Archived Transcript for 24 January 2002: Pages 1 to 50


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1 Thursday, 24th January 2002

2 (10.00 am)

3 THE CHAIRMAN: Good morning, ladies and gentlemen.

4 Mr Sheldon, I thought that I would take the opportunity

5 to respond to the application made by Miss Lawson

6 yesterday.

7 MR SHELDON: Certainly, sir.

8 THE CHAIRMAN: Ladies and gentlemen, you recall that

9 yesterday afternoon I heard an application by

10 Miss Lawson on behalf of Haringey that the time allowed

11 for her to make oral closing submissions be extended

12 from 30 minutes, which had already been specified in our

13 procedural guide, to at least two hours. She drew my

14 attention to a number of points contained in the notice

15 of criticism sent by the Inquiry to Haringey, the fact

16 that represented witnesses will be permitted to make

17 closing submissions and the breadth of the questioning

18 that had been put to Haringey witnesses when compared to

19 witnesses appearing on behalf of other interested

20 parties.

21 You will recall that Mr Williams, who I see is not

22 here but you will no doubt convey to him that I have

23 taken seriously the points that he made -- Mr Williams

24 made a similar application on behalf of the Metropolitan

25 Police in which he adopted this submission made by

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1 Miss Lawson.

2 I inquired whether any of the other interested

3 parties who were present wished to ask for more time and

4 none of them did.

5 Ladies and gentlemen, the procedural guide issued at

6 the outset of these hearings stated that each party will

7 be permitted to make closing submissions for up to

8 30 minutes. The same time limit, it will be recalled,

9 was applied to the opening submissions, when Phase I of

10 this Inquiry began.

11 I was rightly reminded by Miss Lawson of

12 a conversation I had on this subject with Mr Garnham

13 early in October in which I agreed that the interested

14 parties will be able in addition to the oral submissions

15 to submit written representations to the Inquiry at

16 whatever length and complexity they deemed appropriate.

17 Now let me state at the outset that I find nothing

18 objectionable in the concept of strictly time limited

19 oral submissions, in the context of an Inquiry of this

20 nature. Indeed, as I understand it, both the European

21 Court of Justice, and the European Court of Human

22 Rights, which I hope everyone will acknowledge deal with

23 matters of utmost complexity and importance, both limit

24 the oral submissions made by advocates to 30 minutes, so

25 I am very reassured that I appear to be in very good

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1 company. A similar approach I am told was adopted at

2 other inquiries of which the Ladbroke Grove Rail Inquiry

3 is just one example.

4 The basis upon which oral submissions can properly

5 be limited in this way is that parties have the

6 opportunity to put written submissions to supplement

7 them and, as I have indicated, I do welcome written

8 submissions and they will be taken seriously. In this

9 way, the parties are given the opportunity of saying all

10 that they would wish to say on the issues that concern

11 them.

12 In adopting the same approach, I wish to emphasise

13 that precisely the same weight will be given to the

14 representations made to me in writing as if they had

15 been read in this Inquiry room. Such representations

16 will also be placed in the public domain. They will

17 have exactly the same status. That said, it is plainly

18 the case that some of the interested parties will have

19 to deal with a greater volume of evidence and a larger

20 number of potential criticisms in their closing

21 submissions.

22 I have no desire to perform precise mathematical

23 calculations in this respect, but it seems to me that

24 there is no reason why this should not be reflected at

25 least to some degree in the length of time allowed for

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1 closing submissions. I will therefore amend the

2 procedure as follows:

3 First, Haringey and the Metropolitan Police will

4 each be allowed one hour in which to deliver their

5 closing oral submissions. Secondly, every other

6 interested party will be permitted 30 minutes as set out

7 in our guide to procedure. Thirdly, all other witnesses

8 represented or otherwise or in receipt of a notice of

9 criticism and who wish to do so may make a closing

10 submission of no more than 15 minutes in length.

11 Fourthly, all interested parties and other witnesses who

12 have received a notice of potential criticism will be

13 permitted to put in written submissions of whatever

14 length they deem appropriate.

15 Finally, I wish to note that following the point

16 made by Mr Mason about the National Health Service,

17 I suspect that Mr Mason is technically correct to

18 observe, as he did last night, that because he

19 represents three interested parties he should be

20 entitled to 90 minutes. That I regard as being

21 technically correct, I would, however, be surprised and

22 somewhat disappointed were he to feel unable to deliver

23 his closing submissions, in respect of all three

24 interested parties he represents, within the hour, as

25 I have allowed for Haringey and the Metropolitan Police.

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1 I would have thought, in particular, that the relevant

2 issues to Barnet, Enfield & Haringey Health Authority

3 could be economically summarised in this time.

