|
Archived Transcript for 13 December 2001:
Pages 51 to 100
51
1 MS GRAHAM: I did.
2 MR GARNHAM: You were first employed by Haringey in 1992?
3 MS GRAHAM: Yes.
4 MR GARNHAM: And you have been there ever since?
5 MS GRAHAM: Yes.
6 MR GARNHAM: You became Commissioning Manager Child
7 Protection and Family Support in April 1997?
8 MS GRAHAM: That is true.
9 MR GARNHAM: From September 1999 your job title changed to
10 that of Commissioning Manager Child Protection, Quality
11 and Review?
12 MS GRAHAM: That is true.
13 MR GARNHAM: And then in January 2001 you became Acting
14 Assistant Director, Children's Services?
15 MS GRAHAM: That is correct.
16 MR GARNHAM: When did you return to your present job as
17 Commissioning Manager for Child Protection?
18 MS GRAHAM: My last day as the Acting Assistant Director was
19 the last day of June so I returned to the Commissioning
20 Manager post the first day of July.
21 MR GARNHAM: We have a list of your training courses in our
22 papers. Sir they are volume 29 page 59. But it is fair
23 to say I think that the emphasis understandably, given
24 your job, is on child protection in the course of your
25 training.
52
1 MS GRAHAM: That is true.
2 MR GARNHAM: You describe your principal responsibilities in
3 paragraphs 2, 3 and 4 of your first statement. Would
4 I be right in saying that the essential elements of your
5 job when you were Commissioning Manager were firstly the
6 management of the child protection conference system?
7 MS GRAHAM: Yes.
8 MR GARNHAM: Second, management of the child protection
9 advisers service?
10 MS GRAHAM: Yes.
11 MR GARNHAM: And thirdly management of the Quality Protects
12 MAP, the Management Action Plan?
13 MS GRAHAM: Yes, I think you have missed a bit about the
14 looked after children review, so if you mean by that
15 when you say Child Protection Service, if you --
16 MR GARNHAM: It was a deliberate omission only because we
17 are not directly concerned with that but thank you for
18 the correction.
19 MS GRAHAM: Can you repeat the third bit?
20 MR GARNHAM: Quality Protects MAP, Management Action Plan,
21 you were responsible for that I think?
22 MS GRAHAM: Yes.
23 MR GARNHAM: The job description for your role as
24 Commissioning Manager for the period until September
25 1999 and the period thereafter is different in that
53
1 there are different documents but I think you would
2 agree with me, would you not, that they are essentially
3 the same?
4 MS GRAHAM: That is right.
5 MR GARNHAM: During both periods, that is before and
6 after September 1999, the main tasks which you list in
7 paragraph 3 of your statement, and you might like to
8 look at that, were providing an effective service for
9 meeting the needs of children and responsibility for
10 sound professional practice. Is that right?
11 MS GRAHAM: Do you mean 1997?
12 MR GARNHAM: 1997 through to 1999.
13 MS GRAHAM: Right, yes.
14 MR GARNHAM: Then representing the department through the
15 ACPC and being responsible for effective monitoring of
16 child protection and ensuring the development of
17 a quality assurance service for all children and family
18 services.
19 MS GRAHAM: Yes.
20 MR GARNHAM: You asked me what period I was referring to.
21 Did those change significantly before and
22 after September 1999.
23 MS GRAHAM: Before 1999 I had not had the responsibility for
24 Quality Protects.
25 MR GARNHAM: That aside.
54
1 MS GRAHAM: It was largely the same.
2 MR GARNHAM: The Child Protection Advisers Department or
3 group consisted I think of you plus three child
4 protection advisers?
5 MS GRAHAM: The establishment at that time was four but
6 those in post were three.
7 MR GARNHAM: Because you tell us in paragraph 16 of your
8 statement that one CPA was cut in the year 2000 but in
9 fact that post had been empty since, looking at your
10 statement, certainly from the beginning of 1999 and
11 I suspect rather earlier than that.
12 MS GRAHAM: That is right.
13 MR GARNHAM: You say, however, despite the fact that there
14 had been that practical reality that you were working
15 with three CPAs through from the end of 1988 that the
16 loss of a child protection adviser did have an effect on
17 morale.
18 MS GRAHAM: It did.
19 MR GARNHAM: How?
20 MS GRAHAM: The team would report to me that they certainly
21 missed the worker who had been in the vacant post, or
22 rather that a worker was in the vacant post because of
23 the additional responsibilities they felt they had to
24 take on, in particular to do with the calls coming in
25 through to the team and having to respond to that.
55
1 There were also other elements, areas of work that we
2 could not take, and I suppose, as we saw our whole job
3 responsibility, we did feel that we were not able to do
4 everything and hence that impacted on morale.
5 MR GARNHAM: Let me ask you about each of the two elements
6 to that answer. First of all, the fact that there were
7 three of you doing the work originally identified as
8 being done by four, how was the additional work covered?
9 MS GRAHAM: A child protection adviser's job splits into
10 some quite neat areas and so for example the chairing of
11 conferences meant I asked independent chairs to do that
12 portion of work.
13 MR GARNHAM: People like Mr Peatfield?
14 MS GRAHAM: That is right, hence his workload would go up
15 and down. The adviser who was absent from work used to
16 chair the ACPC Children with Disability sub-group and
17 I asked, I arranged for the NSPCC to take over that area
18 of work. The reviewing officers.
19 MR GARNHAM: Who were also part answerable to you?
20 MS GRAHAM: That is right, and the child protection advisers
21 worked to cover what we could but from memory those were
22 the bits that I made arrangements for, from memory.
23 MR GARNHAM: So where you could you farmed the work out so
24 to speak, otherwise you three did the remainder of the
25 additional work.
56
1 MS GRAHAM: Yes, there was another area that comes to mind
2 and that was support for the Children with Disability --
3 did I already say that -- Children with Disability
4 Service within Haringey that I was not able to provide
5 an adviser to that service --
6 MR GARNHAM: I was going to ask you.
7 MS GRAHAM: -- on a more permanent basis, so they too, that
8 responsibility was spread through the team.
9 MR GARNHAM: I was going to ask you in respect of the second
10 part of your earlier answer, you say there and you said
11 in paragraph 16 of your statement that there were
12 projects on which your team could no longer work. What
13 did you have in mind when you said that?
14 MS GRAHAM: For example, although audits are audits I would
15 consider that a project of the worker and there would
16 have been other matters that came up, none immediately
17 come to mind, that would have been right for my team to
18 consider, that I was not able to take up.
19 MR GARNHAM: You cannot give us concrete examples at the
20 moment but there were other such instances?
21 MS GRAHAM: Yes, there could have been pieces of work that
22 I would not have accepted, they may have gone
23 elsewhere --
24 MR GARNHAM: Did you have anything particular in mind when
25 you wrote what you did in paragraph 16?
57
1 MS GRAHAM: No, I think it was just a reflection of some of
2 the work that we were not able to do.
3 MR GARNHAM: Was a consequence of this extra busyness
4 amongst you and your team that it was harder for you to
5 chair strategy meetings?
