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Archived Transcript for 27 Febuary 2002:
Pages 1 to 18
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1
2 Wednesday 27th February 2002.
3 THE CHAIRMAN: Good morning ladies and gentlemen. May
4 I take the opportunity to announce my decision on
5 a matter that has arisen since last we met. You will
6 recall that during the hearing on 24th January
7 I indicated that all written submissions would be placed
8 on the Inquiry's website.
9 On 5th February the solicitor to the Inquiry wrote
10 to all interested parties and witnesses in receipt of
11 notices of potential criticism, indicating that the
12 submissions would be distributed only to those who had
13 signed a confidentiality undertaking. The two
14 statements were plainly contradictory and I regret to
15 say that I did not notice the contradiction at the time.
16 I apologise for the error, particularly as it has
17 led to entirely understandable confusion amongst
18 interested parties and some witnesses. Some proceeded
19 on the basis that my oral announcement represented the
20 Inquiry's approach to this question. Others, that
21 Mr Fitzgerald's letter indicated a correction or at
22 least the Inquiry's decided view.
23 In consequence, final submissions of different
24 interested parties and witnesses have been prepared on
25 different assumptions.
2
1 The error was pointed out to us by Mr Lloyd and I am
2 grateful to him for his assistance in this.
3 Mr Fitzgerald has now written to all interested parties
4 and witnesses seeking their views on how the difficulty
5 which has been created should be resolved. The parties
6 are more or less evenly split, some favouring the
7 decision that all closing submissions be placed on the
8 website, some a decision that avoided that result.
9 It is impossible to devise a solution which will
10 find universal acceptance. Therefore, it seems to me
11 necessary to adopt what might be seen as the lesser of
12 several evils.
13 I am particularly concerned to achieve two
14 objectives. First, some interested parties and
15 witnesses prepared their oral submissions on the basis
16 that all those interested, including the press and the
17 public, would have access to everything they wished to
18 say on the subject through the Inquiry, including that
19 which appeared in their written submissions. Others
20 prepared written submissions believing that their
21 contents would remain confidential to the Inquiry and
22 those who had signed the confidentiality undertaking.
23 Thus, for example, some parties referred to the details
24 of notices of potential criticisms in their written
25 submissions and are anxious that these potential
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1 criticisms, which they refute, should not be made
2 public. That we understood was the rationale behind
3 Mr Fitzgerald's letter on 5th February.
4 In those circumstances I have decided that
5 interested parties and witnesses will be permitted to
6 decide for themselves how their own final submissions
7 will be treated. If they want their statements made
8 public they will be placed on the Inquiry's website. If
9 they wish them to be treated confidentially they will
10 not go on the website. If there are those who prefer to
11 have sections of their final submissions redacted and
12 the balance go on the website, that too will be
13 permitted.
14 Mr Fitzgerald will write to all interested parties
15 and witnesses setting out the decision I have reached
16 and asking them to indicate their preference. The
17 Inquiry will act accordingly. I am sorry for that and
18 thank you very much indeed. Now, then, Mr Verdan.
19 MR VERDAN: Sir, thank you. May I firstly say formally how
20 grateful I am on Enfield's behalf to the Inquiry, sir,
21 and to you for letting me address you one week late.
22 I know it has caused inconvenience to the panel and
23 obviously to everyone who has attended today and
24 personally I am very grateful, as are Enfield.
25 Sir, I know you have had a chance to see the written
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1 submissions that I have submitted on behalf of Enfield.
2 I have no intention of reading those. The oral
3 submissions are to highlight main themes and to answer
4 Mr Garnham's closing submissions, which obviously I had
5 an opportunity to see.
6 By way of introduction, may I make a number of small
7 points, introductory points but important ones. I know
8 Mr and Mrs Climbie are not here. Enfield continue to
9 express to them deep sympathy and were very impressed by
10 how they handled themselves throughout this Inquiry,
11 showing incredible dignity, intelligence and
12 understanding of our procedures.
13 Sir, the main point that runs throughout my
14 submissions is that Enfield were involved for an
15 incredibly short period of time in late July 1999.