4 I hope, ladies and gentlemen, that the points that

5 I have made are regarded as fair and acceptable and

6 I hope it will be seen that I have given thought to the

7 points raised in a way in which I have sought to do

8 throughout this Inquiry.

9 Miss Lawson.

10 MISS LAWSON: I am never satisfied. Since I made my

11 submission yesterday afternoon, we have received

12 a letter from the Inquiry Secretary Mr Fitzgerald

13 dealing with the timetable for written submissions. The

14 position is this: that when the timetable was revised in

15 mid-December, submissions were due to be done by the

16 4th February, and the notice which dealt with that

17 indicated that written submissions were to be submitted

18 by the 8th February. That is a clear understanding that

19 written submissions did not need to be put in before the

20 oral submissions were made. Certainly there was no

21 suggestion at that stage that they had to be submitted

22 in advance.

23 Subsequently, in response to representations made to

24 you, the date for making closing submissions was put

25 back to 18th February. At that stage the evidence was

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1 due to be completed by 30th January. The date for

2 completion of the evidence has now been put back to at

3 least 4th February, and I say in passing that has

4 nothing whatever to do with Haringey or its documents,

5 but simply because of slippage in the timetable. The

6 date for the closing submissions has not altered, and we

7 have now received a letter saying that 30 copies of the

8 written submissions have to be delivered by 10 o'clock

9 on 13th February.

10 The effect of that is that those who have the most

11 ground to cover have the least time in which to do it,

12 because both Mr Williams who is not here but who joined

13 in my submissions yesterday, and I, are in the position

14 that our witnesses have not yet concluded their evidence

15 and are not due to conclude it until the end of this

16 timeframe. Unlike some of the other interested parties,

17 it is still going on. Two of my most important

18 witnesses have yet to give evidence.

19 At the end of last week we received a request for

20 a witness statement from Mr Heatley. No-one knows as

21 yet whether he is going to be required to give oral

22 evidence as well and in addition the legal team are

23 dealing on an almost daily basis with requests for other

24 information as well as requests and representations

25 which arise on a daily basis in this Inquiry.

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1 So there simply has not been the time for us to

2 collate and consider the evidence in a manner which is

3 required for written submissions. We do not have the

4 luxury of a team of people seconded to this Inquiry who

5 can search through all the material to find useful

6 points for us and it is also, as you will appreciate,

7 extremely difficult to get those who have yet to give

8 evidence to think about the submissions which are to be

9 made after they have done so.

10 In addition, sir, I am not sure whether this is the

11 case or not, whether those who have never actually had

12 to do it begin to appreciate the physical and mental

13 demands of having to make and produce detailed written

14 submissions of whatever length they deem appropriate.

15 One difference between those who appear before the

16 European Court of Human Rights and what is now proposed

17 is that they do not have to make all their written

18 submissions in a week. The position, therefore, is that

19 any advocate will tell you that preparing written

20 submissions is far more time-consuming than preparing

21 and delivering oral ones.

22 Quite frankly, sir, I am not sure that I am going to

23 be able to comply with this timescale with the best will

24 in the world and do justice to Haringey's case in the

25 way that you indicated a few moments ago you thought we

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1 would be able to, and I am therefore asking that the

2 timetable for putting in written submissions be

3 extended.

4 THE CHAIRMAN: Mr Mason?

5 MR MASON: Thank you, sir. May I speak in support of what

6 Miss Lawson says. None of the three interested parties

7 for whom I act have quite such a complicated and

8 detailed involvement as Haringey, but there are three of

9 them, and, unlike Miss Lawson, I do not have the

10 advantage of a diligent junior and a team supporting me.

11 It was my application that caused the timetable for the

12 final submissions to be put back.

13 Sir, I was equally as concerned as she was to get

14 this letter yesterday which effectively having gained

15 two weeks takes one of those two weeks away, and so in

16 that regard I would support her application for, or

17 perhaps at least until when the oral submissions are

18 made, for the written submissions be put in. That is

19 all I have to say, thank you.

20 THE CHAIRMAN: Thank you Mr Mason. Anyone else want to

21 comment?

