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Archived Transcript for 23 January 2002: Pages
151 to 221
151
1 MR SHELDON: Which translates theoretically to five and
2 a half days' work?
3 DR LACHMAN: The half a day you are on-call. So it is
4 really ten sessions during the working week and the
5 weekends and after hours is the other half.
6 MR SHELDON: What does "presently there are 2.6 WTE = 29
7 sessions" mean?
8 DR LACHMAN: The model at Central Middlesex is different
9 from Northwick Park in that most of the consultants have
10 a joint appointment with Parkside, soon to be Brent CPT.
11 That means that for example the community
12 paediatricians, ones who have an interest in community
13 child health, will do the majority of their sessions in
14 the community and part of their sessions at Central
15 Middlesex, and the hospital paediatricians the reverse.
16 MR SHELDON: So when we see towards the bottom of that
17 paragraph, about three lines up:
18 "In addition the named doctor for child protection
19 is employed for six sessions only," that effectively
20 means Dr Schwartz was employed at the CMH for slightly
21 over half the week?
22 DR LACHMAN: Yes. The six sessions means that she is more
23 employed by Central Middlesex than by St Mary's.
24 MR SHELDON: Only just.
25 DR LACHMAN: Only just and the whole issue is how can you
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1 cover five days a week if you are only employed for half
2 a day?
3 MR SHELDON: So there are effectively as I understand it two
4 issues being raised here. Firstly the named doctor for
5 child protection is not at the CMH often enough, and
6 secondly, looking at the picture as a whole, there is
7 not enough consultant presence there because we only
8 have 29 sessions?
9 DR LACHMAN: Let me point out the named doctor is
10 responsible to see that the standards for child
11 protection are kept in that Trust, undertake audit and
12 training. But they do not see every child. That would
13 be too much of a burden for one person. All consultant
14 paediatricians in the hospital or Community Trust are
15 required to know about child abuse and so they all have
16 a joint responsibility. So even if the named doctor was
17 not present it did not mean there was no provision for
18 child abuse.
19 MR SHELDON: Which is why you made the second point
20 I indicated, that you need more consultant cover as
21 a whole?
22 DR LACHMAN: That is correct.
23 MR SHELDON: Below the paragraph we have just been looking
24 at, your proposals for a solution are set out, which are
25 effectively that Dr Schwartz go full-time to the Central
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1 Middlesex. Is that right?
2 DR LACHMAN: That is correct.
3 MR SHELDON: An extra five sessions, giving her 11?
4 DR LACHMAN: That is correct.
5 MR SHELDON: That you get an extra three consultant sessions
6 from elsewhere?
7 DR LACHMAN: That is correct.
8 MR SHELDON: Giving you in effect an extra eight sessions in
9 total, up to 37. So effectively what that means is you
10 are getting an extra two-thirds of a consultant,
11 effectively?
12 DR LACHMAN: It depends how you --
13 MR SHELDON: Or eight sessions?
14 DR LACHMAN: It is two-thirds of a consultant, that is what
15 you are getting, but it depends how we employ the
16 consultants to ensure we have full-time cover.
17 MR SHELDON: That would mean in practice that you could
18 achieve twice daily consultant loads on ward rounds?
19 DR LACHMAN: Yes.
20 MR SHELDON: Better training, more -- a greater level of
21 presence of the named doctor, albeit as you say they
22 cannot be there all the time, and that they will not be
23 able to deal with every single case, and more
24 opportunity to discuss difficult cases with your peers?
25 DR LACHMAN: That is correct.
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1 MR SHELDON: Was this proposal taken up?
2 DR LACHMAN: The proposal was submitted to the Trust Board
3 in June. It was accepted. I spent July and August
4 working out the implementation. Dr Schwartz resigned
5 from St Mary's in September and took up the position
6 three months later after her notice had been served and
7 it is now in operation.
8 MR SHELDON: So you have been able to achieve those
9 objectives that we just listed?
10 DR LACHMAN: Yes, with the support of the Trust Board to
11 take on the extra cost.
12 MR SHELDON: Can you give us some idea of the impact that
13 that has made on the level of service you are able to
14 provide at CMH?
15 DR LACHMAN: One has to look at the NHS in general to see
16 why I need to have a consultant there all the time.
17 I am sure that most consultants will recall that when
18 they were registrars consultants were there not all the
19 time because there were not that many, but nowadays the
20 registrars are more junior, they have less experience,
21 and particularly in more complex cases you need
22 a consultant present every day, and my minimum
23 requirement on the ward is that a consultant has a ward
24 round in the morning and a ward round in the afternoon
25 and that there is proper handover to the night time
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1 staff.
2 MR SHELDON: How difficult was it to get that proposal
3 accepted, those eight extra sessions in total?
4 DR LACHMAN: It was not that difficult. I am quite
5 fortunate, I sit on the Trust Board and I have been on
6 the Trust Board for the last three years, so the Trust
7 Board hears about the needs of children and Children's
8 Services continually and they have been very receptive
9 to this.
10 This is, I might say, done against a continuing
11 financial difficulty that the Trust or all Trusts find
12 themselves in, that we have too much expenditure for the
13 service we provide or too little income for the services
14 we provide. So it must have been difficult for the
15 Finance Director but the Trust Board had no difficulty
16 in approving this.
17 MR SHELDON: Because those of us that listened to
18 Dr Schwartz's evidence may have been struck by what
19 a difficult position she found herself in, attempting to
20 manage two sites, and may have formed the view that this
21 was just an impossible situation to put a consultant in.
22 Given that it could be solved in this manner, the
23 question that obviously arises is: why was it not fixed
24 much earlier?
25 DR LACHMAN: The sad thing about it is an adverse event
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1 usually facilitates getting decisions made quickly. If
2 one has to look at the allocation of funding within the
3 NHS, there are many different areas of demand and
4 priorities.
5 Children within society are not a priority,
6 generally, and you have to have advocates fighting for
7 them. One has to take the opportunity to gain extra
8 resources where possible. In this case I think that it
9 would have been inevitable if one put the new standards
10 in to Central Middlesex that Dr Schwartz's sessions
11 would have had to change, whatever happened, even if
12 this tragedy did not occur, because of the change in
13 standards of care that we are expected to adhere to.
14 MR SHELDON: Accepting the difficulty in getting more
15 resources absent the extra impetus that these events may
16 have created, was consideration given as far as you were
17 aware to the fact that if you were going to have a named
18 consultant at CMH, much better to pick one of the ones
19 that was there all the time rather than one of the ones
20 that was only there half of the time?
21 DR LACHMAN: The problem is that at Central Middlesex there
22 is a seven session and an eight session at the maximum,
23 so could have chosen one of them, but the named doctor
24 has to be an expert in child protection and you cannot
25 choose someone who is interested in a different area or
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1 whose experience is in a different area.
2 I agree with you that it would have been more
3 prudent to have the named doctor, someone who is there
4 most of the time.
5 MR SHELDON: Staying on the consultant responsibility theme
6 but turning now to the question of discharge. You have
7 outlined in your statement new protocols in relation to
8 discharge. The principal one as I understand it is that
9 children about whom there are child protection concerns
10 will not be discharged from the CMH until there has been
11 a consultant review of the case. Is that right?