6 MS GRAHAM: I do not think so in that we would prioritise
7 some work above others and a request for a strategy
8 meeting would have been one of those priorities but
9 I would say that if you have three people instead of
10 four then there is that impact.
11 MR GARNHAM: It is easier to do it if you had four?
12 MS GRAHAM: Yes.
13 MR GARNHAM: Because chairing strategy meetings was one of
14 the functions of CPAs?
15 MS GRAHAM: Yes.
16 MR GARNHAM: Both Petra Kitchman and Dawn Green as she now
17 is from whom this Inquiry has heard were responsible to
18 you, I think.
19 MS GRAHAM: That is right.
20 MR GARNHAM: You in turn were accountable to Carol Wilson?
21 MS GRAHAM: That is right.
22 MR GARNHAM: You supervised the child protection advisers
23 and you supervised the reviewing officers?
24 MS GRAHAM: Yes.
25 MR GARNHAM: So that amongst those you supervised would have
58
1 been Petra Kitchman?
2 MS GRAHAM: Yes.
3 MR GARNHAM: You say in paragraph 21 of your statement that
4 you offered formal monthly supervisions.
5 MS GRAHAM: Yes.
6 MR GARNHAM: Ms Kitchman told us that she had nine
7 supervisions in 22 months with you, i.e. less than half
8 you say you provided. Is that right?
9 MS GRAHAM: What I would do at the beginning of the year,
10 whenever that year began, usually around December,
11 I would set out the year and ask that each person puts
12 their name against dates for supervision. It would be
13 true that during the course of that year I would
14 rearrange meetings, perhaps people were off sick or
15 perhaps I was unavailable, but the intention was that
16 people would have monthly supervision. Petra made that,
17 gave her evidence earlier this week and I have not been
18 able to go back and check how much, so I am not able to
19 dispute it one way or the other.
20 MR GARNHAM: Or confirm it.
21 MS GRAHAM: Or confirm it.
22 MR GARNHAM: You may be able to help a little more about
23 that because in your second statement, paragraph 8, you
24 identify four supervisions that you had with
25 Petra Kitchman in the course of the nine months during
59
1 which Victoria was in contact with Haringey.
2 MS GRAHAM: From July to?
3 MR GARNHAM: February.
4 MS GRAHAM: All right, yes, if that is nine months then that
5 is --
6 MR GARNHAM: Which looks as if it is a pretty similar rate
7 to the rate Petra Kitchman was telling us.
8 MS GRAHAM: I have not been able to go back and confirm but
9 I do not dispute it.
10 MR GARNHAM: Can you help with why it was that your
11 intention was that she and the others should be
12 supervised monthly but she actually ends up getting
13 supervised rather less than half as often?
14 MS GRAHAM: I think as I said before that was the intention
15 and the only time I would not give -- when I would have
16 a gap was when I was preparing for the Quality Protects
17 MAP, that there was the deadline of January and there
18 was work through December, so those two months I would
19 own that I wanted to keep those free and that
20 particularly was after -- that was for each of the MAPs
21 really. Other than that it could be due to availability
22 on each side.
23 MR GARNHAM: Is this another consequence of the fact that
24 you were working at less than full strength? I am
25 wondering whether you took on more tasks yourself
60
1 because you were short of one CPA and that in
2 consequence you had less time than you would have liked
3 to conduct supervision to the others.
4 MS GRAHAM: I think I would say I was certainly very busy
5 but I would not say that that was -- I would not want to
6 make that statement. I would own that I was certainly
7 very busy.
8 MR GARNHAM: Would you also acknowledge that the consequence
9 of that busyness was that you were supervising
10 Petra Kitchman less than you had intended?
11 MS GRAHAM: As I say I am not able to confirm and so I would
12 not want one to lead to the other as confirmed evidence.
13 MR GARNHAM: Let us look at what you say in your statement,
14 the second statement, paragraph 8: four supervisions in
15 nine months. So that you can confirm?
16 MS GRAHAM: Shall we go through them?
17 MR GARNHAM: Yes.
18 MS GRAHAM: There is June, there is July. August is
19 a holiday time for us both. There is September.
20 I cannot account for October right now and then there
21 is November and we go into Quality Protects.
22 MR GARNHAM: Which is why there is no January and February?
23 MS GRAHAM: Yes, December and January.
24 MR GARNHAM: And then February at least by the time of
25 Victoria's death there had not been another supervision.
61
1 MS GRAHAM: I am not sure about that but I have not put it
2 forward so I would suspect that is the case, so at that
3 point it would be catching up with work in
4 early February, but I do own that I have not put it
5 forward and so I would say it did not take place.
6 MR GARNHAM: So for whatever reasons you were supervising
7 her less than you had planned?
8 MS GRAHAM: I would agree with that.
9 MR GARNHAM: Petra Kitchman told us that she had never seen
10 the supervision policy which you say in paragraph 54 of
11 your statement applied. You were aware of the
12 supervision policy?
13 MS GRAHAM: What I worked to was the department's
14 performance development and review policy.
15 MR GARNHAM: Not the supervision policy?
16 MS GRAHAM: And within that is the supervision policy so
17 what I would have given to Petra and what I would say
18 Petra had was a PDR folder, every member of staff had
19 one of those, and I think I have given you extracts from
20 that that are objectives and so on.
21 MR GARNHAM: Perhaps we should look at the supervision
22 policy, volume 28A, please, page 105. You are familiar
23 with this Ms Graham?
24 MS GRAHAM: Yes.
25 MR GARNHAM: I showed this document to Ms Kitchman and she
62
1 said that she had never seen it. The reason that I was
2 interested in that is that as I understood it this was
3 a document which should be available both to the
4 supervisor and the supervisee. Is that right?
5 MS GRAHAM: Yes, would it be helpful if we looked at the
6 same time at the PDR?
7 MR GARNHAM: Yes. Volume 28, page 190, please. That is
8 what you were looking for?
9 MS GRAHAM: Yes.
10 MR GARNHAM: What is it in that that you would like to show
11 us?
12 MS GRAHAM: I think on the page I am looking at it may be
13 chapter 4 which starts on page 11 of this document.
14 MR GARNHAM: That is page 199 of our bundle.
15 MS GRAHAM: Yes.
16 MR GARNHAM: That sets out at paragraph 2 the basic
17 principles of professional supervision.
18 MS GRAHAM: Yes.
19 MR GARNHAM: Yes. And at paragraph 3 the key aims and at 4
20 arrangements for professional supervision.
21 MS GRAHAM: Yes.
22 MR GARNHAM: And that document you say Ms Kitchman would
23 have had?
24 MS GRAHAM: Yes.
25 MR GARNHAM: Would she as part of that document have had the
63
1 supervision policy I took you to or do you say the one
2 had superseded the other?
3 MS GRAHAM: To my mind that is how I saw it.
4 MR GARNHAM: Thank you.
5 MS GRAHAM: And as you read both they are quite similar and
6 identical in areas.
