Archived Transcript for 23 January 2002: Pages 101 to 150

101



1 and their families, so she is not directly involved in

2 children now.

3 THE CHAIRMAN: But the situation then is that when according

4 to the Leader he was told that this was the worst social

5 services authority in England, so you report, same

6 members now, is that an indication that in the past

7 members of the authority did not take issues of children

8 very seriously and it takes a death of a child and these

9 terrible circumstances to actually get members to

10 actually take matters seriously?

11 MR TUTT: To be fair to the members, they of course took

12 action long before Victoria's death. Their concern was

13 for children and the state of the services provided --

14 THE CHAIRMAN: Let me correct myself before you go on. Does

15 it require a dreadful SSI report then to get elected

16 members to take matters seriously?

17 MR TUTT: I do not think it should and I do not think it

18 does in all honesty. I think this sounds very arrogant

19 and I do not mean it in that way, but I mean I think it

20 requires a determination of chief officers to keep

21 members informed of the basic quality of the services

22 that they are providing.

23 THE CHAIRMAN: You see, one of the things -- it may be you

24 were in the room when I was asking Ms Goodall about

25 these things. Victoria was in her very short life in

102



1 this country in contact with four local authorities and

2 it did not prevent what happened to her happening. I do

3 not know whether that is something that is to do with

4 Children's Services being given a low priority or it is

5 to do with managerial incompetence or to do with

6 professional incompetence or to do with other factors,

7 so what in your opinion -- where should we be looking?

8 MR TUTT: I think certainly the political managerial

9 interface I would put as one. I mean a measure of

10 managerial competence is to ensure that members do give

11 Children's Services a priority. It is not always

12 a popular position to take and obviously members are

13 concerned about a whole range of other issues which may

14 be more attractive in their eyes for the electorate.

15 It is not a popular issue either when -- as we are

16 in the middle of setting the Council Tax, as we are at

17 the moment, but clearly one has to as a professional

18 I think stake out what is acceptable standard, ensure

19 that members are aware of those acceptable standards and

20 not be deviated from those.

21 THE CHAIRMAN: And because in your view there are many more

22 politically attractive priorities and this is not

23 a popular cause, do you think that questions ought to be

24 asked as to whether or not the safety of children can be

25 entrusted to local government?

103



1 MR TUTT: I think certainly questions have to be asked about

2 that. My assumption, and I have spent much of my career

3 asking the same question, but my assumption is that any

4 other mechanism would not be necessarily much more

5 efficient, and take for example Sure Start Connections,

6 the children's fund, all of those approaches which are

7 disassociated from local government just raise different

8 problems in terms of boundary issues and communication,

9 and I am not sure whether a regional or national

10 organisation of childcare would be any more effective.

11 It would also create problems if, as in this

12 particular case, Housing were to continue in local

13 authorities and Social Services, or I am assuming

14 Children's Services rather than all of Social Services,

15 if Children's Services were somehow taken out of local

16 authority. It would just create another boundary issue.

17 THE CHAIRMAN: It is a rather depressing thought that

18 whatever organisation is given the responsibility of

19 protecting children, we cannot be sure it will be any

20 better than has happened in Victoria's case.

21 MR TUTT: I did not intend to be depressing. As you may

22 well know, I am not normally depressed. Like Ms Goodall

23 I am enthusiastic and committed to ensuring high quality

24 of services to children within local authorities. I am

25 not sure that within social policy context I see that

104



1 there are any other mechanisms for delivering that

2 service that could prove more efficient.

3 THE CHAIRMAN: I did not think for one moment that you were

4 depressing or depressed. I was thinking more the

5 message you were giving me was a depressing message.

6 Because if we are actually going to try to deliver on

7 what I think is a reasonable expectation of the Inquiry

8 that recommendations are made to try and prevent such

9 a thing happening again, where do you think we should be

10 making our recommendations?

11 MR TUTT: Well, I do have to come back to investment and it

12 is not because I have argued resources are key in

13 Ealing, but I mean the kind of communication across

14 borough boundaries that you would be seeking, and

15 certainly I would be strongly supporting, would take

16 enormous investment not only in terms of hardware but

17 skilled staff to set up the systems.

18 Similarly, investment in staff. I mean, I was

19 rightly questioned about the pay and conditions of my

20 staff and they are poor. If I can be anecdotal for

21 a minute, I received a letter only this week from

22 a social worker who was asking whether there was

23 anything I could do about accommodation because they

24 cannot afford to live in the borough. Our own housing

25 needs survey shows that you have to be earning £40,000

105



1 a year in order to rent a single one bedroom flat within

2 the borough. Now, none of our social workers have been

3 paid anywhere near that, so how can we attract staff,

4 talented and skilled, well-educated professional staff,

5 if they are having to labour under those conditions of

6 basically low pay?

7 THE CHAIRMAN: Thank you very much indeed. Mr Sheldon.

8 MR SHELDON: Sir, I have no further questions, thank you

9 very much.

10 THE CHAIRMAN: Thank you Mr Tutt for your evidence.

11 MR SHELDON: Sir, the next witness is Dr Lachman. Before

12 I call him it may be helpful if I state at the outset

13 that a bundle of documents relevant to his evidence has

14 been provided. They were provided to the Inquiry on

15 Monday evening, they reached me yesterday evening after

16 we finished sitting. They consist of amongst other

17 things the new Child Protection Guidelines in force in

18 the North West London NHS Trust and an audit of the

19 standard of work done on 39 child protection cases and

20 a document concerned with child protection training.

21 They are on my reading of them at least all relevant

22 to the ground that Dr Lachman can cover and I will be

23 asking him a number of questions about them today. They

24 have been copied as I understand it and have been

25 incorporated into our new bundle 45I, which the

106



1 documents team with their usual efficiency prepared

2 essentially overnight and have tried to distribute

3 around the interested parties today.

4 As I understand it, there were some copies outside

5 in the break that we had earlier on this morning and

6 I hope that most if not all of the interested parties

7 may have got that by now. I also hope that you may have

8 sight of them.

9 As always, this raises difficulties. The first is

10 that it may be that in my reading of them overnight

11 I have missed something of importance which I should

12 have asked Dr Lachman. Possibly more importantly, it

13 may be that the interested parties will have wanted to

14 read them, so that they could suggest questions for me

15 to put to him.

16 Sir, I would suggest that there is little we can do

17 about that at this stage. Depending upon the extent to

18 which those difficulties arise, it may be that we may

19 have to recall Dr Lachman to deal with those questions

20 or ask him to deal with them by way of a supplemental

21 statement. I would suggest that it is appropriate

22 nonetheless for me to press on today regardless and see

23 how we do. I would leave it to you, should you wish to

24 do so, to make enquiries as to why we are in this

25 position. It is not something I was proposing to

107



1 explore certainly at least with Dr Lachman.

2 THE CHAIRMAN: Mr Sheldon you are considerably ahead of me

3 and I do not know whether you are ahead of my

4 colleagues. I did not know we had got a 45I, let alone

5 had the chance to see these documents. These are

6 clearly important. Mr Mason do please explain to me why

7 I sit here in ignorance of the existence of these

8 documents despite the efforts of the wonderful team that

9 we have.