16 I have distilled that down to probably 8 working hours
17 from 3.15 on 26th July to 4.30 on 27th July, 3.15 when
18 Karen Johns received the referral, 4.30 when she
19 referred the case on to Haringey. That prime period was
20 the period when she was solely responsible as a social
21 worker representing a local authority to make the
22 decisions and to carry out the work.
23 Sir, that is the context in which I would ask you to
24 judge Enfield's work in this case, a very, very short
25 period of time.
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1 Sir, despite that limited role and involvement, the
2 general submission I would make is that Enfield have
3 cooperated fully with this Inquiry. They have followed
4 the evidence closely and carefully and they have taken
5 every step to assist the Inquiry obtain a full picture
6 of that short period.
7 Specifically, sir, I hope that the evidence of
8 Karen Johns in relation to that very short period in a
9 small way, because of its quality, has illuminated to
10 you what happened to Victoria during her admission.
11 Sir, my written submission answers the criticisms
12 made by Mr Garnham in his opening statement and the
13 notice of potential criticism directed to Enfield and
14 the tone of my written submission and its content should
15 be read as the reply to that.
16 It is now apparent from the closing submission that
17 the number of criticisms made against Enfield are
18 reduced and somewhat changed and I will obviously in my
19 oral submissions deal with those.
20 There seem to be four remaining. Firstly, not
21 attending the psychosocial ward round meeting.
22 Secondly, not speaking to Victoria. Thirdly, the
23 handling of the strategy meeting. Fourthly, the failure
24 generally by social services and obviously Karen Johns
25 in particular to get more accurate information as to the
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1 hospital's concerns.
2 All relate to the fifth missed opportunity that
3 Mr Garnham referred to, the admission of the NMH, which
4 he described as multi-faceted, a multi-faceted missed
5 opportunity by a number of different professionals.
6 Can I refer you to Mr Garnham's paragraph 5.78 of
7 his written submission, which with respect Enfield would
8 agree lists the central issues., the central issues
9 relating to the admission.
10 Firstly: "The extent to which it was appropriate for
11 Dr Forlee and Doctor Banjoko as the admitting clinicians
12 not to take a full history and conduct a comprehensive
13 examination of Victoria during the first 24 hours.
14 Secondly: "The extent to which the evidence given by
15 the nurses on Rainbow Ward represents an accurate
16 picture of the nature and extent of the concerns that
17 they felt at the time. If so, the validity of the
18 explanation given as to why those concerns were not
19 communicated to the doctors.
20 Thirdly: "The failure of communication between the
21 hospital and the social services, which resulted in
22 social services getting an incomplete picture of the
23 hospital's concerns and where there the responsibility
24 for that failure in communication lies.
25 Fourthly: "The confusion exhibited by a number of
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1 the medical staff as to precisely what was done for
2 Victoria at what stage and where the responsibility lay
3 for ensuring that the care she received was
4 comprehensive.
5 Fifthly: "What further steps the hospital should
6 have taken to prevent Victoria's discharge before being
7 satisfied that it was safe for her to go home.
8 Lastly: "The extent to which Miss Arthurworrey and
9 Ms Jones elicited sufficient information from Kouao and
10 Victoria to enable them to form a judgment about the
11 safety of her discharge."
12 With respect, I would agree that those are the six
13 central issues and only one of them touches on Enfield's
14 role, (iii) the failure of communication between the
15 hospital and social services and to what extent Karen
16 Johns was herself responsible for gaining an incomplete
17 understanding of the hospital's concerns.
18 May I deal firstly with the psychosocial meetings
19 and the fact that social workers from Enfield did not
20 attend those and had not for a long time.
21 Sir, Enfield acknowledge completely that it was
22 a managerial failing by them not to have taken steps to
23 ensure that social workers attended promptly after the
24 breakdown in relationship between doctors and social
25 workers. Something should have been done far more
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1 quickly.
2 But I would ask you to consider in relation to the
3 first psychosocial meeting relevant to Victoria, the one
4 on 26th July, the notes of which appear at 37059, the
5 following factors. Firstly, Victoria had only been
6 admitted to the hospital the previous Saturday and so
7 information was limited.