7 MR GARNHAM: She was complimentary about the supervision she
8 received from you in some respects but she also said
9 that she did not regard overall the quality of the
10 supervision you gave her as being of a high standard and
11 when asked to identify why, she said she did not believe
12 you interrogated her or pressed her or cross-examined
13 her about the quality of her work so as to test her
14 analysis. What do you say to that?
15 MS GRAHAM: I would not agree with that. I felt that was
16 something that I did and did regularly.
17 MR GARNHAM: I see. She also said that supervision did not
18 deal fully with issues such as training. Day 36,
19 page 59.
20 MS GRAHAM: I feel that Petra came to my team as a new child
21 protection adviser and that I developed her in many
22 areas, so for example I developed her in the area of
23 training. Petra was able to train the memorandum of
24 good practice course. She developed an induction course
25 and domestic violence course. She also developed policy
64
1 and I guided her through that. So I do feel that
2 I trained her and helped her develop.
3 MR GARNHAM: I see and her feelings about that you say are
4 misplaced?
5 MS GRAHAM: No, I accept her feelings, that they are her
6 feelings.
7 MR GARNHAM: But not based on a proper understanding of the
8 facts then?
9 MS GRAHAM: I think it has been very difficult for many
10 people over the course of these past years and I think
11 people have had time to reflect. I do feel, I think
12 I can interpret what I think Petra is saying, that we
13 did not talk about work she should do in other areas but
14 she had come to my team as a new child protection
15 adviser and I was coaching her and developing her in
16 that area.
17 MR GARNHAM: I see, thank you. You tell us, paragraph 6 of
18 your second statement, that you personally monitored
19 Petra Kitchman's work for three months after she started
20 with you.
21 MS GRAHAM: Yes.
22 MR GARNHAM: That would involve, would it, reading her blue
23 book?
24 MS GRAHAM: We would have discussed her blue book. I do not
25 think I would have actually taken her blue book from her
65
1 and read it word for word. We would have had
2 a discussion about the content of her blue book and in
3 that way I may have looked at her blue book, but it was
4 not that I would actually go through the blue book only.
5 MR GARNHAM: You would look at it enough to get a feeling
6 for the way she was going about recording in that book,
7 would you?
8 MS GRAHAM: I would get a sense of how she was working with
9 cases and how she was thinking about cases and the
10 advice she was giving and how she was negotiating and
11 working with people and how she was developing as an
12 adviser.
13 MR GARNHAM: You tell us that all telephone calls were
14 recorded in the blue book and that longer consultations
15 were recorded separately with copies being sent to the
16 district workers.
17 MS GRAHAM: That certainly was my expectation.
18 MR GARNHAM: Why were notes of the shorter telephone calls
19 not sent to social workers routinely?
20 MS GRAHAM: When the advisers first sort of came together as
21 a group we were based at a central office away from
22 both -- well there then were four district offices away
23 from four district offices. We did not have computers
24 and e-mail in those days so the way it operated was that
25 as a social worker would receive a call from the health
66
1 visitor, a police officer or a child protection adviser,
2 they would record that in the child's file and in that
3 way they would record the child protection adviser's
4 call. It was my expectation that the advisers would
5 always keep a record of that for themselves so when you
6 put the two together you had a record that married.
7 MR GARNHAM: That about which you were talking was calls
8 between the social worker on the one hand and the CPA on
9 the other?
10 MS GRAHAM: Yes.
11 MR GARNHAM: What about calls between the child protection
12 adviser and somebody external to Haringey?
13 MS GRAHAM: The blue book is being used as a record of all
14 work. In the same way that a social worker would have
15 a child's file and was expected to keep a record of all
16 contacts, I expected my advisers to do the same using
17 their blue books.
18 MR GARNHAM: I am interested to know how the two are married
19 up. If a child protection adviser takes a telephone
20 call or makes a telephone call with an outside agency,
21 what is the process by which a record of that
22 conversation is added to the child's file?
23 MS GRAHAM: I do think it is a weakness in the system and
24 I do want to own that and I heard already that from
25 Petra, that she has told you that corrections have been
67
1 made, but I go back to when we started, when I started
2 in 1992, we were based separately from the area offices
3 but in relation to information say from a doctor that
4 the adviser would make a judgment as to whether you
5 respond just straight to the doctor, whether it had
6 anything do with the case, it could be a general
7 enquiry, but if it was related to a case we should make
8 contact with the social worker who would then do his or
9 her part.
10 MR GARNHAM: If that does not happen, regardless of the
11 length of the conversation which reading your statement
12 would appear to be the determinative factor, there ought
13 to be a record passed on to the client's file, ought
14 there not?
15 MS GRAHAM: I do understand that and accept that and have
16 made amendments since.
17 MR GARNHAM: Thank you. You supervised Petra Kitchman, you
18 have told us, during the course of the time when she had
19 dealings with Victoria's case?
20 MS GRAHAM: Yes.
21 MR GARNHAM: Were you here when she gave her evidence?
22 MS GRAHAM: I was here for part of her evidence.
23 MR GARNHAM: Did you read the transcript of the rest?
24 MS GRAHAM: I did, yes.
25 MR GARNHAM: How would you characterise her record keeping
68
1 in regard to Victoria's case?
2 MS GRAHAM: It is not the standard I expected.
3 MR GARNHAM: Would you have expected her to follow up her
4 letter of the 19th October to Dr Rossiter for example,
5 and if you have not seen that letter recently we can
6 show it to you.
7 MS GRAHAM: Is that the longer one?
8 MR GARNHAM: It is the longer one. She told us that having
9 spoken to Lisa Arthurworrey she sent that letter on the
10 19th October in reply I think to a letter of
11 2nd September and nothing further on her account took
12 place between them in response to that letter. Do you
13 regard that as satisfactory?
14 MS GRAHAM: Can you put that to me again?
15 MR GARNHAM: Yes. 2nd September, Rossiter writes to
16 Kitchman.
17 MS GRAHAM: Yes.
18 MR GARNHAM: Kitchman speaks to Arthurworrey and on
19 19th October, six weeks or so later, Kitchman writes to
20 Rossiter.
21 MS GRAHAM: Yes.
22 MR GARNHAM: On Kitchman's evidence there is then no further
23 contact with them about this case.
24 MS GRAHAM: Yes.
25 MR GARNHAM: Would you have expected Kitchman to follow up
69
1 with Rossiter, she having written that letter?
2 MS GRAHAM: It is a difficult question I think. I think
3 Petra certainly made the judgment that she should not.
4 I think I would have to go back a few steps and look at
5 the letter that Dr Rossiter wrote and to think that if
6 I were looking at the letter that Dr Rossiter wrote then
7 I would have wanted some follow-up.
8 MR GARNHAM: You would have wanted some follow-up in the
9 light of the letter Dr Rossiter wrote?
10 MS GRAHAM: Yes, I think things could have been done
11 differently. What bit I am -- that stays with me is the
12 enormous concern and so I would have wanted an expansion
13 on what the enormous concern was. So had there been
14 a different phrase in Dr Rossiter's letter, I am not
15 sure if Petra had the discharge summary.
16 MR GARNHAM: She did.
17 MS GRAHAM: So that also causes concern and I would expect
18 there to have been certainly a follow-up.