10 MR MASON: Sir, I saw them for the first time on Monday and

11 got them to the Inquiry the same day. In all fairness

12 the documents are in fact in essence only a few days

13 old. Certainly the latest edition of the Child

14 Protection Guidelines are a follow-on from an earlier

15 latest version that the Inquiry had in the autumn

16 I believe from Dr Lachman. They were finished and

17 printed on 15th January, a few days ago.

18 The update on training, who has had what training,

19 again is something that Dr Lachman has -- it is dated

20 18th January. The audit on past cases is the one

21 Dr~Schwartz referred to in evidence, that is

22 dated December of this year. It is a month old. It is

23 a two-page document. I am sorry you did not have that

24 earlier but the bulk of the material is just a few days

25 old.

108



1 THE CHAIRMAN: Thank you Mr Mason. What I would like to

2 suggest is that contrary to what happens in some places

3 where they do interesting things in their lunch break,

4 we seldom get a lunch break as you know, but I think the

5 sensible thing for us to do is to for all of us if we

6 can to have at least a glance at these documents over

7 lunch and then we will proceed on the basis that

8 Mr Sheldon has set out which is that we will take it as

9 far as we can and if there remain issues that need to be

10 followed up we will follow them up either by letter or

11 by recall. So ladies and gentlemen. Mr Sheldon, unless

12 you ...?

13 MR SHELDON: I am entirely content for that course.

14 THE CHAIRMAN: In view of the circumstances that we find

15 ourselves in I think that we will indulge ourselves

16 somewhat and reassemble at 25 minutes to 2.

17 (12.50 pm)

18 (The short adjournment)

19 (1.35 pm)

20 THE CHAIRMAN: Mr Mason.

21 MR MASON: If I may trouble you for another 30 seconds.

22 THE CHAIRMAN: Of course.

23 MR MASON: Just before lunch I was thinking of the documents

24 that Dr Peter Lachman gave me on Monday, the three

25 documents. There were a couple of other documents that

109



1 the Inquiry first asked me for at the end of Thursday,

2 there are the Trust Board papers and a very short

3 minute. I was not thinking of those when I spoke this

4 morning so I thought I had better mention them now.

5 The Trust Board papers, insofar as they relate to

6 the issues in this Inquiry, should have been disclosed

7 much earlier, especially with Dr Riordan's statement,

8 and Dr Riordan refers to them. I am afraid we missed it

9 under the pressure of work, which I know has been used

10 as a reason for it. It is not a satisfactory excuse,

11 and I am sorry about that. The other minute probably

12 does not take knowledge very much further.

13 THE CHAIRMAN: Thank you very much indeed Mr Mason. As you

14 have observed, I am not terribly sympathetic about

15 reasons why papers that have been available for some

16 time are not delivered to the Inquiry and I hope that

17 I have conveyed that message and I hope that is

18 understood. The stuff that was produced last week, of

19 course I regard that somewhat differently. Thank you

20 very much indeed.

21 Mr Sheldon.

22 MR SHELDON: Sir, thank you. Can I have Peter Lachman,

23 please.

24 DR PETER LACHMAN (affirmed)

25 MR SHELDON: Good afternoon. Could you confirm your full

110



1 name and professional address, please.

2 DR LACHMAN: Dr Peter Erwin Lachman at Northwick Park

3 Hospital in Harrow, Middlesex.

4 MR SHELDON: You have produced one statement for use by this

5 Inquiry in bundle 5 of our green folders, page 114.501.

6 Do you have a copy in front of you?

7 DR LACHMAN: I do.

8 MR SHELDON: Could you have a look at the last page please.

9 Have you signed it?

10 DR LACHMAN: I have signed it.

11 MR SHELDON: Are you happy that the facts and matters in it

12 are true?

13 DR LACHMAN: Yes.

14 MR SHELDON: You are currently as I understand it the

15 Clinical Director of Women & Children for the North West

16 London NHS Trust?

17 DR LACHMAN: That is correct.

18 MR SHELDON: That is a post you have held since April 2000?

19 DR LACHMAN: Yes, it is.

20 MR SHELDON: And the Trust, just so we are clear at the

21 outset, is responsible amongst other things for the

22 Central Middlesex Hospital?

23 DR LACHMAN: That is correct.

24 MR SHELDON: As I take it from your statement, in the post

25 that we have just mentioned you have been responsible

111



1 for or involved with the implementation of the lessons

2 learned from Victoria's case?

3 DR LACHMAN: That is correct.

4 MR SHELDON: One of the effects of those lessons would seem

5 to be a new set of Child Protection Procedures --

6 DR LACHMAN: That is correct.

7 MR SHELDON: -- which we now have in our new volume 45I.

8 I wonder if a copy of that could be put in front of you.

9 Page 19, please. These are the new guidelines, is that

10 right?

11 DR LACHMAN: Yes.

12 MR SHELDON: You are down as the editor.

13 DR LACHMAN: I am.

14 MR SHELDON: And amongst other contributors was Dr Schwartz?

15 DR LACHMAN: That is correct.

16 MR SHELDON: It says on the front sheet that we are looking

17 at there that these guidelines were updated October 2001

18 but we understand from Mr Mason that might not be right.

19 DR LACHMAN: Perhaps I can explain.

20 MR SHELDON: Please.

21 DR LACHMAN: In my original submission I gave the guidelines

22 that we currently held in September at Central Middlesex

23 Hospital, those written by Dr Schwartz, as part of the

24 implementation, in fact before, as part of the merger of

25 two Hospital Trusts in two different boroughs I had

112



1 undertaken as one of the priorities, it was not on top

2 of the list at that stage because we had guidelines to

3 amalgamate guidelines across the boroughs.

4 This is a process that I started in earnest really

5 around about July but was caught up with having to

6 submit something for my statement in September, which

7 I did with Dr Schwartz's Central Middlesex guidelines.

8 Then over the period of September to October I completed

9 the guidelines.

10 So in essence the date is correct. The period

11 thereafter is the consultation period which happened in

12 basically November and December and they were presented

13 to the Harrow ACPC on 4th December and to the Brent ACPC

14 on 20th December and I went on leave on the

15 27th December, hence you received them after I returned

16 from leave.

17 MR SHELDON: I see, but they have now jumped through the

18 various hoops they need to jump through and they are up

19 and running, is that right?

20 DR LACHMAN: They have jumped through the hoops, although

21 I should point out they have been submitted to ACPCs and

22 their policy group will be looking at them and making

23 any comment. But as they are ringbinders, if they have

24 any particular comment they wish to change I could do

25 that quite easily. But they have been distributed to

113



1 50 points within the hospital so they are all over the

2 hospital at the moment and training sessions will

3 commence. Since they have only been given out this

4 week, we will be having implementation programmes over

5 the next few weeks.