12 DR LACHMAN: That is correct.
13 MR SHELDON: Are you able to do that now because you have
14 a greater consultant presence at the hospital? Was that
15 something that you could have done before?
16 DR LACHMAN: Theoretically you could have done it before,
17 but it was the story of having a consultant in two
18 places at one time. Now we have a consultant on the
19 ward every morning and every afternoon. I must just
20 point out the vast majority of children in child
21 protection cases do not get admitted to hospital, they
22 are seen as outpatients or in the community. So it is
23 actually the minority we are talking about. What we
24 have to ensure is that those in the community get the
25 same standards of care as those in hospital.
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1 MR SHELDON: But in relation to those who are in hospital,
2 the position now is the consultant has to okay the
3 discharge before the child is discharged.
4 DR LACHMAN: That is correct.
5 MR SHELDON: That is something one could think could have
6 been done before. Okay, the child may spend more time
7 as an in-patient than one could have done, but there was
8 nothing stopping you having that requirement in place.
9 DR LACHMAN: That requirement has been place since the
10 beginning of last year. I am sure that there was
11 unwritten requirement before then but when we reviewed
12 the case of Victoria and I read the management review,
13 I saw straight away that one of the big problems was the
14 failure to have a consultant the next morning to review
15 the case and I asked with the consultants to provide
16 that service even though we did not have the extra
17 sessions at that stage, and they have been doing so
18 since the beginning of 2000.
19 MR SHELDON: The way in which you put that in your statement
20 is that children for whom there have been concerns about
21 child abuse will now only be discharged following review
22 by a consultant paediatrician. When you say "children
23 about whom there have been concerns", does that mean
24 even those children where the preliminary diagnosis of
25 non-accidental injury has subsequently been superseded?
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1 DR LACHMAN: I think that once you think of the possibility
2 of child abuse in any form, a child needs to be seen by
3 a consultant.
4 MR SHELDON: You understand why I ask the question, because
5 I am wondering whether the new policy would have helped
6 in Victoria's case, given that there had been NAI
7 concerns but there had subsequently been a different
8 diagnosis. Is it the case that the consultant must okay
9 the discharge even if there is a later different
10 diagnosis?
11 DR LACHMAN: I think that in this case, in Victoria's case,
12 with these guidelines they would not have been
13 discharged the next day.
14 MR SHELDON: Turning to what that consultant review of the
15 discharge means in practice. Does that mean the
16 consultant actually going to the foot of the bed and
17 looking at the child and assessing the case, or does it
18 mean a junior doctor collaring a busy consultant in the
19 corridor with a note saying can this one go home?
20 DR LACHMAN: No, it is a formal ward round. So what would
21 happen, there are different models of ward round. The
22 ones that we have is we discuss all the patients before
23 we go on the ward round and assess which ones
24 a consultant needs to see.
25 So for example a child who has an uncomplicated
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1 febrile convulsion, no problems, he is recovering, he is
2 running around the ward, the nurses on the ward round
3 say there is no problem, the consultant does not have to
4 examine that child necessarily, but a child with child
5 protection issues the consultant has to see no matter
6 what.
7 MR SHELDON: The second half of the new system is not just
8 that the consultant has to see the child in those
9 situations but a social worker also has to do so, is
10 that right?
11 DR LACHMAN: That is correct.
12 MR SHELDON: Was that a requirement that was imposed
13 unilaterally by you on Brent Social Services in this
14 case or was that something they bought into?
15 DR LACHMAN: It came out of the ACPC, Part 8, that social
16 workers should be involved. In my discussions with
17 Ms Konisberg we have never had dispute about this.
18 MR SHELDON: You indicated earlier on in relation to some of
19 the questions I was asking you about police protection
20 that your experience is as far as Brent social workers
21 answering your calls, they get down there within the
22 day.
23 DR LACHMAN: Yes.
24 MR SHELDON: So would that apply equally to calls in
25 relation to the discharge of a child about whom there
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1 have been concerns?
2 DR LACHMAN: I must admit in reality there are occasions in
3 which there are delays, but the recommendation is quite
4 clear to all doctors and nurses. I must say that
5 usually the nurses will watch the doctors even more,
6 that a child will not go home unless we are sure the
7 child is going to a place of safety and that is the
8 parents' home. We will not discharge the child.
9 MR SHELDON: Again, this was a point in relation to the
10 guidelines we raised with police protection. Is there
11 somewhere in these guidelines that point clearly
12 expressed to the consultant in charge: "you must not let
13 a child go home until he or she has been seen by
14 a social worker"?
15 DR LACHMAN: Yes, I will find it for you. I will get my
16 copy out and I can negotiate it much easier than the one
17 that is not marked.
18 MR SHELDON: Lastly on this topic the question of the second
19 opinion. Again I take it this is something that is if
20 not entirely made possible but certainly facilitated by
21 the greater consultant presence that your proposals have
22 brought about, is that right?
23 DR LACHMAN: That is correct.
24 MR SHELDON: But it is clearly something that consultants
25 again, like the review of discharge, could have done
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1 before if they wanted to, albeit they may have had to
2 have the child in bed longer than would otherwise have
3 been the case?
4 DR LACHMAN: That is correct.
5 MR SHELDON: You say that this facility is available if
6 there is doubt about the diagnosis of child abuse.
7 DR LACHMAN: Yes. I think that child abuse is one of the
8 most complex areas in paediatrics and child health. It
9 is always grey. It is very rare that I see one that is
10 clear and one that is not clear. There are always
11 different opinions, different advice, some are more sure
12 than others. I wish it was like other medical diagnoses
13 but it is not a medical diagnosis in the first place, it
14 is signs and symptoms that contribute to making a social
15 diagnosis.
16 So my view on child protection is one must always
17 have an open mind. If the issue is raised and there is
18 a disagreement between nurses and doctors, between
19 doctors and doctors, doctors and social workers,
20 a second or third opinion does no-one any harm. In fact
21 it is a benefit. The problem of course is if the second
22 opinion gets it wrong.
23 But I like to think that in the complex cases, and
24 luckily the majority of the time you know what is going
25 on, but in the more complex ones in which you have
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1 a junior doctor saying something to the senior doctor or
2 the nurses saying something to the doctors or the social
3 workers, you ask for a second opinion.
4 MR SHELDON: I wonder in light of that answer whether we can
5 in fact take it further and say not just that a second
6 opinion or a third opinion never does anyone any harm,
7 but that given that you can never really be sure about
8 a diagnosis of child abuse, you should always get
9 a second opinion?
10 DR LACHMAN: No. If you have a child who has been abused,
11 in the vast majority of cases a careful history will
12 give you the diagnosis of abuse and that your clinical
13 findings are supplementary to the actual findings.
14 I really believe in child abuse that it must not be
15 medicalised into a disease. It is really listen to the
16 child, listen to the circumstances, get two different
17 views. I often find it useful for the social worker or
18 the police officer to give me their information because
19 they ask different questions than I ask. They get
20 a different perspective, they get a different answer
21 from the same question because of the way it is asked.
22 So sharing information is very important from the
23 history. But if there is any dispute then I think you
24 do need a second opinion and particularly in the more
25 complex cases of child abuse, such as fictitious illness
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1 in which the parents continually get second opinions.