19 MR GARNHAM: Thank you very much. Looking at it generally,
20 and I know you have gone back -- and I know it is
21 distracting, but there has to be a translation
22 running -- looking back on the conduct of this case as
23 a whole, how would you characterise the quality of the
24 liaison between on the one hand Haringey Social Services
25 and on the other the hospital? Satisfactory liaison?
70
1 MS GRAHAM: I think that I have had the opportunity to hear
2 some evidence and I have had the opportunity to read
3 transcripts and so what I know now is different from
4 what I would have known in 1999.
5 MR GARNHAM: It was a deliberately retrospective question
6 I asked you. Looking back from where we are now, how
7 would you characterise it?
8 MS GRAHAM: Looking back I can see lots of things that
9 should perhaps not have happened -- or let me put that
10 differently -- that we can improve upon, yes.
11 MR GARNHAM: So that I am clear, during the time when you
12 were Acting AD, who was your supervisor?
13 MS GRAHAM: Anne Bristow, the Director.
14 MR GARNHAM: I am about to move to another topic. Now might
15 be a sensible moment to take a short break.
16 THE CHAIRMAN: I was thinking exactly the same. My
17 telepathy --
18 MR GARNHAM: -- is working well.
19 THE CHAIRMAN: Thank you. Ms Graham you perhaps know you
20 are not allowed to discuss your evidence with anyone
21 during this break. We will take a break until
22 12 o'clock.
23 (11.50 am)
24 (A short break)
25 (12.00 pm)
71
1 MR GARNHAM: Ms Graham, we were about to turn to the section
2 of your first statement which deals with systems and
3 processes, paragraphs 23 to 28 of your statement. You
4 described there the child protection systems and
5 processes in operation in Haringey in the period with
6 which we are concerned.
7 MS GRAHAM: Yes.
8 MR GARNHAM: You tell us, paragraph 23, that the case
9 recording guidelines applied to all workers and that
10 they made clear the role of the consultant as well as
11 the recording requirements. What is the consultant in
12 that context?
13 MS GRAHAM: I think in the guidelines I make reference to
14 child protection advisers and psychologists.
15 MR GARNHAM: And you call those consultants for this
16 purpose. That is not a criticism, I am only trying to
17 understand, but that is who you are referring to?
18 MS GRAHAM: People who do not have --
19 MR GARNHAM: Casework responsibility.
20 MS GRAHAM: Yes.
21 MR GARNHAM: Do I take from the way you answered that
22 previous question that you drafted those guidelines?
23 MS GRAHAM: Yes.
24 MR GARNHAM: You say that they should be applied by all
25 social workers and all child protection advisers in
72
1 paragraph 23 of your statement.
2 MS GRAHAM: Yes.
3 MR GARNHAM: Can you account for the fact that Rose Kozinos,
4 a senior practitioner in the I&A Team, had no
5 recollection of ever even seeing those guidelines?
6 Day 32, page 65 sir.
7 MS GRAHAM: I will tell you what happened with those
8 guidelines.
9 MR GARNHAM: Please.
10 MS GRAHAM: That I was principally or I was responsible for
11 drafting them. Once they were produced I had them put
12 into a booklet which I am sure you have seen the
13 booklet, and before I would distribute them to anyone
14 I asked that case recording briefing sessions were set
15 up and it was an instruction that everyone attended the
16 case recording briefing sessions and there were lists
17 kept of those who attended. That list was kept by
18 Training. Certainly we were aware that some people had
19 not been able to attend on the days they said they would
20 and so additional slots were put on.
21 I cannot account for how it was that Rose says she
22 has not either attended a briefing or seen the document.
23 They were well talked about and they were scattered
24 everywhere.
25 MR GARNHAM: But it is pretty hopeless, is it not, if
73
1 somebody of the seniority of Rose Kozinos is not using
2 these guidelines since you intended them to be of
3 universal application?
4 MS GRAHAM: I think I set the system in place and I think it
5 is unfortunate that Rose is saying that she was not able
6 to take advantage of that.
7 MR GARNHAM: One of your jobs was providing an effective
8 service including an effective service to monitor child
9 protection work. If you are going to provide that
10 service you need to have cases properly recorded, do you
11 not?
12 MS GRAHAM: It was because of that that I was very keen to
13 be involved in case recording.
14 MR GARNHAM: Absolutely.
15 MS GRAHAM: And set up the case recording booklet and
16 guidelines and policy and the briefings, and subsequent
17 to that there has been another development that ensures
18 that people actually now read the files and inform their
19 managers that they have read files.
20 MR GARNHAM: We will come on to that but for the moment let
21 me talk about the case recording. It does not matter,
22 does it, how good your policy documents are on paper if
23 the people who are actually running the thing are not
24 using them?
25 MS GRAHAM: I think Rose said that herself.
74
1 MR GARNHAM: Yes, and you would agree with it?
2 MS GRAHAM: I absolutely agree with it.
3 MR GARNHAM: So however much effort was put into your
4 devising these procedures, and it must have been
5 considerable, and setting up training courses to
6 introduce them, all of that is completely wasted if the
7 managers and the social workers are not briefed with
8 them and using them.
9 MS GRAHAM: I think your term "completely wasted" might be
10 a strong term. I feel there are many people who were
11 able to take advantage of the briefings who have read
12 the document and have complied with it and so I would
13 not want to throw it out completely as completely
14 wasted. I would think that it was unfortunate that Rose
15 was not able to take advantage of it.
16 MR GARNHAM: Is the value of it not that everybody is
17 working to the same set of guidelines and as a result
18 the case records for all cases are of a similar quality?
19 MS GRAHAM: Yes.
20 MR GARNHAM: If you have only got some people who have been
21 using this system the danger is that it is only those
22 cases that are properly recorded and the others escape
23 that sort of review?
24 MS GRAHAM: I think in all systems, as I said before, the
25 system was set up and it is unfortunate that Rose, I am
75
1 sure Rose would agree, that she was not able to take
2 advantage of it or that her case recording was not of
3 a standard anyway that could match the requirements of
4 the briefing booklet.
5 MR GARNHAM: You presumably also expected that Haringey's
6 Child Protection Guidelines, the Purple Book, would be
7 used and applied by everyone?
8 MS GRAHAM: Yes.
9 MR GARNHAM: When was it permissible to breach those
10 guidelines to step outside those?
11 MS GRAHAM: The guidelines were in place and I think that as
12 happens developments take place and I think it is
13 unfortunate and I will own that I did not update the
14 guidelines as frequently and as regularly as I perhaps
15 should have, in fact as I should have, and so it may
16 appear that breaches have happened when in fact there
17 has been developments in the guidelines. So I would
18 like to make the distinction between developments in
19 practice and absolute breaches. It is not acceptable
20 that there were absolute breaches but I do think that
21 there are developments that take place and the
22 guidelines have not been updated.
23 MR GARNHAM: I suspect you have in mind the same as I have
24 in mind, which is the practice that appears to have
25 developed of holding strategy meetings?