8 Secondly, Dr Forlee had yet to examine Victoria and
9 make the child protection referral. She was to do this
10 at 3.30 pm. We heard that the meeting, the ward round
11 meeting probably was between 1 o'clock. and 2 o'clock.
12 Thirdly, the time given to Victoria's case at such
13 a meeting would inevitably have been very limited as
14 they were discussing every child on the ward.
15 Fourthly, the meetings were the doctors acknowledged
16 informal and unstructured.
17 Fifthly, the notes that do exist at 37059 in
18 relation to this first meeting do not contain new
19 information that Ms Johns did not have from other
20 sources, so I would ask you to consider the causative
21 relevance of her non-attendance.
22 Sixthly, the detailed recollections that nursing
23 staff and doctors now have were not documented or
24 conveyed to other agencies at the time, and lastly the
25 fact that there were many other ways, better ways
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1 I would submit, in which that information could and
2 should have been exchanged.
3 Having said that, I repeat that Enfield accept that
4 Karen Johns should have attended and she herself said
5 that in her experience such meetings were useful.
6 Sir, I should also mention, which I do not in my
7 written submission, the second meeting on 2nd August
8 I think it was, the second Monday during which Victoria
9 was in hospital, for I have no wish to mislead the
10 Inquiry obviously and Karen Johns, had she attended,
11 would have in all likelihood, and she answered your
12 question specifically, gathered more information.
13 The note of that meeting is at 37069. It is not
14 detailed. It only goes two pages but certainly it is
15 arguable from that page and a half that there was more
16 information that Karen Johns could have obtained and,
17 given how she took her notes and what she did with her
18 information it is likely that she would have passed that
19 information on to Haringey.
20 All I can say in relation to that second meeting,
21 sir, but I say it with some force and I submit it is an
22 important point, is that her attendance at that meeting
23 is and should not be any substitute for a proper means
24 of communication between the hospital and Haringey in
25 relation to child protection concerns. It would be
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1 another avenue but certainly not the most important one.
2 Secondly, sir, can I deal with the question of not
3 seeing Victoria, which obviously is a matter which has
4 concerned the Inquiry greatly and is one of the most
5 emotive criticisms perhaps made, that she was not seen
6 until the 6th.
7 Sir, my main submission in relation to this is that
8 I would ask you not to judge Enfield for collective
9 failing. Just because she should have been seen during
10 her admission at the hospital earlier than the 6th does
11 not mean that she should have been seen by everyone who
12 had the opportunity to see her. Taking that argument to
13 an extreme, had everyone who could have seen her seen
14 her it would have probably been confusing and upsetting
15 for her and I would submit that Karen Johns, given the
16 guidance that existed at the time, is the person who
17 should not have seen her, and in reality had Haringey
18 seen her the day after the strategy meeting, the 29th,
19 there could be and there would not be any criticism at
20 all of Karen Johns for not having seen her in those
21 first couple of days.
22 The only reason why appropriately of course the
23 issue is being considered in such depth is because she
24 was not seen quick enough, but the blame for that
25 I would submit is not Enfield's.
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1 Sir, I list all the factors in my written submission
2 as to why Karen Johns said she took the decision not to
3 see Victoria, and you will remember when she was giving
4 evidence that she said it was a deliberate decision she
5 made, an exercise of her professional judgment.
6 It was clear from her evidence that she had in the
7 past seen Haringey children. It was not an objection by
8 her in principle to seeing Haringey children. She had
9 decided specifically in this case that it was not
10 appropriate, given the very short period of time that
11 she was involved.
12 Sir, I have listed all the matters she took into
13 account. Sir, it may be that this Inquiry decides that
14 professionals are too cautious when seeing children or
15 interviewing them and I appreciate fully there is a
16 distinction to be made between a formal interview and
17 simply speaking to a child, but at the time certainly
18 social workers, and many have given evidence at this
19 Inquiry but Karen Johns also said that she did not see
20 it as a simple issue, a simple issue of simply walking
21 up to Victoria, introducing herself and talking. She
22 was cautious. I would submit that given the guidance
23 that existed at the time she was rightly cautious and
24 concerned of the implications of what could follow from
25 even a simple conversation with Victoria.