2 Second opinions can be more harmful because they can
3 confirm an illness that is not there. So one has to be
4 very careful that your second opinion is a valuable one.
5 MR SHELDON: Item 30 of the Part 8's recommendations, which
6 we find dealt with in your statement at page 7, touches
7 on this question and deals with the matter of when more
8 than one medical opinion is given in the course of
9 a child protection investigation, the doctors involved
10 must discuss their views to establish what is agreed and
11 what is not. From a lay person, that sounds like basic
12 common sense.
13 DR LACHMAN: That is correct.
14 MR SHELDON: That is something I should imagine you would
15 expect would be done in any event, is that right?
16 DR LACHMAN: That is correct.
17 MR SHELDON: You set out the position relating to the
18 question of second opinions as far as Northwick Park
19 Hospital is concerned and your response to that item
20 which, as I understand it, consists of three elements.
21 Firstly, a daily consultant-led ward round allows
22 for this sort of discussion. Secondly, there is a child
23 protection team meeting at which these sort of cases can
24 be discussed. Thirdly, there is a peer review group
25 that has been established at the hospital which can
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1 provide support.
2 You then go on to say that we will be able in view
3 of the new arrangements to provide this service as CMH.
4 By this service, do you mean all three of those things
5 or just the ward round?
6 DR LACHMAN: Slightly differently. There would be a daily
7 ward round at Northwick Park, the difference between
8 Northwick Park and Central Middlesex, and that we are an
9 integrated service and that the community child health
10 service is managed from Northwick Park, so I have the
11 community paediatricians in the same area.
12 So there is a critical mass of paediatricians
13 available each day and that we can have this two-weekly
14 meeting. The peer group, peer review group will be the
15 two named doctors and myself and possibly the designated
16 doctors, so the experienced doctors will look at the
17 very complex cases of child abuse and those are the ones
18 that cause most difficulty.
19 Now that is almost an audit review allowing people
20 to bring their cases where they are not sure and these
21 are more chronic situations rather than acute situations
22 where you have someone presenting.
23 Within the Parkside Trust they do have review of
24 their cases with the paediatricians, who see the
25 majority of child protection issues in Brent.
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1 MR SHELDON: Let me clarify one element to make sure I have
2 understood it. As far as the peer review group is
3 concerned, that would be you plus Dr Schwartz plus the
4 named doctor at Northwick Park?
5 DR LACHMAN: Yes.
6 MR SHELDON: Meeting how often?
7 DR LACHMAN: I would say as often as needed. My intention
8 is it is something that I have given some thought;
9 I would like to have a monthly meeting with the named
10 doctors anyway, in which case we would look at all the
11 complex cases. But of course if you have a monthly
12 meeting and you have a complex case on day one of the
13 month, you have just missed it. You do not want to wait
14 30 days until the next one, so it must be as needed.
15 The idea is that if there is any case that requires
16 discussion, I have an open door.
17 MR SHELDON: Is that a door that is being used?
18 DR LACHMAN: At Northwick Park, definitely. At Central
19 Middlesex, fortunately they have not had any complex
20 cases recently so I have not had to offer my skills.
21 MR SHELDON: Focusing just on the ward round as a mechanism
22 for this review of opinions and exchange of views.
23 Could you just explain the mechanism by which this
24 consultant-led ward round allows for this discussion,
25 because what is not clear to me is the extent to which
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1 it is not dependent upon the person with the other view
2 being on the ward at the same time.
3 DR LACHMAN: The expectation I have, and I have not written
4 it out exactly how they should do it, is that
5 consultants should talk to each other if there is
6 a disagreement. A ward round would consist of the
7 nursing staff providing information, the junior medical
8 staff or the middle grades providing information, the
9 parent providing information, the consultant listening
10 or providing information if the consultant was involved
11 from the start. This would allow us to have an exchange
12 of opinion.
13 The philosophy I have with nurses is that they are
14 equal partners in the ward round, and often their
15 information is more important than the junior doctors'
16 because they observe the child over the period of
17 admission. So I would expect a healthy review. Now if
18 the consultant on the next day disagrees with the
19 admitting consultant, it is expected that they would
20 discuss the case.
21 We have two systems: again, Northwick Park the
22 consultant on the ward is on for a week or two at a time
23 so you have the same consultant from Monday to Friday,
24 so you have consistency. At Central Middlesex, because
25 we do not have the same number of consultants and
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1 because they work community and hospital, they are
2 different consultants every day but working to
3 consistent procedure and they are expected to discuss
4 things with each other.
5 MR SHELDON: Thank you. Sir, I am just about to move on to
6 another topic. That might be a convenient moment, if it
7 is for you.
8 THE CHAIRMAN: It certainly is. Thank you very much indeed,
9 Mr Sheldon.
10 Dr Lachman you are not allowed to discuss your
11 evidence during the course of this break with anyone.
12 Ladies and gentlemen we will break until 3.10.
13 MR SHELDON: I was just going to remind Dr Lachman, I am
14 sure he remembers but it was the photos and the question
15 of not letting the children go home until the social
16 worker has been.
17 THE CHAIRMAN: That would be very very helpful. Just after
18 3.10.
19 (3.02 pm)
20 (A short break)
21 (3.12 pm)
22 MR SHELDON: Dr Lachman, you were kind enough to agree to
23 look during the short break for first of all the section
24 of the guidelines which deals with the requirement to
25 take photos of injuries when there are suspected child
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1 abuse concerns. Did you have any luck?
2 DR LACHMAN: Not much luck and I think that is something
3 that will go in tomorrow.
4 MR SHELDON: The second thing you were going to look for was
5 a clear instruction to consultants that they should not
6 let children go home if (a) no social worker had visited
7 following a police protection or EPO or (b) where there
8 had been child protection concerns and no social worker
9 had visited.
10 DR LACHMAN: I am in a section on parent's attempt to remove
11 a child as subject of a court order. It is implied but
12 not said explicitly. So I will add an explicit
13 statement that they should consult social workers.
14 MR SHELDON: It is not quite consult social workers, it is
15 do not let them go home until the social worker has
16 been --
17 DR LACHMAN: It is explicit that any child with child
18 protection concerns should be seen by a social worker
19 before they go home whether they have a court order or
20 not and I think if they have a court order I think it
21 makes it even more important they do. But I agree
22 I will make a clearer addendum with lessons to learn
23 from the Inquiry or from today.
24 Just to say on the photographs, I will be drafting
25 something on that because it is quite important for us
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1 for medicolegal point of view to ascertain how we obtain
2 these photographs, and how they are documented.
3 MR SHELDON: Thank you very much. Returning to your
4 statement, we are slightly out of order with the items.
5 If I could take you back to item 27, page 6. This is
6 the item that deals with the need for a revised standard
7 discharge plan and pro-forma including various matters
8 that are listed there.
9 Now as I understand it, the short answer to that is
10 you have done exactly what was recommended, and I think
11 it is at page 129. Is that right?
12 DR LACHMAN: That is correct.
13 MR SHELDON: Just looking at that pro-forma, it was also the
14 one that we have in our bundle at volume 43A,
15 page 000.453. So it is one that was in use with
16 Dr Schwartz's guidelines as well, was it?
17 DR LACHMAN: That is correct. In fact there are two. The
18 next one is the one that was sent at Northwick Park.