76
1 MS GRAHAM: Yes, that is what I had in mind.
2 MR GARNHAM: In respect of hospital patients in the office
3 rather than at the hospital?
4 MS GRAHAM: No. I make the distinction. What I have in
5 mind is the chairing of strategy meetings by senior
6 practitioners and practice managers. I think that has
7 been a development that has happened in Haringey but the
8 guidelines saying that strategy meetings where a child
9 is placed in the hospital take place in the hospital
10 remains.
11 MR GARNHAM: I see. So in the former case that is
12 a development overtaking the guidelines, in the latter
13 case that is a breach of the guidelines.
14 MS GRAHAM: I think it is a breach.
15 MR GARNHAM: It is inevitable --
16 MS GRAHAM: Can I add there may be situations, and I think
17 the guidelines take account where it may not be.
18 MR GARNHAM: You were anticipating my next question
19 precisely.
20 MS GRAHAM: I am sorry.
21 MR GARNHAM: Not at all, because it is inevitable that it is
22 impossible to provide for every situation in a set of
23 guidelines and therefore good guidelines themselves set
24 out procedures to be adopted when you want to step
25 outside them.
77
1 MS GRAHAM: Yes.
2 MR GARNHAM: And these did in that they indicated that that
3 was permissible if approved by a team manager and
4 recorded, but in respect of both of the two instances
5 you talk about, the use of senior practitioners to chair
6 strategy meetings first, and second the holding of
7 strategy meetings other than at hospital in respect of
8 patients, there was no such approval by a team manager
9 and record in the case file, was there?
10 MS GRAHAM: I will come to the second part. As I understand
11 it, it was not written in the file that the strategy
12 meeting for Victoria should have been in the district,
13 instead of the hospital, and having read the transcript
14 and so on I have to accept that neither was it recorded
15 that Carole Baptiste should chair the strategy
16 meeting -- sorry, that Rose should chair the strategy
17 meeting on behalf of Carole Baptiste.
18 MR GARNHAM: Correct. With regard to those two departures
19 from the guidelines we have a situation where neither
20 were properly authorised in accordance with the
21 guidelines but there is a difference in that in one you
22 say events had overtaken the guidelines and in the other
23 there is a frank breach.
24 MS GRAHAM: Yes.
25 MR GARNHAM: I am interested in your evidence as to the
78
1 circumstances in which events overtake guidelines,
2 because one might have thought that it should be the
3 other way around, that guidelines should be leading
4 practice rather than practice leading the guidelines.
5 MS GRAHAM: I think it happens a bit of both I am sure. So
6 for example a lot of people may be pre-empting outcomes
7 from this Inquiry and may not yet have updated their
8 guidelines, that sort of thing.
9 MR GARNHAM: The instance that we are talking about is the
10 chairing of strategy meetings by people other than team
11 managers and CPAs.
12 MS GRAHAM: Yes.
13 MR GARNHAM: Was there a decision made by management that
14 that was acceptable?
15 MS GRAHAM: I will tell you what happened or as I understand
16 it what happened. When strategy meetings first came
17 about, at that time in Haringey we had team managers and
18 we had social workers and we had child protection
19 advisers. Team managers and child protection advisers
20 would chair strategy meeting. Reorganisations created
21 the post of senior practitioners and senior
22 practitioners would delegate for their managers, and at
23 that time I do remember raising the fact that senior
24 practitioners were chairing strategy meetings and it was
25 on a delegated basis.
79
1 We later developed to have practice managers and
2 I am not sure and I cannot say whether it is in the job
3 description of the practice managers that they chair
4 strategy meetings.
5 MR GARNHAM: I think it is.
6 MS GRAHAM: But I would say that it would be general to
7 chair meetings.
8 MR GARNHAM: So that was a positive decision, that is not
9 just practice developing, it was a positive decision
10 that they could do that?
11 MS GRAHAM: The practice manager bit, yes.
12 MR GARNHAM: You were aware from what you said a few moments
13 ago that senior practitioners and team managers were
14 routinely not reading files?
15 MS GRAHAM: Yes.
16 MR GARNHAM: You were aware of that, that we have had
17 evidence to that effect?
18 MS GRAHAM: Yes, that you have had evidence, yes.
19 MR GARNHAM: We have been told by those who followed that
20 practice that managers knew of this and approved it.
21 Now, did you know of it?
22 MS GRAHAM: Not routinely. I would not accept that I knew
23 that people were saying they could not read files and
24 that I accepted that they should not read files. I did
25 know that people did say to me that it is time-consuming
80
1 to read files, but at the same time I was hearing about
2 case recording, about what you hear, and it was always
3 my view that it was absolutely critical that you read
4 files.
5 MR GARNHAM: You see, Dave Duncan told us that this point,
6 this practice of not reading files had come to the
7 attention of senior practitioners like Carol Wilson and
8 he says that Carol Wilson asked you to chair a working
9 party to do something about it. Is that true?
10 MS GRAHAM: Yes.
11 MR GARNHAM: When was that?
12 MS GRAHAM: I think that would have been -- you may know.
13 MR GARNHAM: I do not.
14 MS GRAHAM: I think that would have been in 2000 some time.
15 MR GARNHAM: So after Victoria's death?
16 MS GRAHAM: I think so, yes.
17 MR GARNHAM: You are then describing the date when you were
18 asked to chair this working party, are you?
19 MS GRAHAM: Yes.
20 MR GARNHAM: Do you know whether senior managers were aware
21 of this practice prior to that? They must have been
22 aware some time prior, do you know how much prior to
23 that they were aware?
24 MS GRAHAM: I think I would need to be clear that what I was
25 aware of was that people were complaining about reading
81
1 files. I was aware of that.
2 MR GARNHAM: From when?
3 MS GRAHAM: I think people always complained about reading
4 files. I will put that differently. That some people
5 complained about reading files but people at the same
6 time do read files. I think that people --
7 MR GARNHAM: Are they different groups of people or is it
8 the people who read them who complain?
9 MS GRAHAM: If I just finish with the first lot that might
10 answer your question, that people would -- I think it is
11 that people were expected to read files and there was
12 a sense that perhaps people jumped to reading all the
13 files. So if you had a family and there was a case,
14 a child with six files, I think it would be reasonable
15 to read the last file and to read key elements of that
16 and so there was a sense of reading files may stretch to
17 reading all files all of the time, and so I think it was
18 a bit about that. I hope I am being fair to people but
19 we got into those sorts of discussions I think.
20 MR GARNHAM: The Chairman has made the point several times
21 to several different witnesses that experienced social
22 workers can pick up a case file, skim through it and
23 identify the documents that matter, read those. You do
24 not have to read every dot and comma of every piece of
25 paper.
82
1 MS GRAHAM: I would absolutely agree with that and I think
2 that that would be what I would have wanted to -- what
3 I think I would have expressed but certainly a focus of
4 the group that I chaired.
5 MR GARNHAM: What I am interested to know is why that was
6 not happening in 1999.
7 MS GRAHAM: I was not the direct line manager of those
8 managers and so --
9 MR GARNHAM: I appreciate that but you have had a role
10 during that period that includes an element of quality
11 control.