6 MR SHELDON: Have a look at 43A, page 000.401. Just so we

7 are clear, Dr Lachman, these are the old guidelines,

8 Dr Schwartz's ones?

9 DR LACHMAN: Yes.

10 MR SHELDON: These are now superseded by the ones you are

11 the editor of?

12 DR LACHMAN: These have been superseded, they have been

13 withdrawn but in fact I must admit a lot of what is in

14 here are in the ones I have edited so I did not write

15 from scratch, I took what was in operation at both sides

16 and tried to get a convergence and practice where

17 possible, given they are two different boroughs with two

18 different ACPCs.

19 MR SHELDON: One of the things you had in mind I take it

20 when you were updating those guidelines and producing

21 the ones we now have in front of us were the

22 recommendations made by the Brent Part 8 review, is that

23 correct?

24 DR LACHMAN: That is correct.

25 MR SHELDON: So we should look to these new guidelines in

114



1 volume 45I for the Trust's approach and implementation

2 of those recommendations?

3 DR LACHMAN: I agree.

4 MR SHELDON: Before we come to look at that in a number of

5 particular points there is one point I want to explore

6 with you at the outset. You mention in paragraph 6 of

7 your statement that many of the measures that we are

8 about to look at have been complicated in their

9 implementation by the fact that some of the procedures

10 are different in the two local authorities, namely Brent

11 and Harrow. Is that right?

12 DR LACHMAN: Yes.

13 MR SHELDON: Does that remain the case?

14 DR LACHMAN: Fortunately it does not remain the case. Brent

15 ACPC has redone their procedures and Harrow has followed

16 suit and had the same also. So hopefully when they both

17 adopt it by the two ACPCs they will converge and we will

18 not have that problem many hospitals have of having to

19 please ACPCs which are next to each other, and that has

20 made it easier for us in writing the guidelines.

21 The principles in child protection are the same

22 wherever you work, so it is a matter of practice and how

23 you contact Social Services, which might differ

24 slightly, and there are still variations between the two

25 boroughs but that is because we have a hospital social

115



1 workers team at Northwick Park and we do not have on

2 site hospital children social workers at CMH.

3 MR SHELDON: But there has been harmonisation at least at

4 ACPC level?

5 DR LACHMAN: There has and at referral procedures, so the

6 doctors will follow the same procedures no matter which

7 Social Services they refer to.

8 MR SHELDON: If we go back to volume 45I, please, page 13.

9 When we look there at this document which, if we

10 turn over to page 15, we will see you wrote on

11 12th September of last year, the point you make at

12 number 5, namely that although the requirements of the

13 two boroughs differ, there are two individual ACPCs, it

14 is proposed to consolidate and unify the procedures and

15 protocols including documentation across the Trust, that

16 now has been done?

17 DR LACHMAN: That has been done.

18 MR SHELDON: Thank you. Are there any difficulties caused

19 by the residual differences in approach or procedure

20 between the two authorities or is it now all as it

21 should be?

22 DR LACHMAN: I should hope it is all as it should be but

23 I am being practical that there are always difficulties

24 in the work that we do, but there are good

25 communications between myself and the Director of

116



1 Social Services in both boroughs, so I think that should

2 difficulties arise we could address them. But I think

3 we have minimised it.

4 MR SHELDON: Because it would seem to be the case from

5 paragraph 6 of your statement that it is not just

6 a problem between Brent and Harrow. As a Trust you have

7 to deal with five local authorities, is that correct?

8 DR LACHMAN: Yes, that is correct. We also had referrals

9 from Hillingdon, Ealing, Chelsea and Westminster and

10 Barnet.

11 MR SHELDON: Have you managed to achieve the same level of

12 harmonisation as regards those authorities and referrals

13 to them?

14 DR LACHMAN: I would say that the vast majority of children

15 that we deal with come from Brent and Harrow and that

16 has been our first priority. The next step is to

17 present these procedures to the other hospitals. In

18 terms of Barnet, we do undertake clinics at Edgware

19 Community Hospital, in fact I do those clinics so I am

20 in a good position to work closely with Barnet social

21 workers and I have done so in the past and we have good

22 relationships with the paediatricians there.

23 Ealing we do not receive many referrals and

24 Hillingdon, the Brent and -- the Community Trust in

25 Harrow and Hillingdon, so we had good relationships on

117



1 that ground too.

2 So I think as far as possible we have minimised it

3 but the next step is to take it to the other agencies as

4 well.

5 MR SHELDON: I am wondering to which extent in practice an

6 individual doctor, when they are dealing with what they

7 think may be a child protection case and they want to

8 know what to do, has to go to a shelf full of procedures

9 for local authorities, decide which one to pull off and

10 then decide which form to fill out because it happens to

11 be a Hillingdon child rather than a Brent child. Is

12 that the position?

13 DR LACHMAN: In an ideal world there are one set of

14 principles to follow, one set of practice in the area

15 that you live. For example, in London if we had to

16 follow -- have 32 different boroughs' proceedings or

17 protocols on our shelf, we would never look at them.

18 What we should have is a core set of proceedings of how

19 to contact social workers. It is no different to me if

20 I have to contact or make a referral to a Barnet social

21 worker than I have to do to a Brent social worker. The

22 principles are the same, they are principles that I have

23 in this document which will be the same and that is what

24 we will follow. What we would like to see is that our

25 standard is accepted as the acceptable standard by

118



1 Barnet, Brent, Ealing, Harrow and Hillingdon, which are

2 major agencies.

3 MR SHELDON: You have achieved that as far as Brent and

4 Harrow are concerned and you are now attempting to roll

5 that model out into the other boroughs with which you

6 deal?

7 DR LACHMAN: That is what I would do in the future. The

8 essence is I would expect that Brent and Harrow, having

9 reviewed the ACPC guidelines, would be really up-to-date

10 and their having accepted, I should not have any problem

11 with the other boroughs' acceptance.

12 MR SHELDON: So you are optimistic?

13 DR LACHMAN: I am particularly optimistic following this.

14 MR SHELDON: Can we turn back to your statement and the

15 various items you deal with in it relating to the

16 recommendations made by the Part 8. Let us start at

17 item 1, which is at paragraph 7 on page 2.

18 This is a recommendation that all agencies

19 identifying suspected child protection concerns must

20 make an immediate referral to Social Services in

21 accordance with the procedures. Now there would seem to

22 be two elements to that recommendation. Firstly, that

23 the referral is made. Secondly, that it is made

24 immediately. Is that right?

25 DR LACHMAN: That is correct.

119



1 MR SHELDON: Do you regard the second one, the fact it is

2 done immediately, to be significant?

3 DR LACHMAN: That is correct. I think that one needs to

4 make a timely referral and once one has a suspicion one

5 should share that information with Social Services or

6 the responsible agency.

7 MR SHELDON: The part of the new manual which deals with

8 referral to Social Services would seem to be at page 29

9 of volume 45I. Perhaps you could turn that up.

10 DR LACHMAN: Yes.

11 MR SHELDON: It says there under the heading "8": "Children

12 with alleged, suspected or actual abuse should be

13 referred to Social Services", then it has working hours

14 procedures and after hours procedures. It does not say

15 "immediately". Any reason for that?