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1 Sir, given that in my written submission I deal with
2 all the matters which exercised Karen Johns' mind,
3 I have listed some eleven individual matters which made
4 her think that it was not appropriate during that short
5 period of time before the strategy meeting to interview
6 or speak to Victoria. I will not repeat them now but
7 I certainly say that after the strategy meeting, when
8 the case was formally taken over by Haringey and they
9 built up a list of 18 tasks to do, it then would
10 certainly have been completely inappropriate for
11 Karen Johns on the ward to have gone to speak to the
12 child.
13 It was Haringey's case. It could have jeopardised
14 their investigation, had they done it promptly, and it
15 would not have helped Victoria, I say in my written
16 submission, for Karen Johns to have introduced herself
17 and explained in some way which was child appropriate
18 "I am not really your social worker any more. I have
19 handed the case on. You are not going to be seeing me
20 again." One wonders really what Victoria would have
21 made of that. It would have been confusing enough for
22 her to distinguish between nurses, social workers and
23 doctors that she was seeing, but simply to meet someone
24 to be told "You are not seeing me again" in the
25 circumstances of this case would have been most
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1 unhelpful.
2 Sir, it is small comfort also but I would submit it
3 is relevant to consider what in all likelihood would
4 have been gained by either a conversation, let alone an
5 interview of Victoria by Karen Johns. The reality is,
6 for the reasons we know, in all likelihood Victoria
7 would not have spoken. The most she ever said of
8 forensic relevance was I think to nurse Davidson, the
9 comment referred to by Mr Garnham in his opening, the
10 "ssshhh".
11 The closest relationship she may have had was with
12 nurse Taub. She did not say anything of forensic
13 relevance to her. Again that is not surprising on the
14 assumption that by then she had been abused in different
15 ways and on a number of occasions. It is completely
16 understandable why she was far too scared to speak to
17 strangers.
18 It is small comfort but it is relevant to bear that
19 in mind when analysing who should have spoken to her.
20 Sir, I turn to the third point, the handling of the
21 strategy meeting. Enfield would submit that they can no
22 longer be criticised for the way that meeting was set
23 up. It was clearly Haringey's responsibility. Haringey
24 accepted responsibility for it. They did not ask
25 Karen Johns to assist with the invitations.
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1 She said in oral evidence that she would have done
2 had she been asked. More pertinently she said in oral
3 evidence that after being invited to the meeting by
4 Shanthi Jacob she asked if the location could be changed
5 to the hospital, as otherwise it was unlikely doctors
6 would attend. I say in passing that she specifically
7 wanted to attend herself, knowing the doctors were not
8 going to be there. She said that Shanthi Jacob said she
9 would check with her own manager, which she did, but
10 then called back to say that that was not possible, and
11 the reference to that is 15th November, page 103, line
12 4.
13 Miss Jacob, when she was asked about this
14 conversation, said she had no recollection but did not
15 dispute that it occurred, and that was on 27th November,
16 page 155, lines 15 to 20.
17 On the basis of that evidence I would ask you, sir,
18 to accept Karen Johns' recollection, given that it is
19 a positive one, and given the general quality of her
20 evidence.
21 She attended the meeting. She contributed as fully
22 as she could on the basis of the information she had at
23 the time, and it was agreed that Haringey would clarify
24 the medical information, not Karen Johns.
25 Sir, whatever Dr Rossiter may have thought or
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1 expected, reference is made to her saying that she
2 expected Karen Johns to clarify the medical information,
3 the reality is that at that strategy meeting that task
4 was given to Haringey and not Karen Johns. Had
5 Karen Johns been asked, it is likely she would have
6 accepted that task, but she was not and so therefore sir
7 I submit that no criticism of Enfield can be made in
8 relation to the strategy meeting.