19 You may ask why we have two. It is because both like
20 their forms. My view is that during the course of this
21 year we will end up with one. How I will do that is get
22 the nurses to decide mainly which one they prefer to
23 use. The nurses at Northwick Park like their form
24 particularly, they helped devise it. The nurses at
25 Central Middlesex do that and ultimately I let them
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1 choose which single one they will use.
2 MR SHELDON: But both of them are fit for purpose in your
3 view?
4 DR LACHMAN: Both are fit for purpose. One must emphasise
5 this does not replace the report, this is just
6 a discharge form with the briefest information that is
7 required. A full medical report will have to follow.
8 MR SHELDON: The question is not what forms there are but
9 how well they are filled in and have you been able to
10 assess, and we will come on to documentation in general
11 in a moment, but in respect of that form alone have you
12 been able to assess how well they are being used and how
13 completely they are being filled in?
14 DR LACHMAN: Yes. With Ms Konisberg I asked for the most
15 recent cases that we have had between the Brent and CMH
16 and I have identified two cases in the last few months.
17 I reviewed the notes and I must say I was pretty
18 relieved to see they had done all I had asked them to
19 do, in that they had documented telephone calls,
20 documented the referral and had documented and the
21 referral form had been filled out. I was pleased that
22 when I reviewed the notes with Ms Konisberg it was
23 likewise in Social Services, the notes were very well
24 kept.
25 MR SHELDON: Good. If we could turn whilst we are on the
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1 subject of documentation to Dr Amodu's audit at page 14
2 of volume 45I. This I take it is an example of the sort
3 of audit that the Part 8 recommended be carried out on
4 a regular basis and it is item 28 in your statement
5 page 7, is that right?
6 DR LACHMAN: Yes I agree.
7 MR SHELDON: What was the purpose of it?
8 DR LACHMAN: I think that the audit was conducted between
9 May and September of this year and written up the day
10 after. It was really to look at the standard of
11 documentation. For me it was to get a baseline before
12 change was introduced. It is something I can measure
13 the improvement in standards against.
14 MR SHELDON: Dr Amodu it would seem looked at six cases in
15 that period, May to September, and he or she?
16 DR LACHMAN: I think it is a she.
17 MR SHELDON: She got those names it would seem off the
18 Central Middlesex Hospital's Child Protection Register,
19 is that right?
20 DR LACHMAN: That is correct.
21 MR SHELDON: Of these 56 she was only able to find 39 case
22 reports and entries. Pausing there, is that something
23 with which we should be concerned?
24 DR LACHMAN: Yes. I would -- I have not had the opportunity
25 to discuss this. I would say it is of course a concern
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1 that not all the notes are found, all the cases but if
2 I actually look at it, the 14 cases were not found and
3 that is of concern to me as to ask the next day for me
4 to look behind the audit and say in fact the most
5 important notes are the ones that were not found and to
6 see what we had to do about those.
7 MR SHELDON: But just as a balanced statistic without
8 further investigation, the fact that just over a year on
9 14 out of 56 sets of notes cannot be found is a worry,
10 is it not?
11 DR LACHMAN: Oh yes, I fully agree with that.
12 MR SHELDON: If we could turn to page 18, the conclusions.
13 At bullet point 4 we see:
14 "Cases were seen by doctors of an appropriate
15 grade."
16 That would be either a consultant or specialist
17 registrar, for these purposes?
18 DR LACHMAN: Yes, that would be true.
19 MR SHELDON: Further down we see that body charts albeit
20 present in 69 per cent of cases were only signed and
21 dated in a third of them. Is that something that causes
22 some concern?
23 DR LACHMAN: The standards has changed. Each page of the
24 body chart now has a name and date on it and a place for
25 the doctor to sign. It is a cause of concern but I am
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1 not surprised in a way.
2 MR SHELDON: Why not?
3 DR LACHMAN: One of the things that doctors need to be
4 constantly reminded about is signing legibly and
5 printing their names and putting dates and times and who
6 they spoke to, who was present. These might sound quite
7 logical to do but it is part of the training that we
8 continually have to do and we have programmes to train
9 our junior staff to do just that. In the new pro-forma
10 there are reminders at every point for them to sign and
11 date and put the child's name and hospital number where
12 appropriate.
13 MR SHELDON: You say it is something that you are constantly
14 having to remind staff to do. Is it something you think
15 is taken seriously by medical staff in this field as
16 a whole?
17 DR LACHMAN: Generally in this field, yes. I would say that
18 one has to have one medicolegal case and I would case
19 every case since thereafter. Doctors often do not take
20 into account the fact that everything they write is
21 a medicolegal document and needs to be treated as such
22 so that we can determine who wrote the notes, when and
23 why they wrote the notes. I do not think that the audit
24 is particularly different from any other place. I think
25 that most probably it is a little better than some
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1 places that you would go to. It is something throughout
2 the country that needs to take into account.
3 MR SHELDON: We see for example that in only 17.9 per cent
4 of cases was there any documentation of consent.
5 DR LACHMAN: That is a very interesting point because I need
6 to clarify that, is: who did the consent -- whose
7 consent; parents, carer or child? It is only in the
8 past six months that the NHS has published guidelines
9 for consent from children, and in fact taking consent
10 from children has always been implied consent.
11 For example, if you wished to take a blood sample,
12 do you ask a child or not? If you went around the
13 country most people do not. We have to change the
14 culture on consent and it is deciding who is the
15 patient, the parent or the child.
16 Now of course in emergency situations there is
17 a different view of consent but in all elective
18 procedures and examinations one should ask for consent.
19 What we are saying now is that one should, if possible,
20 have a written consent for examination, so that you ask
21 the child to be examined, particularly in child sexual
22 abuse, you ask the child beforehand and you document
23 that you have done so.
24 MR SHELDON: Particular areas aside -- consent, body maps
25 and so on -- the basic picture of this audit is that the
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1 record keeping of those 39 cases that could be found was
2 not of an adequate standard. Is that fair?
3 DR LACHMAN: It depends how you define "adequate". I would
4 say that there are some areas I would look at that were
5 not adequate in terms of the -- I am a little unhappy
6 that one report was written after 20 days. There may be
7 a valid reason for that and I would go in and say what
8 was the situation there. I am not happy that there were
9 only 27 out of 39 body charts present, but body charts
10 may not be used in all cases. So one must not just
11 accept this at face value.
12 This is the first report I received on my return
13 from leave, so I have had it a little longer than you
14 have. My next aim is to go behind it, and an audit is
15 worthwhile only if one is sure that what it is saying is
16 true.
17 MR SHELDON: But this was an area to which your attention
18 was directed by the Part 8 as well, because we have item
19 31: "Recording procedures and practice should be
20 reinforced for all medical staff and the subject of
21 regular training".
22 DR LACHMAN: Yes, but you must remember that the time, the
23 date is end of September 2000. Most of my
24 implementations would be in 2001. So the next audit
25 which should virtually commence pretty soon to repeat
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1 this would hopefully find an improvement.
2 MR SHELDON: You hope to find an improvement and your hope
3 would be based upon what, training?
4 DR LACHMAN: Number one is training and number two is that
5 we have now documentation that reminds the doctor to
6 fill in these things at all points. So if you look at
7 pro-forma, they are reminded about consent, about
8 signing body maps and about signing the form in general.