16 DR LACHMAN: It is a given.

17 MR SHELDON: I see. You are confident that anybody reading

18 these procedures will know or anybody involved with the

19 protection of children will know it has to be done

20 straight away?

21 DR LACHMAN: The procedure is that child protection -- in

22 fact following this Inquiry I have always held that

23 child protection is of such importance that it is at

24 consultant level a decision should be made. So if

25 a registrar considers a child protection issue, that

120



1 will be discussed with the consultants and an immediate

2 referral will be made. I could put the word "immediate"

3 in there if it made it more clear but in training that

4 is the essence that we have; that referrals are made as

5 soon as you consider the issue.

6 MR SHELDON: I see. It says in that section 8 that as far

7 as Northwick Park is concerned, if the referral needs to

8 be made during working hours then the member of the

9 medical staff concerned can take advantage of the social

10 work team that is based at the hospital. There is no

11 resident team from Brent at Central Middlesex, is that

12 right?

13 DR LACHMAN: No there is not.

14 MR SHELDON: Does that place Central Middlesex Hospital

15 staff at a disadvantage in making referrals?

16 DR LACHMAN: You could say yes and no. This is the whole

17 argument of whether to have hospital social work teams

18 which as I understand were cut due to finance or due to

19 lack of social workers, because at times you may not

20 have a team to have. In fact the Harrow team that we

21 have has always been under pressure in terms of staff.

22 The advantage of working with a social work team in

23 the hospital is that you do not have that boundary of

24 having to refer. I could walk into the social worker's

25 office, discuss a case that might seem to me trivial or

121



1 seem to others trivial, but I can discuss the case and

2 that is how we work at Northwick Park.

3 The other model which many boroughs follow is to

4 have a link social worker which we are establishing in

5 Brent. That is a little harder work because you have to

6 pick up the phone and telephone to discuss a case. But

7 if you develop very good working relationships with your

8 local borough, you can achieve the same level of

9 referral.

10 So there are two models. Each have their

11 advantages. One of the advantages of the Harrow model

12 is that we take a very broad view of child protection

13 and so children in need will be discussed far more

14 readily than otherwise. But I am not saying to Brent

15 you need to have a team there, what you need to do is

16 have very good relationships and where the team is cited

17 does not really matter.

18 MR SHELDON: Do you feel you have that standard at present

19 at CMH?

20 DR LACHMAN: One of the recommendations was to develop good

21 working relationships with CMH, and prior to that when

22 Miss Konisberg came into post I met her and have met her

23 regularly to discuss issues and develop the working

24 relationship. I do not work at Central Middlesex

25 Hospital, I work at Northwick Park, but I am the Head of

122



1 Department and I think it is very important that the

2 heads of department set the example and have very good

3 relationships, so that is diffused downwards into the

4 rest of the department.

5 I am working with Brent to establish this

6 relationship. We have a new liaison health social

7 worker who I will be working to give my expectations of

8 what we would want, and I think that -- in fact I am

9 very positive that we are going to have a good outcome.

10 MR SHELDON: You feel, do you, that Ms Konisberg

11 individually and Brent as a whole are as keen as you are

12 to develop this relationship?

13 DR LACHMAN: I think they are very keen.

14 MR SHELDON: And some progress is being made, is it?

15 DR LACHMAN: Progress is being made. I should say that the

16 Inquiry has been both an impetus and a holding back at

17 the same time because we are busy trying to establish

18 relationships at the same time as looking at past

19 practice.

20 What we have to do is say we have to work in the

21 interests of children together and I think we are doing

22 that. Definitely at management level. For the social

23 workers and the doctors it is very important to say the

24 child is at the centre and that we are achieving this

25 through close working together with the child as the

123



1 core of our purpose. So trying to keep these

2 professional boundaries that are inevitable in most

3 organisations.

4 MR SHELDON: Is this process you are in with Brent at the

5 moment, so meeting Ms Konisberg and discussing ways with

6 which the communications can be improved and liaison

7 improved, is that a second best option given that you

8 are not going to get a team situation at the CMH?

9 DR LACHMAN: No, I would say it is an alternative not

10 a second best. Different approach to the same problem.

11 There are many arguments for having a team based in

12 a different area. For example, most of the child

13 protection that we see is not necessarily at CMH but it

14 is in the community, at the community clinics in

15 Wembley. That is run by a different Trust, namely

16 Parkside at the moment, soon to be Brent CPT. So if we

17 based the hospital social workers there then they would

18 have a knock-on effect, so possibly it is best for

19 Brent.

20 MR SHELDON: One of the things that we have considered

21 during the course of this Inquiry and it may be

22 something that you have picked up from your reading of

23 the Part 8, if nothing else, is that Victoria when she

24 was in the CMH was not seen by a social worker,

25 Michelle Hines in that instance.

124



1 Is it more likely that a child who is in hospital

2 for a fairly brief period of time like Victoria was on

3 that occasion is going to be seen and assessed by

4 a social worker, if there is a social work team on site?

5 DR LACHMAN: In reality, yes. I think that there is no

6 doubt that if there were unlimited resources within the

7 country then we could attract the social workers to fill

8 these teams, and we would go for that model.

9 MR SHELDON: If there were unlimited resources and you had

10 free rein to organise this sort of system as you would

11 want, then would you have a social work presence at CMH?

12 DR LACHMAN: I would like to have a team at CMH but I would

13 not just say yes, I would like to look at the number of

14 children who would be seen at the team because at the

15 moment we are about to reorganise the way we present at

16 the paediatric services at CMH and it may be premature.

17 What I would really like to see is in terms of child

18 protection a unified team between social workers and

19 doctors. That is the way I have always worked, in which

20 we all are one big team. We might be paid by different

21 agencies but we work together.

22 I think where your office is does not necessarily

23 have to be an impediment, but obviously at

24 Northwick Park, if we have access right on the door, and

25 that is an advantage.

125



1 MR SHELDON: The other element to your response to that

2 first recommendation, as you put it in your statement,

3 is to make referral procedures more rigorous. What

4 exactly do you mean by that?

5 DR LACHMAN: One of the issues in medicine in general is how

6 do we keep notes. In all the child protection issues

7 that -- or Part 8's I have been involved in I have

8 noticed the same theme coming through: who do people

9 refer to another agency? And does a referral discharge

10 one's responsibility? My view is that a referral does

11 not discharge one's responsibility, one's responsibility

12 for what happens to the child only ends once you know

13 that action has taken place and you have had a feedback

14 about that referral.

15 That applies whether I refer a child with a medical

16 condition or with a social condition such as in child

17 abuse. So what I mean here is that there has to be good

18 documentation and a referral that gives the agency that

19 is accepting the referral all the information that they

20 require to carry out their function, and also lets them

21 know what your expectation is so that they can meet what

22 you expect them to fulfil. Likewise, I expect

23 a referral to health to the same standards.