22 Well, Miss Lawson, I am sorry that you are never

23 satisfied. I had thought that I had for once done

24 something that might have actually achieved that and

25 I think I have to say that I take some exception to your

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1 comment about the luxury of having a team of staff

2 seconded to the Inquiry. I have to say that it is only

3 because of the exceptionally long hours that the team of

4 staff all have worked that we have actually managed to

5 keep to the timetable that we have managed to keep, and

6 I am indebted to them; and I am sure you do not want me

7 to analyse the reasons why this has occurred but I do

8 not think Haringey should make any great claims on that

9 point.

10 I did take very seriously the points that were made

11 earlier about the 4th, 5th and 6th February being too

12 close, especially in the light of the fact that we were

13 slipping, and that was the reason why it was moved to

14 18th, 19th and 20th. I was told, we were all told, in

15 this room by the Chief Executive of Haringey that

16 Haringey would give whatever resources were necessary to

17 enable the Inquiry to keep to this timetable. It might

18 be thought unreasonable. I do not take that view and

19 therefore I have to say I am not prepared to agree to

20 this further application.

21 Mr Sheldon.

22 MR SHELDON: Thank you. Today's first witness is Dr John

23 Riordan.

24 DR JOHN RIORDAN (sworn)

25 MR SHELDON: Good morning.

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1 DR RIORDAN: Good morning.

2 MR SHELDON: Could you confirm your full name and

3 professional address, please.

4 DR RIORDAN: John Finbar Riordan, North West London

5 Hospitals Trust, Harrow.

6 MR SHELDON: Dr Riordan you have prepared a statement for

7 use by this Inquiry a copy of which I think is in front

8 of you. Could you have a look at the last page of it,

9 please. Is that your signature?

10 DR RIORDAN: Yes.

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

12 that statement are true?

13 DR RIORDAN: Yes.

14 MR SHELDON: Dr Riordan, as I understand it you are

15 currently the Executive Medical Director of the North

16 West London NHS Trust, is that right?

17 DR RIORDAN: Yes.

18 MR SHELDON: That was the role that you were occupying in

19 mid-1999, the period with which we are principally

20 concerned?

21 DR RIORDAN: Yes.

22 MR SHELDON: Can we start please with the role of the

23 Medical Director, the one that you fill? You provide

24 for us in paragraph 2 of your statement a summary of the

25 various elements of your role. Perhaps if I can

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1 paraphrase them: they seem to be firstly to advise the

2 Trust Board on matters affecting the medical services

3 within the Trust?

4 DR RIORDAN: Yes.

5 MR SHELDON: Secondly, to supervise and to facilitate the

6 work of the clinical directors?

7 DR RIORDAN: Yes.

8 MR SHELDON: One of whom was Dr Lachman from whom we heard

9 yesterday?

10 DR RIORDAN: Correct.

11 MR SHELDON: And thirdly, to attend a number of meetings

12 which are organised principally to further the Trust

13 business in a number of fields?

14 DR RIORDAN: Yes.

15 MR SHELDON: As I understand it, the Executive Medical

16 Director post itself -- and we will come on to the

17 clinical governance role in a moment -- that role has no

18 responsibility for the maintenance and monitoring of

19 clinical standards within the Trust, is that correct?

20 DR RIORDAN: Under clinical governance it has.

21 MR SHELDON: Under clinical governance but the Executive

22 Medical Director role which was the one you were filling

23 in mid-1999, at that stage prior to clinical governance

24 did you have responsibility for the monitoring and

25 maintenance of clinical standards?

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1 DR RIORDAN: Yes, I did. Sorry if I had not made that

2 clear.

3 MR SHELDON: Perhaps it is my misunderstanding. As

4 I understood the position from your statement, the

5 advent of clinical governance which is about a year old,

6 is that right?

7 DR RIORDAN: Yes. I cannot remember exactly when the

8 guidance came out. Probably a bit longer than a year

9 but yes, it is about a year. The reason I did not make

10 it absolutely clear perhaps is that -- and perhaps I can

11 do it now -- is that clinical governance is really

12 a ratification or an improvement on what was

13 a relatively informal mechanism previously, whereby

14 I still as Medical Director did accept responsibility

15 for clinical standards and clinical quality. But what

16 clinical governance has done is to take that from

17 a relatively informal rule with no clear mechanisms to

18 one where the mechanisms have been set down as

19 a framework which is an evolving framework.

20 MR SHELDON: I think the way you described it in your

21 statement is the previous system was somewhat piecemeal,

22 is that right?

23 DR RIORDAN: No, that is correct, yes. But the

24 responsibility still rested with me. What I am trying

25 to convey is that it was a relatively informal system.

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1 MR SHELDON: Yes. Informal and piecemeal as it may have

2 been, you were still concerned to know, as Medical

3 Director in mid-1999, what the clinical standards were

4 like?