9 MR SHELDON: Is there formal training offered to paediatric
10 medical staff about note taking, record keeping and
11 documentation?
12 DR LACHMAN: If I refer you to the document on training.
13 You would have to help me in your...
14 MR SHELDON: I think it is page 139. It starts at 138.
15 DR LACHMAN: 138. There is a training programme currently
16 under way at Central Middlesex and writing reports is
17 one of them but the standard of having the consultants
18 being involved in child protection case means that
19 I expect an ongoing training. Most areas in writing
20 notes and reports are monitored on a daily basis. Our
21 clinical risk manager now attends the wards on a monthly
22 basis or two-monthly basis to go through random notes
23 with the medical staff to assess the quality of the
24 notes, from both a medical point of view and from
25 a medicolegal point of view. And we have noticed at
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1 Northwick Park where we started this programme a few
2 years back that the standard of note-keeping did
3 improve. It is something one has to do continually.
4 Our junior staff change every six months and they come
5 from different specialities where the detail is
6 different, so we have to continually keep going at this.
7 MR SHELDON: Is there some sort of training offered or is
8 there some sort of training in the pipeline for new SHOs
9 who arrive for six months to be taken through these
10 forms and informed of their obligations in filling them
11 out?
12 DR LACHMAN: Yes. In the induction programme they have
13 a session with a named doctor in the first two weeks of
14 coming on board. In fact, I noticed in this audit I did
15 of the training programme, when I looked at the training
16 across the board, that for example the neonatal SHOs
17 were not getting training and that has changed as of
18 next week when they restart, at the end of February.
19 Because they were involved on the neonatal units and not
20 anywhere else in the hospital and they were forgotten,
21 so that has changed. Now every SHO in paediatrics,
22 whether in the frontline or intensive care, will have
23 training.
24 MR SHELDON: So there would be in your view no excuse now
25 for note-taking of poor standard in child protection
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1 cases?
2 DR LACHMAN: There is no excuse at any time. It is
3 something that the consultants need to be on the lookout
4 and I think that in any medical cases no excuse is there
5 for poor note-taking.
6 MR SHELDON: You would say the forms are clear, the training
7 is there, the consultants know it is something they
8 should be keeping an eye on and so I should expect to
9 see a better audit the next time around?
10 DR LACHMAN: In an ideal world yes, and I hope we are in
11 that ideal world.
12 MR SHELDON: Do you have an audit plan?
13 DR LACHMAN: Yes. I have looked to it myself. I will now
14 identify an SpR for learning purposes to do the audit on
15 my behalf. It will be just interesting to see how
16 extensive I should do it and I would like to have it
17 cross-site so it is not only Central Middlesex. The
18 reason for that is I do not want to make Central
19 Middlesex feel that they are being audited and the other
20 site is not being audited; rather to say that we are
21 auditing note-keeping in child protection across the
22 Trust.
23 MR SHELDON: Back to the statement, page 8, item 32:
24 "When staff changeover occurs, there must be full
25 and proper handover of patients and outstanding issues."
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1 Another one I should imagine that you thought, "well
2 yes of course they should", when you read it. Would
3 that be right?
4 DR LACHMAN: Yes, I agree. I think that is just so logical
5 and such -- it is so obvious that it should occur that
6 one often wonders why one has to write it, and I have
7 done a site inspection to make sure it is occurring and
8 last week I visited Central Middlesex and observed that
9 this happened and I have done that this week as well.
10 I know it happens at Northwick Park because I have been
11 on the ward and I do on-calls at Northwick Park but
12 there is a proper handover now at both sites. I predict
13 it happened beforehand at Central Middlesex in any event
14 but now it is part of this standard expectation.
15 MR SHELDON: I was going to ask how you monitor the quality
16 of handovers and it seems you have foreshadowed that in
17 your last answer; namely, you go down to the ward and
18 have a look.
19 DR LACHMAN: The handovers on the site that I work at which
20 is easier for me to monitor is something that I do
21 myself when I am on-call so I can assess what the
22 situation is. From my own personal experience I have
23 learned that one has to discuss every child on the ward,
24 or have knowledge about every child on the ward as part
25 of the handover if you are the consultant, and if you
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1 are the registrar you definitely need to have seen every
2 child.
3 My practice is not to examine every child
4 necessarily, but to walk past the bed of every child on
5 the ward so I know who is in the bed for the night and
6 what the problem is. And sometimes I may make
7 suggestions, examine the child et cetera. That is what
8 I expect of the consultants, to know about every child
9 who they are looking after that night.
10 MR SHELDON: But in relation to the monitoring or auditing
11 of the quality of handovers is there not a danger in the
12 approach that you have indicated -- I am not saying you
13 should not go down and look, but the danger is junior
14 staff are always going to do a good handover when they
15 know the clinical director is standing in the back of
16 the room?
17 DR LACHMAN: I do not go routinely to the wards when I am
18 not on-call. I do think that the idea that the clinical
19 director is around and knows about quality is not a bad
20 thing. It is far better than the clinical director not
21 being around.
22 MR SHELDON: Oh absolutely, but I am just wondering how you
23 can be sure the practice you are seeing is
24 representative.
25 DR LACHMAN: I have a good team of consultants who I have a
182
1 lot of faith in, they are very experienced and they will
2 let me know very quickly if something goes wrong. In
3 fact, they will have an e-mail talk shop for the
4 consultants at Northwick Park at least, so I hear the
5 next morning if there have been any problems because it
6 comes on to my e-mail network. So I pick up the
7 Northwick Park quite clearly. At Central Middlesex
8 I have a Deputy Clinical Director in John Loftus and
9 I expect him to monitor it there.
10 MR SHELDON: You are satisfied at present that the standard
11 is adequate?
12 DR LACHMAN: Yes, I am satisfied, and when I was at Central
13 Middlesex I note that the handover -- I was there on
14 Tuesday -- on Monday for a meeting and so I popped down
15 to the ward just to observe the handover to see whether
16 the doctors -- whether the handover had taken place. It
17 was a random check, I do not normally go there. So it
18 is not a usual occurrence that I turned up on the ward.
19 MR SHELDON: The last item you will be relieved to hear on
20 page 8 is item 34:
21 "When the discharge plan includes a child in need of
22 referral to Social Services, the Social Services
23 Department should be contacted to make the referral."
24 Again, one might say that that is fairly
25 self-evident, is it not? If they need a referral then
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1 a referral should be made?
2 DR LACHMAN: Yes. Comment is that most Part 8
3 recommendations are self-evident, and these fit most of
4 them. I would say that this is reinforced in the new
5 document. What we have done is made sure that it is
6 quite clear that they need to contact Social Services.
7 We have gone through this before, Mr Sheldon, on the
8 procedures and this is reiterated in the document.
9 MR SHELDON: Two brief issues to finish with, Dr Lachman.
10 One of the issues that you raised in the September 2001
11 document that we have looked at which is at 45I, page 11
12 is the issue of the named nurse and some discussion
13 about whether or not there may be a need for additional
14 sessions to develop that service further. Before we
15 look at the named nurse in particular in relation to
16 that comment, can we just understand the roles.
17 Firstly, what is the function of the named doctor
18 and named nurse, as you see it?