24 MR SHELDON: The second recommendation with which you deal

25 in your statement is that referrals should not just be

126



1 rigorously made, that the referrals themselves should be

2 complete, with all the relevant information.

3 DR LACHMAN: Yes.

4 MR SHELDON: Your response to that recommendation seems to

5 have several stages, and we will take them one by one.

6 The new system, as I understand it, is that first of all

7 there will be a telephone call to Social Services by the

8 medical or profession concerned saying there is going to

9 be a referral coming down?

10 DR LACHMAN: That is correct.

11 MR SHELDON: Then that referral is made in writing?

12 DR LACHMAN: That is correct.

13 MR SHELDON: Then the Social Services are contacted by the

14 medical professional to check that the referral has been

15 received?

16 DR LACHMAN: That is correct.

17 MR SHELDON: And there should always be this three-stage

18 process at the outset. If we could go back to 45I,

19 page 29, where it says "Referral to Social Services",

20 does it say there that the medical professional has to

21 go through that three-stage process: phone call,

22 writing, phone call to check, because I could not find

23 it if it does.

24 DR LACHMAN: Not in this section but I think I have it in

25 another section which I will just check for you.

127



1 MR SHELDON: Yes, thank you.

2 DR LACHMAN: There is one section on page 83 which is

3 guidelines for report writing which gives what they have

4 to put in the report. That might be your next

5 statement. And I think that I have it somewhere else,

6 but if it is not clear then I will put it back in --

7 MR SHELDON: If you are the editor and you cannot find it

8 then a busy paediatrician may struggle as well.

9 DR LACHMAN: I am going to the Central Middlesex one.

10 MR SHELDON: I am prompted from my left that page 47 may

11 help us. I think we find ourselves in the

12 Northwick Park section.

13 DR LACHMAN: On page 49 which is the Central Middlesex

14 section, it has the word "immediate", so --

15 MR SHELDON: Excellent.

16 DR LACHMAN: That is under "the examination must not be

17 performed", that is the bold one.

18 MR SHELDON: Yes.

19 DR LACHMAN: Then it does not -- then it goes on further

20 about the "record all telephone conversations. Copies

21 of letters should be sent to named and designated

22 doctors' secretaries".

23 MR SHELDON: Where are you looking, sorry?

24 DR LACHMAN: Page 50.

25 MR SHELDON: Yes.

128



1 DR LACHMAN: Then I agree I have not put the three points

2 in. Thank you for pointing that out, I will amend it.

3 That is the purpose of these documents, is that things

4 might be missed out. I am sure that -- I will correct

5 that when I get back because it is all on my terminal

6 and no-one else can correct it.

7 MR SHELDON: While we are with the process, the next stage

8 of the response would seem to be the production and use

9 of some new forms.

10 DR LACHMAN: Yes.

11 MR SHELDON: We have this in bundle 40 page 90.501, but

12 I think they are also in here, page 106, are they not?

13 You say that these new forms have been amended in line

14 with the Brent Part 8 recommendations?

15 DR LACHMAN: The forms you originally had are virtually the

16 same.

17 MR SHELDON: Yes, they are.

18 DR LACHMAN: We have been trying them out for the last six

19 months to see if they work and they gather the

20 information. The only real difference is that I have

21 included far more extensive body maps because

22 I considered the original body maps to be insufficient

23 and in not enough detail and I therefore wanted to give

24 doctors the opportunity to have good body maps they

25 could use in court if they need to which would be

129



1 acceptable and of a good quality.

2 MR SHELDON: Moving on a stage. The second paragraph of

3 your response in your statement indicates there should

4 also be a typed report or letter sent by the

5 paediatrician concerned to the social worker.

6 DR LACHMAN: That is correct.

7 MR SHELDON: And also to the primary care team, when there

8 is suspected child abuse.

9 DR LACHMAN: Yes, that is correct.

10 MR SHELDON: That is in addition to these forms we are

11 looking at now?

12 DR LACHMAN: These forms take the place of the hospital

13 record. They would be in the hospital folder but they

14 are a protocolised way of collecting information. They

15 act as an aide-memoire to the doctors to make sure they

16 ask the right questions, that they do not miss out any

17 information and they are particularly good when you do

18 an audit.

19 So they replace the usual blank form of hospital

20 notes that doctors traditionally like to use and give

21 them free rein and try to get them to ask the questions

22 we want them to ask and to have answered. So I think

23 that if we were to go and say to a child protection

24 meeting, we could take these forms and they would

25 provide all the information that we would regard in that

130



1 child.

2 MR SHELDON: I see. But in addition to those forms there

3 are these two letters to primary care and social worker.

4 DR LACHMAN: Yes. Basically the forms are the hospital

5 record. What you would want to generate from that is

6 a report that would go to Social Services.

7 MR SHELDON: Who would write those letters, is that the

8 consultant?

9 DR LACHMAN: That is the responsibility of the consultant.

10 Now for training purposes registrars might write the

11 letter but they would not be allowed to send the letter

12 without the consultant reading it and that is very

13 important because when they become consultants they need

14 to know how to write these letters.

15 MR SHELDON: Finally, within ten days of discharge the

16 paediatrician in charge of the care, who presumably will

17 be the consultant again, will phone up and find out what

18 follow-up, if appropriate, has been put in place. Is

19 that right?

20 DR LACHMAN: Yes. That is a new innovation which I have yet

21 to audit fully. It is what I see as good practice in

22 all referrals to whoever you refer to, that you have

23 feedback. And it is what I would hope is that the

24 feedback is both ways, that Social Services would feed

25 back as well as Health feeding back to Social Services.

131



1 But that is the ideal.

2 MR SHELDON: Yes. Then once the feedback has been received

3 and an indication has been given as to what the

4 follow-up is, then that should be recorded in the

5 clinical notes?

6 DR LACHMAN: Yes. In terms of clinical risk it is very

7 important that all contact with Social Services, good or

8 bad news, is recorded in the notes. Particularly for

9 when I am in a position where I review notes I would

10 like to know that the feedback has taken place. This

11 will take some training because it is an additional task

12 for doctors to do and we have to emphasise how important

13 it is for them to do it. So in a year's time hopefully

14 I will know the audit of how it has worked.

15 MR SHELDON: Perhaps we can just recap then as to the

16 procedure facing a doctor dealing with a case of what he

17 or she thinks might be child abuse.

18 Phone call to Social Services saying there is going

19 to be a referral coming down. Referral completed, and

20 sent in writing to Social Services. Phone call to

21 confirm that it has been received. A typed letter or

22 report to the social worker and also to the primary care

23 trust. Phone call within ten days of discharge saying

24 what follow up are you doing, and then recording that

25 follow up in the clinical notes. Is that right?

132



1 DR LACHMAN: That is correct but it may not be all in that

2 sequence because usually you have ongoing contact with

3 the Social Services, not for the ten days you may -- it

4 is not usual that you do not have any contact at all

5 with Social Services. So that is the minimum that

6 I would expect and what I am trying to do is say to

7 doctors this is what you should go through, you may not

8 do everything in that order but at the end of the ten

9 days you should know where you stand.

