
Manager to share information and avoid any duplication of effort. An investigation plan
setting out the requirements for the parallel sanction will be established and maintained
throughout the investigation process.
In liaison with the Director of Finance, HR, NHS CFS Operational Fraud Manager and
LCFS the health body will consider the following three sanctions in cases where there is
prima facie evidence of NHS fraud:
‣ Criminal – A criminal sanction is pursued where evidence of offences has been
obtained so that relevant punitive sanctions and redress can be sought. This
sanction can only be pursued if agreed by the Director of Finance and the NHS
Operational Fraud Manager.
‣ Civil - Where it is cost effective and desirable for the purpose of deterrence, it
may be decided that civil redress is the most appropriate course of action. It is then
the responsibility of the Trust to use the civil law to recover any losses.
‣ Disciplinary – Disciplinary procedures are designed to test whether a person
should be permitted to practice or continue their employment. Recovery should be
considered whenever this action is pursued where the organisation has suffered a
financial loss due to inappropriate actions. Those conducting disciplinary hearings
should never make an express or implied statement that criminal proceedings will
not be undertaken. Dismissal of an employee need not wait until the conclusion of
any simultaneous criminal sanction that the LCFS may be undertaking.
Either one or a combination of these sanctions can be pursued. This will be assessed on
a case-by-case basis.
4.6 The LCFS will be responsible for establishing a prosecution file.
4.7 A concluding report will be issued with recommendations to strengthen controls in
identified areas of weakness. This report will be distributed in accordance with the
requirements outlined in Directions. The recommendations will be followed up by the
LCFS as part of future fraud prevention work
5 Associated risks if effective interaction is not in place
5.1 The organisation may not be able to pursue all appropriate sanctions. This may lead to the
perception that the organisation does not take fraud seriously in that appropriate deterrent
penalties will not be applied in full for perpetrators of NHS fraud. Without appropriate
deterrent factors they may be an enhanced risk of fraud within the organisation.
5.2 Disciplinary hearings may be compromised if the organisation has failed to follow, and
evidence compliance to instructions and the local counter fraud policy when dealing with
potential fraud or corruption activity.
Page 29 of 30

Referral Process for Potential Fraud Investigations
HR Referral
LCFS
Initial Review
No case to
answer
Meeting between Director
of Finance (DoF) and LCFS
Case to
answer
LCFS to advise
HR and handover
any evidence
obtained for HR to
use in any internal
disciplinary
investigation
LCFS and HR
to provide
regular updates
to each other
during
investigation
LCFS to advise HR
& DoF if
investigation reveals
that the use of
parallel sanctions
may be appropriate
in accordance with
policy. HR to carry
out simultaneous
internal investigation
Sanction Decision
CRIMINAL
CIVIL
DISCIPINARY
Prosecution file
prepared by
LCFS/NHS CFS.
Consider County
Court/Small Claims in
consultation with Trust
solicitor
HR appoints
Investigating Manager
and follows disciplinary
procedure. LCFS may
be witness
Redress