19 DR LACHMAN: The named doctor and nurse are the quality
20 control for child protection within the Trust. They are
21 there to ensure that we have good procedures, good
22 training, review the cases that we have seen, ensure
23 that it functions well, foster good relationships with
24 Social Services, prepare reports for Part 8s if we need
25 to prepare reports for Part 8s, section 8 reviews, make
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1 sure that all the procedures are followed and report
2 back to me accordingly.
3 Now, within the NHS, within our Trust actually the
4 named nurse post has been taken on by the lead nurse for
5 the ward and I wondered whether or not we should expand
6 the role.
7 MR SHELDON: That is the named nurse role and I will come
8 back to the question of expansion in just a moment but
9 I just want to understand before doing so how that fits
10 in with the role of the designated nurse and doctor.
11 DR LACHMAN: Designated is more borough-wide, it is more
12 strategic and covers the whole borough. So the
13 designated doctor for child protection will sit on the
14 ACPC, help develop policy, work on the audit or the
15 ACPC, advise the Health Authority or soon to be PCT on
16 child protection matters and ensure the Trust is doing
17 a good job. So they are almost the next layer above the
18 named doctor.
19 So the named doctor only has responsibilities within
20 the Trust. The designated doctor has responsibilities
21 for the whole borough and they cover more than one
22 Trust.
23 MR SHELDON: I see, thank you. At the time with which we
24 are concerned I think the named nurse was Paula Johnson,
25 from whom we have heard.
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1 DR LACHMAN: That is correct.
2 MR SHELDON: She worked three days a week she told us. Is
3 that what you are referring to at 45I, page 11 when you
4 say that additional sessions may be necessary?
5 DR LACHMAN: Currently the named nurse at Central Middlesex
6 is Krishna Chapman who is full-time but works on the
7 ward. My view is that we should proceed with a separate
8 post in due course and I am trying this out at
9 Northwick Park. You might say why is because I have
10 identified funding at hand and we have just appointed
11 a named nurse for Northwick Park in the Trust.
12 I suspect that in due course she will pick up Central
13 Middlesex as well and we will have a named nurse for the
14 Trust rather than a named nurse for the site.
15 MR SHELDON: And so the difference will be that that named
16 nurse is able to concentrate solely on child protection
17 issues or child abuse issues and not have to worry about
18 the other elements of nursing?
19 DR LACHMAN: Will have no other commitments other than child
20 protection. I am pleased to say that I was appointed
21 a very experienced named nurse to start on the 1st April
22 in the Trust, and I am sure that she will be inundated
23 from both sides in providing the service that they need
24 and the main area will be in training.
25 MR SHELDON: So the situation in relation to named
186
1 professionals at CMH is now better than it was when we
2 were concerned, because firstly the named doctor is
3 there full-time and, secondly, the named nurse is
4 full-time, and it is about to get even better because
5 the named nurse is going to be relieved of other duties?
6 DR LACHMAN: Yes. We intend to increase our input in the
7 positions of named nurse and doctor. In terms of named
8 nurse, the new named nurse will be based initially at
9 Northwick Park, but I would expect her to roll out the
10 programmes at Central Middlesex as well.
11 MR SHELDON: I see. One last post that I would appreciate
12 your help on is referred to at page 34 of that volume
13 where reference is made about halfway down the page to
14 the Child Protection Coordinator. I wondered who that
15 was and what they did.
16 DR LACHMAN: At Northwick Park we have a half time post for
17 a personal assistant to the named doctor, basically.
18 She is a very experienced secretary or administrator
19 I should say whose job is to collate the child
20 protection folders, to have good liaison with
21 Social Services and to be the focal point for all
22 referrals to Northwick Park.
23 So if Social Services -- a social worker wishes to
24 contact one of the duty doctors during working hours,
25 that would be the point of contact. It makes it much
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1 easier for Social Services to know there is only one
2 place to phone and they can obtain the doctor very
3 quickly.
4 She is also responsible for making sure all reports
5 are sent out timeously, are filed, that notes are
6 followed and that all aspects of child protection are
7 kept up-to-date. I think that is a vital post and would
8 need to be expanded as we get more sophisticated in
9 keeping our documentation.
10 MR SHELDON: Thank you. In light of these matters that we
11 have spent the afternoon discussing and the improvements
12 that have been put in place in your professional
13 assessment, are you confident that were Victoria to be
14 presented to the Central Middlesex Hospital in the same
15 way now her case would be handled differently?
16 DR LACHMAN: I am very confident that it would have been
17 a different matter if she came now. One of the things
18 that worries me all the time is how safe is our service,
19 what kind of service do we provide? Particularly in
20 terms of child protection, is our level or our threshold
21 at the right level?
22 I have always taught students and fellow doctors
23 that one always has to think of child protection no
24 matter what is wrong with the child. I have a very
25 broad view of child protection. I separate it from
188
1 child abuse and I would say every opportunity must be
2 used to assess the needs of the child. So a child who
3 presents to our hospital for any condition, I expect the
4 doctor or nurse or physiotherapist or whoever sees the
5 child to assess the needs of the child in the most
6 holistic way, so I am confident.
7 MR SHELDON: Thank you very much Doctor, thank you sir.
8 THE CHAIRMAN: Thank you very much Mr Sheldon. Mr Mason,
9 please.
10 MR MASON: Thank you sir, good afternoon Dr Lachman. One
11 very brief question about the guidelines if I may.
12 There are a number of flow charts in those guidelines
13 which I do not want to take you to, but does anyone
14 wanting to use those flow charts have to hunt through
15 the whole bundle or are they more accessible?
16 DR LACHMAN: No, there is a bit of a lag. They are
17 currently being printed and laminated and will be in all
18 the areas where the folders are. The aim of those flow
19 charts is to allow people to have a quick look to see
20 what is expected of them. I had thought whether
21 I should give flow charts because then people will not
22 look at the procedures and one of the things that I am
23 going to change on the flow chart is a clear instruction
24 that they have to consider the procedures as well, which
25 I know is not on the flow chart, because flow charts,
189
1 while they are short cuts, can lead to problems if
2 people do not consider the procedures.
3 MR MASON: Thank you. Once the guidelines are completed,
4 which I understand is going to be tomorrow, is it
5 sufficient in your view for you to say to
6 yourself: "I became aware that there are a number of
7 problems in the service. I have now written a bundle of
8 procedures to address those issues and I can now relax
9 because that is my job done" or do you believe you have
10 is a continuing commitment to meet.
11 DR LACHMAN: I have a commitment while I am Clinical
12 Director to ensure the safety of children is paramount
13 within the Trust. I have a number of functions. One is
14 to make sure at Trust Board level children are the
15 highest priority and that they continue to be the
16 highest priority, that they are at a high priority
17 within the CPT and within the local community and
18 hopefully within the regional NHS as well. So my job
19 will never be finished.
20 In terms of these procedures, I have already started
21 to think of the dates I have to revise them, to publish
22 them by next October, which means that in April I will
23 be calling out for amendments to the protocols to make
24 sure that I spend the summer months revising them and
25 have them published in October 2002, as a next version.
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1 As a Clinical Director one is never satisfied with what
2 one has done.