10 That is not the end of the case, because in most

11 cases of child protection and child abuse it is longer

12 than ten days that action has been taken.

13 MR SHELDON: But there are at least, in every case, I think

14 seven particular steps that they should take?

15 DR LACHMAN: Sure.

16 MR SHELDON: Far be it for me to tell you how to write your

17 guidelines but do you think it may be of assistance if

18 they are set out in one place accessibly?

19 DR LACHMAN: I could do that. Any suggestions -- the only

20 profession that has not provided anything is the legal

21 profession so it is quite useful to have them.

22 MR SHELDON: The next item that you deal with in your

23 statement is item 3, the question of interpreters, and

24 the recommendation was that the ACPC must establish

25 a policy on the use of interpreters for all agencies

133



1 involved in child protection, referrals and assessment.

2 Has the Brent ACPC done that for you yet?

3 DR LACHMAN: No. The policy is that you should have an

4 interpreter when the child or parents or carer cannot

5 speak English. Now we work in a borough, Brent, and in

6 Harrow, in which almost 50 per cent if not more of our

7 population come from ethnic minorities. In fact in our

8 area we have over 140 languages spoken, so child

9 protection or child abuse is just one of the many areas

10 that we have to have interpreters and it is good

11 practice at both hospitals that as soon as you have any

12 child, that is any child who could present at the

13 hospital whose home language is not English or it is not

14 English and they cannot speak adequate English, you

15 would have an interpreter. So within the guidelines

16 there are policies of how to do that. I do not think it

17 is ACPC's responsibility, it is the Trust's

18 responsibility to ensure that that happens.

19 MR SHELDON: And it is the responsibility that you have

20 discharged within these new guidelines, is that right?

21 DR LACHMAN: Yes. There is a section on interpreted

22 service, about page 50-something. It is page 63.

23 MR SHELDON: Yes, "hospital based interpreter service".

24 DR LACHMAN: That is correct. That is put into these

25 guidelines to remind people but it is a basic principle

134



1 of courtesy to people who cannot speak English that we

2 speak their language, particularly when we are trying to

3 get a medical history that may be difficult to

4 ascertain, so it is good practice in all areas of

5 paediatric care.

6 MR SHELDON: Have you been able to assess the extent to

7 which that system is working well?

8 DR LACHMAN: I can assess in my out-patient clinic in which

9 we have -- when a patient is referred by the general

10 practitioner, one of the questions we ask is, "Do you

11 speak English?" We ask the general practitioners to let

12 us know if the patient speaks English and the

13 interpreter is booked at the same time as the

14 appointment prior to the parent coming. So I have

15 currently many Afghani refugees in our area and Kurdish

16 refugees and I often have those interpreters there.

17 MR SHELDON: It may be just a problem that is incapable of

18 solution, but one thing that occurs to me looking at

19 these guidelines at page 63 is that depending on which

20 language is required, a minimum of 24-48 hours' notice

21 is needed to book your interpreter, yet as we have

22 established, your assessment has to be done immediately.

23 DR LACHMAN: The vast majority of languages spoken of an

24 interpreter is easily obtained in our area. It is

25 Ghujarati and Hindi and Afghani is more common, so it is

135



1 possible to get an interpreter. If you had a problem in

2 not getting an interpreter then you would not complete

3 your history and therefore you would not discharge

4 a child if the child is in hospital. It is not perfect

5 because of the situation. Most cases in child

6 protection occur at times you can get interpreters.

7 MR SHELDON: So the procedure would be that if, in doing

8 your initial immediate assessment, you find that you

9 cannot do it thoroughly because of a language

10 difficulty, then the child must not leave hospital until

11 that difficulty has been solved with the use of an

12 interpreter?

13 DR LACHMAN: That is correct. That would be under the

14 section that you would have to be satisfied that you had

15 all the history, and obviously you would not be.

16 24-48 hours is generally for languages that are not that

17 common in our area, but that is more the unusual case.

18 I suppose you have to be prepared for the unusual and in

19 that case you would not discharge the child if you were

20 not happy about the safety of the child.

21 MR SHELDON: Moving on to item 5, Dr Lachman. This one

22 concerns police protection and emergency protection

23 orders. To paraphrase, it effectively says that the

24 child must be seen by a social worker before the police

25 protection or the EPO is discharged. That was the

136



1 practice before, as I understand your statement.

2 DR LACHMAN: Yes.

3 MR SHELDON: So the fact that in Victoria's case the police

4 protection was stopped before she was seen by a social

5 worker was a breach of the guidelines that were in place

6 at the time, is that right?

7 DR LACHMAN: I would agree. I think that -- if one has

8 a police protection order on a child one would have to

9 be totally satisfied that the reasons to lift it have

10 been removed. So one would have to go through

11 procedures and I hope the new guidelines emphasise that;

12 to ensure that we have an assessment by a social worker.

13 And I think that that will take place if it does happen.

14 MR SHELDON: It is included as you say in the guidelines and

15 we will come to the bit in a minute. It is also

16 included in your statement as one of the things that the

17 hospital should bear a responsibility for. But what

18 role does the hospital have in ensuring that there is

19 adequate social work input before the police take the

20 action to counsel police protection? Is that your job?

21 DR LACHMAN: It is not really my job, it is my

22 responsibility in shared care. I think that if the

23 child is in my care in the hospital I am responsible for

24 the safety of the child and cannot say it is

25 Social Services. In essence I do not perform the duty

137



1 but I must be satisfied that the child is safe.

2 Now there are times in which I might disagree with

3 Social Services or Social Services disagree with my

4 assessment but I have always attempted to have a good

5 working relationship with the social workers I work with

6 to try and get to know them at Northwick Park. It is

7 a little easier because the team is there and I know the

8 same social workers all the time. But with the Brent

9 social workers, one has to go that little step further.

10 If Social Services are happy that the child should

11 go home and that means they have done their full

12 assessment, then I would agree with them. But if

13 I really disagreed I would want to take it further and

14 I would discuss with the senior social worker.

15 MR SHELDON: If you had been in the position of consultant

16 looking after Victoria back in July 1999 and you had

17 heard or learned from the notes that police protection

18 had been discharged prior to a visit by a social worker

19 or a policeman, what would you have done? You would

20 have been on the phone to the police, would you?

21 DR LACHMAN: No. This is the hindsight and I know what

22 happened.

23 MR SHELDON: What should you have done according to your new

24 procedures?

25 DR LACHMAN: According to the procedures, once there was

138



1 a police protection order a full assessment would have

2 had to have taken place before the child went home and

3 that is quite clear; that the child could not be

4 discharged from hospital unless a full assessment had

5 taken place and the Social Services were satisfied that

6 the child had a place of safety to go to, which in that

7 case would be the parent's home in most cases.

8 MR SHELDON: So you would call Social Services and say this

9 child is not going anywhere until one of you get down

10 here and look at her?