9 Sir, I turn lastly to the failure by social services
10 generally to get a more accurate picture of the hospital
11 concerns which Mr Garnham refers to in his closing
12 submissions. I have dealt already in my written
13 submissions with the extent to which Karen Johns
14 provided Haringey with medical information, which is
15 obviously one side of the coin, and I submit that she
16 provided them with everything she had.
17 I would submit that you can find that she did take
18 accurate notes, illuminating and helpful notes as to
19 what the hospital's concerns were, and anything that the
20 hospital told her she would have passed on, for that is
21 in fact what she did.
22 Mr Garnham says that perhaps she was best placed to
23 obtain more information from the hospital to clarify
24 information, given that she was based there, and that
25 must be right and Enfield would accept that. But given
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1 the very short period of time that she was involved, the
2 8 working hours I have referred to earlier, I would ask
3 you to consider whether it is reasonable to expect her
4 to have done more than she in fact did, and I have
5 attached to my written submission an appendix detailing
6 the work that she did do.
7 In summary, she attended the ward in person five
8 times. She spoke to the ward on the telephone six
9 times. She spoke to three different doctors, Forlee,
10 Alexander and Rossiter. She memoed a fourth, Dr Meates,
11 twice. She memoed the nurse once and then she attempted
12 to telephone Dr Meates I think on 3 occasions. There
13 was ample opportunity, given all of those contacts for
14 her to be given the full picture. Sadly, the hospital
15 admit that she was not given the full picture. They
16 admit that they did not record their concerns properly
17 and did not convey them, regardless of whether they had
18 recorded them or not.
19 Ms Johns was available even after the strategy
20 meeting in attending the ward and communicating with
21 nurses. She was proactive. This is certainly not
22 a case of the hospital social worker simply sitting in
23 her office and waiting to be given information. She was
24 there in person and one simply does not know why, given
25 that she attended the ward five times, all the terrible
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1 concerns which the hospital now have were not conveyed
2 to her properly, for you can be assured that if she had
3 been told she would have done something with that
4 information, she would have passed it on to the
5 appropriate person.
6 Sir, can I deal with lessons very briefly. The most
7 relevant lesson that Enfield have learned from this is
8 the lesson which is most causatively relevant.
9 I appreciate fully that a number of criticisms were put
10 to Enfield witnesses about procedural and managerial
11 failings, but the most relevant lesson is that Haringey
12 cases are no longer managed by Enfield and within the
13 hospital. Haringey have their own workers either there
14 or responsible for Haringey cases.
15 This is the relevant lesson, but I should say there
16 is no intrinsic problem I would submit with a system of
17 referral. Often it is necessary to refer from one
18 discipline to another, from one level of seniority to
19 another, from one person to another. The system that
20 existed at the time of Enfield referring cases on to
21 Haringey was not in itself problematic. It could have
22 worked, had it been acted on quickly and promptly.
23 Sir, by way of conclusion I would ask you not to
24 judge the local authorities involved in this case
25 collectively but look at Enfield's role discretely.
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1 A minor point, but one mirroring the submission made
2 by the London Borough of Brent, I would ask the Inquiry,
3 if they are able to comment favourably on some aspects
4 of social work practice seen in this case, to do so, for
5 it may assist not further discouraging people from
6 joining that profession.
7 Lastly, sir I would say that despite Enfield's very
8 limited role, of course Enfield will implement all
9 recommendations made by this Inquiry. Unless I can
10 assist further.
11 THE CHAIRMAN: That is very helpful Mr Verdan. I am very
12 grateful to you and I hope that you may have had the
13 chance to observe that when we last met I ended by
14 thanking a number of people, including the advocates,
15 who had helped Phase I of the Inquiry and I hope that
16 you will include yourself in that general thanks.
17 MR VERDAN: That is very kind, thank you, sir.
18 THE CHAIRMAN: Ladies and gentlemen, we have now reached the
19 end of the oral submissions for Phase I and we will be
20 now moving on as far as the actual public part of the
21 Inquiry is concerned to Phase II, and so I will adjourn
22 the proceedings now until 10.00 am on 15th March. Thank
23 you very much indeed.
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25 Adjourned until 15th March at 10.00 am.
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