3 MR MASON: If I may now move you back in time. You said
4 that your past experience was working with unified teams
5 of health care and social workers. Was that in
6 South Africa?
7 DR LACHMAN: Yes. I was fortunate to work in a large
8 teaching hospital with 20 social workers and about
9 50 consultants and I was one of three consultants in the
10 Child Protection Team and we met every week to discuss
11 every case. Now of course we were inundated, we had
12 20 new cases a week on a minimum --
13 MR MASON: Could I interrupt you? By every case is that
14 every case --
15 DR LACHMAN: Of child abuse.
16 MR MASON: Is that a child in the hospital or outside the
17 ward?
18 DR LACHMAN: A child that presents to the hospital. Now
19 because we were the biggest centre in the city,
20 Cape Town, we saw the majority of child abuse in the
21 city. In fact my MD was on referral patterns, first on
22 referral patterns to the hospital and the second thesis
23 was on reported child abuse in Cape Town.
24 Now we were seeing at least two-thirds of all cases,
25 if not more. The other hospital on the other side of
191
1 the city was seeing the other third. We had a very
2 close working relationship with the social workers.
3 There were no boundaries. And the difficulties, if any,
4 were the social workers working with the social workers
5 in the community. If anything, that was where the
6 boundary may have been.
7 It is of course a time of change when we were doing
8 this work, of less resources than I have here, and
9 I think in a way we achieved a lot more than with the
10 resources we do have here in England. I had
11 a prevention programme that starred on 5,000 rand, in
12 those days that was about £5,000, and within three years
13 it was running at 500,000 rand. We had a programme
14 aimed mainly at prevention of child abuse.
15 The reason that I would make that distinction is
16 that a lot of the work I am doing now is a reaction to
17 abuse that has already taken. My dream is that if we
18 could really work on prevention of child abuse as the
19 major thrust of child protection then possibly I will be
20 out of a job in child abuse work in many years to come.
21 That is my dream and that is what I was trying to do in
22 South Africa, and an experiment of having a child
23 prevention programme at the same time as having the
24 child abuse programme which I sat on both.
25 MR MASON: In your view was this prevention programme
192
1 successful?
2 DR LACHMAN: It is hard to say. It was at a time of great
3 change. It was set up in 1989 and I chaired it for five
4 years. It was successful in that it raised the profile
5 of child abuse within the city, it was a children's
6 rights programme so we were championing the rights of
7 the child. We were educating adults but we were not
8 seeing children. We were seeing schoolchildren but the
9 aim was to educate people about child abuse, to take
10 away their myths and to develop prevention programmes.
11 One of the successful things was that we had
12 a poster campaign and in many departments in England one
13 of the posters we devised, which is a cartoon version of
14 what is child abuse, is visible and every time I look at
15 it I think how successful that programme was because it
16 has every reached many of the departments in this
17 country.
18 So, yes, I think it was successful in raising the
19 profile. Successful in preventing child abuse? The
20 reality is that we are never going to prevent child
21 abuse totally but can we minimise it? Yes we can. It
22 is a long-term project and I think that is what I would
23 like to see positive coming out of this Inquiry is ways
24 of preventing child abuse, not only reacting to child
25 abuse.
193
1 MR MASON: Thank you Doctor.
2 THE CHAIRMAN: Thank you, Mr Mason.
3 Dr Lachman, I would like to carry on with that theme
4 because when Victoria was referred to Central Middlesex
5 Hospital it was a perfect opportunity to prevent child
6 abuse, so why did that not happen?
7 DR LACHMAN: I ask that myself. I think to me it was the
8 failure in the support the next day. When I analyse the
9 situation it was the fact that there was not a chance to
10 review the situation the next day. There was not
11 a consultant present on the site to look at her the next
12 day and she was handled by junior members of staff.
13 That will not happen again. I am pretty sure that had
14 there been a consultant there to see her the next day
15 and to take a general overview again and to have
16 a second look, maybe would have had a different outcome.
17 I cannot say it would have, but that is what I think.
18 THE CHAIRMAN: But she was seen by a consultant.
19 DR LACHMAN: She was seen by a consultant the night before,
20 and admitted to hospital and decisions made and concern
21 raised. I would have expected the next day a review by
22 a consultant and that might have made a difference.
23 I am not saying that consultants will always get it
24 right, that would be foolish for me to say that, but it
25 would have been a second chance for her. I think that
194
1 the Trust should have been in a position to offer that
2 the next day and now we definitely can.
3 THE CHAIRMAN: But that time in July was absolutely crucial
4 so, okay, the consultant was not available the next day
5 for reasons that we can explore, but surely the system
6 does not depend solely on something like that. Are
7 there no actual safeguards built into the system at all?
8 DR LACHMAN: There are safeguards. I think that the actual
9 visualisation within the minds of the doctors and nurses
10 involved is what is a child protection case or not? It
11 is quite complex in itself with professionals throughout
12 the world. This is not something that is unusual. When
13 you say "were there safeguards" I would have expected
14 there were safeguards, that a more senior person would
15 have discharged her, if at all. And that is the
16 disappointing part for me, when I review it, that that
17 did not happen.
18 I reckon that in hindsight one can say, well, we
19 should have had that there. The circumstances of the
20 day on the ward in which she was discharged were
21 unacceptable to me and will not happen again. But
22 I think that there is also something that maybe the
23 Inquiry would like to look at, is how professionals go
24 through this period of denial of abuse. It is quite
25 complex. There is quite a bit of research on it, on
195
1 professionals not accepting the horror of abuse, or the
2 difficulties of abuse and I think it is even more
3 difficult for junior staff than for more senior staff
4 and for frontline workers in Social Services, et cetera.
5 It is something that I wonder whether we have to work
6 more closely with those in the frontline, to allow them
7 to explore these issues of working with the most
8 difficult part in child health.
9 THE CHAIRMAN: I will come back to that if I may. What did
10 you think of the standard of recording and the
11 communication with other agencies?
12 DR LACHMAN: I was not happy with that. When I reviewed it
13 I thought that perhaps I thought more information should
14 have been given to the agencies. I think Dr Schwartz
15 has accepted that she should have written her own notes
16 and I think that a doctor who examines a child should
17 write their own notes particularly in child protection,
18 and that is one of the things I have tried to implement
19 of the new pro-forma, but I was not happy with the
20 outcome of the referral. That was not strong enough.
21 THE CHAIRMAN: You see you said earlier on in answer to
22 Mr Sheldon that in an ideal world recording would be if
23 not of a high standard, at least good enough. Actually,
24 that is no basis on which we can operate in an ideal
25 world. In this world today, and every day, recording
196
1 should be good enough.
2 DR LACHMAN: Yes, I agree.
3 THE CHAIRMAN: If doctors, whether they are consultants or
4 junior doctors, do not record properly, what is the
5 Trust doing about it, apart from exhortation and fine
6 words?
7 DR LACHMAN: I think that the process of recording notes is
8 a continual audit, a continual ongoing assessment of how
9 people keep notes, how doctors record different
10 procedures, different interventions and how those are
11 assessed. It is very important for us to monitor them
12 continually. The issue of clinical governance and
13 assessment is part of the process, appraisal of doctors,
14 ongoing appraisal. In terms of the junior staff they
15 are appraised every two months by their tutors.