11 DR LACHMAN: I routinely do that on my ward.

12 MR SHELDON: Do you?

13 DR LACHMAN: Yes.

14 MR SHELDON: Do you have difficulty, do you ever experience

15 difficulty in relation to CMH -- and I am not sure the

16 extent to which you are going to be able to answer this

17 so say if you cannot -- in relation to CMH in getting

18 social workers to come down to the hospital and look at

19 children?

20 DR LACHMAN: It is difficult for me to comment on that

21 because I do not work there. In my experience I do not,

22 but I do have children from Brent who come to

23 Northwick Park. After all Northwick Park is in north

24 Brent and we have a large population of children who

25 come to our hospital. We have recently, in fact in the

139



1 last two years things have improved dramatically I must

2 say, since Ms Konisberg and I started meeting we have

3 a far better response than we had before.

4 If you say what was it like before then? Well,

5 generally when a doctor has a patient on the ward, the

6 urgency is far greater for the doctor than for the

7 social worker who has not seen the child. So our

8 expectations are always greater and we want immediate

9 assessment but need to accept that the social workers

10 have others in the community they are assessing at the

11 same time.

12 My aim is that when I want a referral, and this

13 happens at Northwick Park so I presume it happens at

14 Brent, when we phone the duty social workers they are

15 usually there the same day.

16 MR SHELDON: I see. You say that the position that you have

17 described, namely children do not go home if they have

18 been subject to an EPO or police protection until they

19 have been seen, is reinforced in the new guidelines.

20 You could not direct us to the bit, could you?

21 DR LACHMAN: I will. It is soon after the interpreter

22 service or before.

23 MR SHELDON: We have "parents attempting to remove a child

24 subject to a court order" at page 64.

25 DR LACHMAN: That is one area and the other area is in -- if

140



1 I go back to -- it will be under the --

2 THE CHAIRMAN: I think it is 98.

3 DR LACHMAN: Thank you. Just to say, the guidelines are in

4 sections so it is far easier to negotiate in the ones

5 that have been issued. They are not all together. So

6 Central Middlesex sections I have read and find it much

7 quicker ...

8 MR SHELDON: Does page 98 help us?

9 DR LACHMAN: Page 98 is the extract from the ACPC guidelines

10 which deal with it and that does help us because that

11 does give us the background that we applied. I have put

12 in the most relevant part of the ACPC guidelines in the

13 guidelines, so they could have referred to those.

14 MR SHELDON: One might suggest, and as I say again it is

15 a matter for you, one might suggest in order for it to

16 be entirely clear to the medical practitioner concerned

17 what they should do and what may be a difficult

18 situation for them, namely what to do about this child

19 who they do not think should go home when everyone else

20 is saying they should, it should be some way expressly

21 and clearly set out.

22 DR LACHMAN: Yes. I can add that again any suggestions are

23 helpful.

24 MR SHELDON: Turning back to your statement, I do not think

25 I need to trouble you with item 6 on page 4, "The ACPC

141



1 must always be formally informed ... of the death or

2 serious injury to a child ..." other than to ask you was

3 that a problem in the past?

4 DR LACHMAN: No, it is not a problem and in fact I am

5 informed of the death of any child for any reason and

6 I undertake an investigation if needed or I ask the

7 circumstances, even in expected deaths, to make sure

8 that all areas have been covered. So this is not

9 a problem.

10 MR SHELDON: Perhaps we can deal with items 23 and 24

11 together. It would seem to me -- and you can correct me

12 if I am wrong -- that the composite picture given by

13 those two recommendations and your response is this.

14 The hospital education service should check paediatric

15 ward admission information twice a day. When they do so

16 they should be on the lookout for children who are not

17 registered with a school or who have some sort of other

18 educational difficulty, and if they find that a child is

19 not attending school then that child should be referred

20 to the Education Welfare Service. Is that the position?

21 DR LACHMAN: That is correct.

22 MR SHELDON: You say that a procedure has now been agreed

23 with the local Education Authority, whereby children who

24 are so identified are brought to the attention of the

25 Education social worker?

142



1 DR LACHMAN: Yes, that is on page 60.

2 MR SHELDON: Where it says at paragraph 13.3 that the

3 Education Welfare Service is to be informed and the

4 relevant numbers are over the page?

5 DR LACHMAN: That is correct.

6 MR SHELDON: Which all seems clear enough. Is that working?

7 DR LACHMAN: That is working. I work very closely with the

8 Education Team at Northwick Park. The advantage is that

9 Brent LEA provides the school service both for Central

10 Middlesex and for Northwick Park and they wrote these

11 guidelines for me and it is working.

12 The teacher at both sites attend psychosocial

13 meetings, is in regular contact with the doctors and

14 would pick up referrals on a daily basis.

15 The issue that we would need to address of course is

16 what happens in school holidays because that is a good

17 proportion of the year and one needs to make sure that

18 you close that door as well when you do not have

19 a school teacher and you do not have an education social

20 worker in the school holiday.

21 MR SHELDON: Do you not?

22 DR LACHMAN: Well, education social workers also have

23 holidays.

24 MR SHELDON: They are the same holidays as teachers.

25 DR LACHMAN: As teachers. I think that will be something

143



1 needed to be addressed by the Inquiry, probably. My

2 suggestion is if we had any concern about a child not

3 attending school we would speak to Social Services in

4 general because there is an area of neglect of

5 withholding education, but we also should keep and

6 discuss the education with social workers when we return

7 from holidays. But that is the only area that I see

8 a problem throughout the country, because of school

9 holidays.

10 MR SHELDON: It is a problem reflected as well possibly in

11 who to refer children to for ongoing follow-up, for

12 example if they are of school age and they come in in

13 the school holiday.

14 DR LACHMAN: I think that one has to be clear what the

15 educational social workers' role are --

16 MR SHELDON: I am thinking of school nurses in that example.

17 DR LACHMAN: In terms of school nurses as well they take

18 school holidays as well, so there is that gap and it is

19 something that I think it is easy to cover if one has

20 a fallback which is Social Services and our community

21 nurses. So there is a way of getting around the issue,

22 and health visitors, particularly in the under-5s, but

23 in the over-5s. Health visitors have a lot of knowledge

24 about the families in the area and they could be

25 utilised to do this work as well.

144



1 MR SHELDON: You say it is something that would be helpful

2 if the Inquiry addressed its mind to. Have you looked

3 at suggestions that this problem could be dealt with?

4 DR LACHMAN: Yes. Locally what we could do is if we have

5 any concerns about a child not attending school we

6 really would mark that up and during the school holidays

7 they do not attend the school anyway so we would contact

8 the Social Services team and discuss it with them and

9 see whether or not it was a reason.

10 Children do not attend for many reasons and in fact

11 one of my current interests is trying to rehabilitate

12 children who have not attended school for years and we

13 do that with our school education of social workers. It

14 is a particularly difficult area. One has to find out

15 what the reason is and in a small minority there may

16 well be a child protection issue. It may be bigger than

17 a small minority but it is not always the case.

18 The fallback I have is I have social workers I can

19 phone up and say I have a concern, and call in the

20 parents and discuss it with them. Most parents are

21 concerned when their children do not attend school.