12 MS GRAHAM: Right, so what I would go on to say is that when
13 I was certainly a child protection adviser people did
14 read files and managers did read files and I also do
15 audits and I remember a file I audited where not only
16 the file -- the manager had read the file but had read
17 it during supervision and given instruction to a social
18 worker as to how to improve her recording, and you could
19 see the development of that over time. So I would not
20 agree that managers were not reading files but I felt
21 that an issue did develop.
22 MR GARNHAM: I did not suggest that no manager ever read
23 a file. I suggested that in this case nobody seems to
24 have read Victoria's file and on occasions that was
25 routinely the position.
83
1 MS GRAHAM: I will agree that in this case Victoria's file
2 was not read. I would not go as far as to say it was
3 a routine position because I think what we have got is,
4 if you are agreeing with me that the case I described
5 through audit was a manager reading a file.
6 MR GARNHAM: Yes.
7 MS GRAHAM: And that was a routine through supervision and
8 that Victoria's file was not read, then there must be
9 something in between that was the position.
10 MR GARNHAM: Angella Mairs for example told us that in 1999
11 she never read files, there was not time she said.
12 Rose Kozinos told us that she did not read files during
13 1999.
14 MS GRAHAM: I cannot account for that, I am sorry.
15 MR GARNHAM: It is plainly self-evidently inadequate.
16 MS GRAHAM: If Angella were to say to me, "Look Ann, I never
17 read files", I would say that is not acceptable. If
18 Rose were to say to me, "Ann I never read files" I would
19 say it is not acceptable.
20 MR GARNHAM: The suggestion is that senior managers -- and
21 I want to know whether that included you -- knew that
22 that was what was happening in that team at that time.
23 MS GRAHAM: No, I did not know that was happening.
24 MR GARNHAM: And do you know whether other senior managers
25 did?
84
1 MS GRAHAM: No, I did not know that the Duty managers were
2 not reading files. I do not think that was common
3 knowledge at all.
4 MR GARNHAM: How did it come about then that this working
5 party that you chaired was set up to deal with this
6 problem? What was the trigger for that?
7 MS GRAHAM: As you know, my service does a number of audits.
8 MR GARNHAM: Yes.
9 MS GRAHAM: We do them in a variety of ways and one of the
10 things that came up through audit is the reading of case
11 files and I certainly did want to promote the reading of
12 files and I think it was perhaps for that reason that
13 I was chosen to --
14 MR GARNHAM: What was the trigger to start this process of
15 changing this practice?
16 MS GRAHAM: I am sorry, I do not remember the specific date
17 that I was asked to do that piece of work. I think it
18 would have come about either through one of my team
19 meetings chaired by Carol or a children and family
20 sub-group meeting chaired by Carol so I cannot give you
21 what the trigger was.
22 MR GARNHAM: Right. No mention in these paragraphs, 23 to
23 28, of the ACPC child protection procedure handbook
24 although you do mention it right at the end,
25 paragraph 54. Was the ACPC handbook seen as part of the
85
1 system and process which you were describing?
2 MS GRAHAM: Yes.
3 MR GARNHAM: So it was used, was it?
4 MS GRAHAM: I think that might be putting it -- certainly it
5 was used, yes.
6 MR GARNHAM: But not used by all and not used regularly?
7 MS GRAHAM: I think it is my perception that it was used
8 from time to time, that the main book that we would have
9 worked from would have been what is referred to as the
10 Purple Book.
11 MR GARNHAM: Angella Mairs, a team manager in this team,
12 told us, Day 35, page 138, that she had never seen
13 a copy of it. Does that surprise you?
14 MS GRAHAM: It does surprise me and I will tell you what
15 happened. As I came into post in 1997 I think the ACPC
16 handbooks dated June 1997, I do remember we had boxes
17 and boxes and boxes of these documents and a letter went
18 out, I cannot remember who it was from, I think it was
19 from -- I cannot remember who it was from, but certainly
20 a letter went out and copies went to everyone. So I am
21 surprised that Angella did not get a copy.
22 MR GARNHAM: It does not sound as if she was alone.
23 Rose Kozinos had never seen a copy, Day 32 page 101, and
24 David Duncan said he was not familiar with the handbook,
25 Day 33, page 155.
86
1 MS GRAHAM: I cannot account for what they were and were not
2 familiar with in that sense. I can tell you that copies
3 went out to everyone and I know that happened.
4 MR GARNHAM: What is the process?
5 MS GRAHAM: I remember it because we had a yellow binding
6 that was call the ACPC handbook and people were asked
7 specifically to take out the old documents and replace
8 it with the new. So certainly people should have had it
9 and I think when I walked around Haringey I would see
10 the ACPC handbook on shelves.
11 MR GARNHAM: You will understand why this is of concern to
12 this Inquiry because it may be that perfectly good
13 procedures are devised but what appears to be emerging
14 from the evidence in this Inquiry is that they are not
15 used.
16 MS GRAHAM: I have read the transcript and I can see that
17 certainly that is the case but can I also add that we
18 are probably not alone in having procedure developed and
19 guidance and systems in place that are not followed 100
20 per cent.
21 MR GARNHAM: There is a difference between not being
22 followed 100 per cent and senior managers being unaware
23 of their existence.
24 MS GRAHAM: I am not sure that that is the same thing.
25 MR GARNHAM: I agree it is not.
87
1 MS GRAHAM: Sorry, I have lost your point.
2 MR GARNHAM: It does not matter how much time and effort
3 goes into producing these sort of procedures if they are
4 unused by the people at the sharp end.
5 MS GRAHAM: You have asked me that before earlier on in my
6 evidence.
7 MR GARNHAM: I have and now I am asking you the same
8 question in relation to the ACPC handbook. What is the
9 point of the authors of that handbook producing it if
10 people like Duncan, Kozinos, Mairs either do not know of
11 its existence or are not familiar with its contents?
12 MS GRAHAM: I think the ACPC handbook is a valuable document
13 and it is certainly a document that I value. And I do
14 feel it has its place and I am not able to explain why
15 they were unfamiliar with it or did not know of its
16 existence.
17 MR GARNHAM: But ought not you or someone else to have known
18 that?
19 MS GRAHAM: I suppose if you are undertaking an audit and
20 you are seeing practice and you are trying to apply that
21 to procedure and standards I would not have necessarily
22 been able to identify which document people were drawing
23 from in the sense because documents do overlap.
24 MR GARNHAM: Is there a problem that there is an excess of
25 procedures and policies and documents, so much so that
88
1 people cannot use it all and it therefore gets left on
2 shelves at best?
3 MS GRAHAM: I would not agree with that because what you
4 have said is that people are not using any.
5 MR GARNHAM: Any of some of them and I am not suggesting
6 they do not use any documents at all.
7 MS GRAHAM: No, I think that policy and procedure has its
8 place.
9 MR GARNHAM: Is there a problem of there being an excess of
10 it?
11 MS GRAHAM: No, I think that good practice is good practice
12 and good practice falls in line with procedure.
13 MR GARNHAM: Would it not be better if all of this was
14 reduced to a single document to be applied by each
15 individual?