16 So what we are doing about it is continually
17 assessing and continually pushing it. I must admit
18 I cannot tell you right now that every note that is
19 being kept today is of a 100 per cent quality, but what
20 I can say is it is getting close to a standard -- well
21 it is at a standard that is acceptable but I will always
22 ask for more.
23 THE CHAIRMAN: But these are doctors we are talking about
24 who are in training and therefore they have to achieve
25 a certain standard before they qualify. How much is
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1 actually note-taking taken seriously by you and your
2 colleagues as part of the requirement of them in their
3 training?
4 DR LACHMAN: It will be part of their requirement that in
5 order to be signed off by the tutor they take notes
6 adequately. If on a constant audit and looking through
7 the notes we are unhappy with the particular doctor,
8 that doctor will be spoken to and assessed. Now most
9 trainee doctors are generally fairly good note-takers,
10 so I think that what we need to do is consistently hope
11 that the doctors in full-time employment in the hospital
12 are the ones that we need to continue to monitor, and
13 I believe that all doctors, no matter what grade, should
14 be monitored on a continual basis.
15 THE CHAIRMAN: If I heard you right, and if I did I not must
16 apologise, at least correct me: what you said in answer
17 to Mr Sheldon was it takes very often a serious
18 complaint against a doctor before a doctor begins to
19 realise how important note-taking is.
20 DR LACHMAN: I think just to clarify that it was that --
21 that does drive it home but I have a -- I wrote serious
22 complaints. I have a fairly low threshold for
23 assessment of clinical risk and I assess in the
24 directorate many cases that probably would not be
25 assessed elsewhere. We have regular reports and we look
198
1 at note-taking at the same time.
2 I am trying to get into the culture of doctors that
3 at any one time we might want to assess quality and
4 therefore the notes have to be good, and I think we are
5 succeeding. It is a long-term project. I agree it was
6 problematic in the past. It is most probably
7 problematic now, I cannot speak of other units, but
8 I think less so in our unit than before. I do not think
9 it is very unusual but I must stress that doctors taking
10 notes in detail is something that needs to be emphasised
11 continually and it is a problem that we need to address
12 face on.
13 THE CHAIRMAN: When was the study by Dr Amodu commissioned?
14 DR LACHMAN: It was commissioned last -- about last April.
15 Around about last April. It was not done within North
16 West London Trust, it was done within Parkside Trust, so
17 I was always one removed from it. It took about four or
18 five months to do. Now you might say -- I mean one of
19 the supplementary questions is why did it take so long
20 to carry out an audit? I was not the supervisor of the
21 audit and I just received the audit but I would expect
22 it would be a two to three month audit rather than
23 a four to five month audit. That is my expectation.
24 THE CHAIRMAN: Looking at the timetable, Victoria died
25 in February, the audit was not commissioned until April
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1 the following year. Am I right?
2 DR LACHMAN: Right.
3 THE CHAIRMAN: Looking back at September, and then the
4 report is produced in December, presumably the
5 imperative being to get it to us today. That is just
6 coincidence?
7 DR LACHMAN: The report -- I was scheduled to give evidence
8 in November originally. The report was commissioned as
9 part of the recommendations, following the
10 recommendations that came out -- there was a Trust Board
11 in April. It followed that. And I agree I should have
12 been pushing it more to get an outcome of the report.
13 But I did not wait for the report to come out to tell me
14 what to do in the interim, I implemented the new
15 pro-forma so that people would be -- would have the
16 opportunity to record the information in a more accurate
17 way.
18 So it did take a long time. I did not just produce
19 it today because I was coming today. It came out at the
20 end of December and I thought it would be opportune to
21 give it to you once I am here today, but it is not so
22 much what is in the report, it is what happens from the
23 report that counts.
24 THE CHAIRMAN: Leave the first part of that to me, if you
25 may. I think that it is a bit concerning, is it not,
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1 when, as Mr Sheldon has indicated, a lot of the case
2 notes could not be found, but let me just go to one of
3 the conclusions which I guess you have before you. It
4 is on page 18 of 45I. I have only had a little time, as
5 you know, whilst struggling with this language, to
6 actually look at this. But in only 33 per cent of the
7 body charts were they signed and dated.
8 When you consider what this Inquiry has heard and
9 what I assume you would regard as just basic everyday
10 essential practice, not in an ideal world, not a great
11 vision for the future, not a great dream but just what
12 you would expect any professional to do, and two-thirds
13 did not do it, can you explain that to me, please?
14 DR LACHMAN: I agree with you that it is not acceptable
15 practice on behalf of the doctors that did that.
16 I think that that is an issue that will require
17 attention. I should assume that if the audit of 2001 is
18 carried out, I would expect all of them to be signed.
19 THE CHAIRMAN: Yes. The question that is on my mind
20 is: does the Trust or do any of the doctors actually
21 take seriously what happened to Victoria?
22 DR LACHMAN: I would say they do.
23 THE CHAIRMAN: Well some of the basic lessons do not seem to
24 have been taken much to heart in terms of converting
25 them into practice, do they?
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1 DR LACHMAN: No. I think that there are many lessons from
2 Victoria, and the signing of the documents might be one
3 in which the -- might be a continuing problem but
4 I think many lessons have been learned from Victoria.
5 THE CHAIRMAN: Well, reassure me and tell me what you think
6 are the main ones.
7 DR LACHMAN: The main ones for me is the taking a holistic
8 view of a child who comes into hospital; not being
9 constrained by purely medical diagnoses; having good
10 relationships with other professionals; ensuring that
11 referrals and discussions of other professionals are
12 held; ensuring that the most appropriate person and the
13 most well-trained person sees the child and makes
14 decisions on children; and ensuring that the safety of
15 the child is paramount in what everyone does.
16 THE CHAIRMAN: So let us then turn to the guidelines that
17 you have gone through.
18 I want to say something very -- it is kindly meant
19 and I hope you will take it in the spirit of generosity
20 that is intended, which is despite Mr Sheldon's very
21 skilful work and your knowledge of these guidelines, and
22 the fact that I only looked at them again over lunch and
23 listening to the evidence, I have to say I find the
24 guidelines rather difficult to follow.
25 DR LACHMAN: If one looks at the actual -- the way they are
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1 set out, and they are separated out into each area so
2 that makes it much easier to follow. I agree all put
3 together they are very difficult to follow and that is
4 why I had trouble negotiating them like this. But they
5 are separated into each area of operation.
6 THE CHAIRMAN: The essential thing is that these apparently
7 are -- and I am prepared to accept it -- hugely busy
8 people that they are intended to ... people who as you
9 have indicated may not feel terribly capable with child
10 protection work and may in fact want to deny the
11 existence of child abuse. These guidelines are
12 presumably intended to make sure that they have a clear
13 step by step must-do.
14 DR LACHMAN: That is correct.
15 THE CHAIRMAN: Is there any significance that we got them
16 today and you came today or is that another pure
17 coincidence?
18 DR LACHMAN: I completed them -- first of all sir you had
19 the core of the guidelines in my initial submission.
20 I completed them virtually the day I went on leave and
21 I returned from leave last Tuesday. I would have
22 preferred to have had them here earlier, I really would
23 have, but they were finished printing on Tuesday and
24 I had hoped that they had got here before today. I did
25 not prepare these guidelines for this Inquiry,
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