22 MR SHELDON: Have you looked -- I wonder, and this again

23 just for our assistance more than anything else -- have

24 you looked at the possibility of organising some holiday

25 rota cover of educational social workers so there is

145



1 always somebody manning the phone?

2 DR LACHMAN: Unfortunately that is not my remit because I do

3 not work for the LEA, but what I would -- one of the

4 ways around it is for example in Harrow I chair the

5 strategy group that has members of the LEA on it and

6 I am meeting next week in fact or two weeks' time and

7 I will raise this issue with the head of the LEA who

8 sits on the committee, and say, "Could we come up with

9 some suggestions? I would imagine that they do have

10 some fallback they could provide.

11 MR SHELDON: Yes. It might be helpful if you let us know

12 the outcome of that conversation.

13 DR LACHMAN: I will do that.

14 MR SHELDON: Turning now to the issue of the assessment

15 itself when a child with suspected abuse comes in. Can

16 we just establish at the outset what good practice

17 should look like in cases of suspected child abuse? We

18 have already said the assessment should happen

19 immediately, as soon as possible. And it should be

20 done, should it, by a consultant or a specialist

21 registrar?

22 DR LACHMAN: I wish to just clarify the immediate.

23 I believe that when one is assessing children in terms

24 of child abuse, one must be careful not to abuse the

25 child in the process of the assessment, particularly in

146



1 medical examinations. Therefore, for example, if

2 a child comes in at 3 in the morning, one would need to

3 assess whether the child is safe, admit the child and

4 have the child assessed the following morning,

5 particularly if you want a forensic examination.

6 For example, we had my worst case of child abuse,

7 the worst I have ever seen was a child and mother who

8 both were raped on Boxing Day just after the end of

9 Christmas Day, and I was on-call and I was asked to come

10 in. My process was not to do the assessment but was to

11 assess the safety of the child and do the examination at

12 a more humane time for the child and the mother, when

13 they were more comfortable.

14 So the immediate is: as long as you have assessed

15 the safety of the child, you may wish to have the full

16 examination a few hours later but it is still an

17 immediate assessment in terms of safety. The place is

18 at the most appropriate place, which is not in a busy

19 A&E but in a quiet area where the child will feel

20 comfortable, and the person is the most experienced

21 person.

22 Now at the hospital we have said that no senior

23 house officer, because they are very early in their

24 training --

25 MR SHELDON: When you say the hospital do you mean

147



1 Northwick Park or both?

2 DR LACHMAN: Both, the Trust. That a senior house officer

3 can attend for training purposes but not to carry out

4 the examination. The registrar that is now called

5 specialist registrars are training for four years, so

6 you have a specialist registrar in year 1 who has had

7 limited experience, and a year 5 is almost a consultant.

8 So you would know who would be able to be on the

9 rota for assessing. But a consultant should be in

10 attendance at all times. In fact, at Northwick Park we

11 were slightly more rigorous than we were at Central

12 Middlesex and now we are at the same standards at both

13 sites, that the consultant is involved on all occasions.

14 MR SHELDON: That is reflected, is it, at page 31 of our

15 bundle 45I, where we have the subject heading

16 "Paediatric Assessments of Children who are Suspected to

17 have Suffered Abuse"?

18 DR LACHMAN: That is correct.

19 MR SHELDON: Just one point arising out of that. If you

20 could look at page 5 of your statement, item 25 of the

21 Part 8 recommendations. You will see that one of the

22 recommendations was:

23 "Documentation of lesions, skin conditions, injuries

24 et cetera seen in children with suspected abuse who are

25 examined at CMH should include good quality photographs

148



1 taken at the time of the examination."

2 Now, there is no reference to the taking of

3 photographs in those sort of cases in the page of

4 guidelines which deals with it, page 31. Is it dealt

5 with elsewhere?

6 DR LACHMAN: It is dealt with in the procedures for the

7 examination, I think, that you should take a photograph.

8 My practice usually is to ask myself and also ask the

9 social worker or the police officer, are we going to go

10 to court? What is the use of the photographs?

11 Now there are a number of reasons for the

12 photographs. If one wants them for medical reasons one

13 needs to have a police photographer take the photographs

14 and I would try to have that police photographer there

15 before I undertook the examination. The digital

16 photograph is to allow us to be able to assess what the

17 injury was at the time. It is now good practice for us

18 to keep a record of that.

19 MR SHELDON: Yes. Is that in here somewhere?

20 DR LACHMAN: Yes, I will find it for you.

21 MR SHELDON: Thank you. I am sure we will have a short

22 break some time this afternoon. If it would be more

23 convenient to find it then that will be fine, unless you

24 can go to it quite quickly.

25 DR LACHMAN: I will look during the break.

149



1 MR SHELDON: When you are doing so, it may be helpful to

2 consider the question of whether or not the guidelines

3 deal with the issue of not just when photographs should

4 be taken, or the situations in which they are

5 appropriate, but also how they should be dealt with

6 after they have been taken. For example, how quickly

7 after they have been taken should they be produced?

8 So it may be that you are unaware of this because it

9 does not deal with your hospital, but we have heard

10 evidence that photographs were taken of Victoria at the

11 North Middlesex Hospital which never saw the light of

12 day until after she was dead. There are numerous

13 explanations for that which I do not need to trouble you

14 with but it may be a consideration that is useful, to

15 consider how the photographs are dealt with.

16 DR LACHMAN: Mr Sheldon you have found another area that

17 I need to write a paragraph on, on the processing of

18 photographs. I think that it is something I had not

19 thought of. As I say, you take the photograph but if it

20 is digital then we have a problem because you have to

21 actually download it, and so I will write a section on

22 that particularly. I think that is a deficiency here.

23 MR SHELDON: Turning now if we can to the role -- we have

24 touched on it in respect of other issues but if we can

25 return to it -- the role of the consultant in all of

150



1 this. Firstly, their presence which is probably the

2 most important part of the whole set up. You say at

3 paragraph 6 of your witness statement that there is

4 a need for a discussion about child abuse and child

5 protection cases at an appropriately senior level.

6 DR LACHMAN: That is correct.

7 MR SHELDON: If we turn to volume 45I, page 11, there is

8 a more detailed discussion of that issue, namely the

9 availability of a consultant in order to deal with the

10 question of child abuse and to be on hand to discuss it

11 as necessary.

12 DR LACHMAN: That is correct.

13 MR SHELDON: You say under heading 2:

14 "The Part 8 review in the Climbie case noted that

15 need to ensure adequate consultant cover at CMH."

16 Before we go on to consider in detail what follows,

17 I wonder if you could just translate some of the jargon

18 for us. In relation to this matter, what constitutes

19 a session?

20 DR LACHMAN: In terms of the NHS consultant contract,

21 a session is a morning or an afternoon, three and a half

22 hours to be exact, although most consultants work longer

23 than the three and a half hours that the session

24 consists of. Most consultants, most paediatricians are

25 employed for 11 sessions, and that is a full-time post.