16 MS GRAHAM: Certainly that is a thought I have had and
17 I think it would be a way of improving things but I do
18 feel if you look into those guidelines that they do
19 relate to each other, they are not completely separate
20 and unrelated.
21 MR GARNHAM: It might be possible if one was taking
22 a postgraduate degree to sit down and mesh together all
23 the documents and policies that you refer to but it is
24 not a practical possibility for somebody at the
25 coalface, is it?
89
1 MS GRAHAM: I think you will find if you take the Child
2 Protection Guidelines they refer constantly to good
3 recording practices. I think if you take the ACPC
4 handbook it too refers to recording and if you take the
5 case recording policy it expands upon that, so I would
6 not say that what you are suggesting is not to some
7 degree already in place. It is not the case that you
8 have a Child Protection Procedures guidelines that makes
9 no relation whatsoever to case recording. It is the
10 same the other way around.
11 MR GARNHAM: Look at paragraph 54 of your statement please,
12 your first statement. According to that, the relevant
13 policies, procedures and guidance in operation consisted
14 of 13 documents.
15 MS GRAHAM: Shall we go through them?
16 MR GARNHAM: No, just answer my question please, is it right
17 that there are 13 documents there that you say are in
18 place and in operation?
19 MS GRAHAM: Yes.
20 MR GARNHAM: So that the cross-reference and meshing
21 together that you say would be necessary needs to
22 encompass all of those?
23 MS GRAHAM: No, I think the purposes of my statement are
24 different as to working practices and so I do think it
25 is important I take you through them.
90
1 MR GARNHAM: I will come back to those documents, I promise
2 you. For the moment I want to understand the evidence
3 you are giving this Inquiry as to the way in which they
4 should be used.
5 MS GRAHAM: I list these 13 documents to support my witness
6 statement. The first of those are the Child Protection
7 Guidelines which contains within it a child in need
8 policy. The case recording document does stand alone but
9 there are elements of it within the Child Protection
10 Guidelines. The performance development and review
11 document, as I have said to you, has within it the
12 supervision policy and so on.
13 MR GARNHAM: I see. We will look at some of those later.
14 Thank you for that. I have suggested to you that at
15 least some of the staff who we have been focusing on
16 were unaware of the ACPC handbook. Did you expect other
17 agencies to comply with the ACPC handbook?
18 MS GRAHAM: The ACPC handbook is the overarching document
19 for Haringey Area Child Protection Committee.
20 MR GARNHAM: So is the answer to my question yes?
21 MS GRAHAM: Yes.
22 MR GARNHAM: Would it be fair for them, those other
23 agencies, to assume that Haringey Social Services were
24 using and applying that handbook?
25 MS GRAHAM: Yes.
91
1 MR GARNHAM: And yet we know that at least as regards some
2 workers and managers they were not.
3 MS GRAHAM: Yes, they say that they were not.
4 MR GARNHAM: Does that concern you, that on the one hand
5 other agencies are expected to comply with the book and
6 are entitled to expect that you will do so also, but on
7 the other your staff or at least some of them are not
8 doing so?
9 MS GRAHAM: The ACPC handbook and the Haringey Child
10 Protection Guidelines do overlap considerably, and so
11 I suppose it would be at the point of difference that
12 they would need to know to refer to one document or the
13 other, and at those critical points it is important you
14 use the appropriate document.
15 MR GARNHAM: Are your staff trained so they know how to do
16 that and when to do it?
17 MS GRAHAM: We have an ACPC working five-day course and on
18 that course both the ACPC handbook is taught, is
19 discussed and the Child Protection Procedures as well.
20 MR GARNHAM: So they would know when to come out of one
21 booklet and go into the other, would they?
22 MS GRAHAM: In all cases I would not expect that to be the
23 case but certainly then you have the advisers where you
24 can consult if you are not sure, but I think the point
25 you are wanting to make is that people were not using
92
1 the ACPC handbook and that they were not as familiar
2 with it as they should be and I agree with that.
3 MR GARNHAM: Thank you. The next section of your statement,
4 paragraphs 34 to 52, you describe the systems and
5 processes in place to identify children in need or
6 likely to suffer harm. I paraphrase but you are
7 responding to one of our questions.
8 MS GRAHAM: Yes.
9 MR GARNHAM: You talk about trained social workers fully
10 familiar with the Children Act, social workers able to
11 rely on their own judgment and the assistance of
12 managers, that is paragraph 34.
13 MS GRAHAM: Yes.
14 MR GARNHAM: You talk about complex systems and processes,
15 meeting Haringey's statutory obligations and systems
16 expanded to incorporate other social care areas,
17 paragraph 35.
18 MS GRAHAM: Yes.
19 MR GARNHAM: Paragraph 39, guidelines enhanced by additional
20 systems and processes and supported by more defined
21 assessment process.
22 MS GRAHAM: These are extracts from my statement, yes.
23 MR GARNHAM: I am wanting to make sure I have understood
24 what you are trying to say.
25 MS GRAHAM: I think you may need to take it in sequence
93
1 because if you put it like that it does sound as though
2 it is weighted and complex but actually the systems and
3 processes, number 35, I have not read it all now but
4 I think I am using that to narrow into social services
5 aspect.
6 MR GARNHAM: Thank you for that. Paragraph 40, guidelines
7 reflecting the need to take into account the wishes and
8 feelings of children.
9 MS GRAHAM: Yes.
10 MR GARNHAM: Paragraph 44, child protection advisers
11 offering advice and guidance on all matters relevant to
12 children's needs.
13 MS GRAHAM: Yes.
14 MR GARNHAM: There is not a breath in any of that or
15 anywhere else in your statement of any of the disastrous
16 errors and mistakes that came about by the application
17 of those systems and processes in Victoria's case, is
18 there?
19 MS GRAHAM: Could you say that again?
20 MR GARNHAM: There is not a breath anywhere in those
21 paragraphs that describe these marvellous systems and
22 processes or anywhere else in your statement of the
23 disastrous mistakes and errors made by Haringey Social
24 Services in respect of Victoria's case.
25 MS GRAHAM: I did not include that in my statement, no.
94
1 MR GARNHAM: One reading that statement in ignorance of the
2 rest of the matters we have heard might come to the
3 conclusion that there was in place in Haringey a Rolls
4 Royce system providing protection at every possible
5 juncture through which no child could possibly slip.
6 MS GRAHAM: I think the title was "The systems and processes
7 in place to identify children in need" and so on.
8 MR GARNHAM: Yes.
9 MS GRAHAM: I have identified those systems.
10 MR GARNHAM: There is no suggestion, is there, in your
11 statement that those systems were inadequate?
12 MS GRAHAM: I do not think I was asked that specific
13 question but if I can go on to say that certainly what
14 was added in my statement is the auditing process and so
15 an auditing process is about checking and I suppose it
16 would suggest that the systems were checked.
17 MR GARNHAM: It would indeed but even the auditing system is
18 described in a way that suggests that it is perfect.
19 That was one of the safety nets, reading your statement.
20 MS GRAHAM: Mr Garnham I wrote my statement -- you are
21 wanting to make a point I think.
22 MR GARNHAM: Of course I am and you can see where it is
23 going. I am trying to understand why it is that you
24 prepare for this Inquiry a statement that describes
25 a Rolls Royce system when you knew that it manifestly
95
1 failed at least in one case and perhaps in others. It
2 is a complete lack of candour about this statement.
3 There is no suggestion of error or failings or
4 weaknesses. I want to know why that is.
5 MS GRAHAM: I was asked to complete a witness statement as
6 to the systems and processes in place and that is what
7 I have done. I was asked to say in what way I was
8 involved in Victoria's case and I did that. I was not
9 asked to give an analysis of the failings of Victoria's
10 case and I am sorry if you expected that. I did not
11 include that in my witness statement.
12 MR GARNHAM: Plainly you did not but what I am struggling to
13 understand is how it is possible for you to put together
14 a statement of that sort describing in those sort of
15 terms the system and process you have in place when you
16 knew that that system was on many occasions breaking
17 down.
18 MS GRAHAM: As I say I wrote my statement.
19 MR GARNHAM: Those particular paragraphs, 34 to 52, read as
20 if you are entirely content with the system. Were you?
21 MS GRAHAM: I undertook many audits that showed weaknesses
22 within the system so I was not entirely confident with
23 the system and I think what you have seen is the
24 developments in my statement that have been put in place
25 to assist the system. What I did not do is what you are
96
1 asking for, is put in reasons why we made developments,
2 but I think that for example I was clear that there was
3 not -- our case recording was not as it should be and so
4 therefore I developed a case recording policy guidance
5 and so on.
6 MR GARNHAM: Your statement provides no sense of balance.
7 If we had your statement and nothing else to describe
8 the systems and processes in place in Haringey we would
9 have no idea of the myriad of errors and faults that
10 there were in it.
11 MS GRAHAM: I go back to I followed the outline given to me.
12 MR GARNHAM: We did not expect you just to paint one side of
13 the picture if there are two.
14 MS GRAHAM: I am sorry that my statement has not met the
15 need that you are stating.
16 MR GARNHAM: Could you have volume 15, please. Page 106.
17 This is the report of one of the audits you have
18 described and it is a document with which we are
19 becoming wearily familiar in the course of this Inquiry,
20 the review of district cases following Victoria's death.
21 MS GRAHAM: Yes.
22 MR GARNHAM: I think you were in charge of this audit, were
23 you not?
24 MS GRAHAM: Yes.
25 MR GARNHAM: It is an audit demonstrating worrying
97
1 deficiencies in Tottenham.
2 MS GRAHAM: Yes.
3 MR GARNHAM: Particularly in case recording.
4 MS GRAHAM: Yes.
5 MR GARNHAM: And a situation in Haringey that was described
6 by your colleagues Dawn Green and Petra Kitchman as
7 appalling.
8 MS GRAHAM: That is how they described them.
9 MR GARNHAM: Hornsey. We need to be more specific, so the
10 Hornsey part of Haringey.
11 First of all, why was this audit limited to
12 reviewing files? Why did you not review referrals as
13 well?
14 MS GRAHAM: The referrals are part of the file.
15 MR GARNHAM: Yes, but the quality of the process by which
16 cases are taken from first referral to their final being
17 dealt with, or is that all on the file?
18 MS GRAHAM: The referrals are on the file, yes.
19 MR GARNHAM: Okay. You refer to this audit twice in the
20 course of your statement, paragraphs 24 and 30, but
21 nowhere do you set out what the audit says about the way
22 the system was operating. Why not?
23 MS GRAHAM: I think it is again I followed the structure
24 that was given to me for my statement and also I suppose
25 I was aware that the other documents had been given to
98
1 the Inquiry but I think I followed the structure that
2 was given.
3 MR GARNHAM: Do you agree with the description given of the
4 results of that audit by your colleagues: "worrying" in
5 the respect of North Tottenham and "appalling" in the
6 respect of Hornsey?
7 MS GRAHAM: I think I accepted their report and I thought
8 hard before we agreed that we were concerned and
9 surprised about the quality of work we found in Hornsey
10 District Office.
11 MR GARNHAM: Ms Kitchman says -- both Ms Kitchman and
12 Ms Green said that they would substitute the words at
13 the end of that document "concerned and surprised" by
14 "appalled." Would you?
15 MS GRAHAM: I prefer to stick with the document that
16 I wrote, that I accepted at the time that we were
17 worried and we were concerned.
18 MR GARNHAM: Do I take it from that that those findings and
19 particularly the examples that are listed there did not
20 appall you?
21 MS GRAHAM: It is very difficult Mr Garnham and I would like
22 to stay with the fact that the conclusion I came to
23 I would not want to rewrite this report and substitute
24 other words. What I came to, and it was very difficult
25 for me, it was very difficult, I said that I was very
99
1 concerned and surprised by the quality of work.
2 MR GARNHAM: It must take quite a lot to appall you then if
3 you do not find this appalling.
4 MS GRAHAM: This is a document that was going to go to other
5 people and how I felt is separate to what is recorded
6 here.
7 MR GARNHAM: I am asking you for the moment then what you
8 felt.
9 MS GRAHAM: I felt a range of things and amongst that was
10 I was very surprised and I was very concerned.
11 MR GARNHAM: And in your feelings, since I am not now asking
12 you to rewrite your report, were you appalled?
13 MS GRAHAM: I was.
14 MR GARNHAM: Could you have volume 2 please. Page 172.
15 This is a case review into Victoria's case conducted by
16 you I think.
17 MS GRAHAM: Yes.
18 MR GARNHAM: Why no reference to this in your statement?
19 MS GRAHAM: It was a case review of the file really and
20 a discussion with Petra Kitchman. It was no broader
21 than that.
22 MR GARNHAM: Why no reference to it in your statement?
23 MS GRAHAM: It was a case review of the file. I did not
24 expand into the workings of Haringey as far as
25 I remember, I went through the file or this was taken
100
1 from another document.
2 MR GARNHAM: Amongst the huge quantities of documents which
3 we have received from Haringey it would have been
4 perfectly possible for us to have missed this but it is
5 critical, is it not, to an understanding of your view of
6 what was happening in your department, so why was it not
7 referred to in your statement?
8 MS GRAHAM: Which one are you talking about now?
9 MR GARNHAM: This case review at page 172.
10 MS GRAHAM: This was part of Part 8 report that I think you
11 got and so in that sense was not missed.
12 MR GARNHAM: Were you intending when you prepared this
13 statement to paint a complete picture of your views of
14 the way the systems and processes were operating in
15 Haringey?
16 MS GRAHAM: What I did was inform the Inquiry to the systems
17 and processes that were in place. I did not give an
18 analysis of those or an assessment of how I felt they
19 were functioning.
20 MR GARNHAM: Will you turn to page 181, please. "Issues
21 arising for Housing and Social Services from the case":
22 "Even at this early stage there are clear
23 indications of misjudgment of the nature of the case
24 which determined the department's level of
25 intervention."
|