5 DR RIORDAN: Yes.

6 MR SHELDON: For example in respect of child protection work

7 within the Central Middlesex?

8 DR RIORDAN: Yes.

9 MR SHELDON: How would you get the information upon which

10 you would base your judgment on those clinical

11 standards?

12 DR RIORDAN: At that time I would depend on the relevant

13 clinical director and the designated doctor and the

14 ACPC. I would depend on those mechanisms to bring to my

15 attention if there were problems.

16 MR SHELDON: Would you be having meetings with the relevant

17 clinical director?

18 DR RIORDAN: I would but not specifically about child

19 protection issues.

20 MR SHELDON: We have heard from senior managers in other

21 organisations during the course of this Inquiry and one

22 of the things we have been concerned to know is how they

23 found out what was going on on the ground. There seem

24 to be three principal mechanisms by which they can find

25 out that information. The first is by being told by

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1 their subordinates who pass up the information through

2 the management chain through supervisions. The second

3 is by formal auditing, so requiring surveys and audits

4 to be carried out and then looking at the management

5 data that they produce. And the third is what has been

6 described to us as dip sampling of work, where they go

7 out on to the shop floor and have a look and see in

8 respect of individual cases how good the work is.

9 Now, which if any of those were available to you, in

10 your Executive Medical Director post, prior to the

11 advent of clinical governance?

12 DR RIORDAN: I guess certainly -- well, I guess all three.

13 Sorry, remind me, the first one was ...?

14 MR SHELDON: The first one was bad news travelling up

15 through the management chain.

16 DR RIORDAN: Yes, that certainly was one mechanism I would

17 rely on and the then -- the previous Clinical Director

18 Dr Bridget Edwards who I believe gave evidence, I would

19 expect her to come to me if she had significant problems

20 in any area of paediatrics. On the other hand, I would

21 not formally go through with her at that time child

22 protection issues. I would equally, at that time, have

23 expected the mechanism which I did not understand in

24 detail I have to confess of the ACPC, as a joint body

25 looking at child protection issues, to also involve me

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1 if it, as a body looking at the whole system, had

2 problems. Sorry, what was your second mechanism?

3 MR SHELDON: The second was audits and management

4 information.

5 DR RIORDAN: Well when I refer to a piecemeal system,

6 clinical audit at that time was very much the

7 directorates did what they thought was important, and it

8 was a relatively unstructured system.

9 MR SHELDON: So you would not commission audits yourself,

10 you would just get whatever the ...

11 DR RIORDAN: I would do if I had concerns, so if a problem

12 had arisen about a particular problem I might ask for an

13 audit.

14 MR SHELDON: But one perhaps might say you did not know

15 there was a problem until you had done the audit?

16 DR RIORDAN: Well at that time the system -- you might say

17 that, but then given a very complex organisation you

18 could end up auditing everything and, you know, it just

19 would not be possible. So what clinical governance is

20 trying to do is to address these complexities and give

21 a system that is more systematic.

22 MR SHELDON: The third was dip sampling, going out to the

23 shop floor and seeing what the practice was like on the

24 ground.

25 DR RIORDAN: Again I would do that as part of my everyday

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1 work. I would be around the hospital, I would go into

2 the children's ward, and meet colleagues. Broadly

3 speaking there is still a very effective mechanism to

4 find out whether a organisation is working well enough.

5 MR SHELDON: Should we regard the advent of the clinical

6 governance and the new structures that have come with it

7 an acknowledgement that the previous system of quality

8 assurance was not sufficiently focused and not

9 sufficiently well organised?

10 DR RIORDAN: Yes.

11 MR SHELDON: Should we take it from that, therefore, that in

12 your role prior to the advent of clinical governance,

13 there was not a sufficient mechanism in place for you to

14 accurately be able to assess the standard of clinical

15 work in the hospital?

16 DR RIORDAN: Yes, the system was -- it was no worse than

17 systems in other hospitals. It was a standard system

18 but yes, it was inadequate.

19 MR SHELDON: Because it sounds, and it may be that I am

20 mischaracterising it, but it sounds as if in your

21 position it is a fairly passive role. You are waiting

22 to hear bad news from other people or you are waiting to

23 find out what audits other people have commissioned are

24 going to tell you. There is very little proactive work

25 it would seem in your role to actually find out what is

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1 going on.

2 DR RIORDAN: I would come back to the point that auditing as

3 a proactive process is not -- I do not believe someone

4 in my position, it is the right mechanism of managing

5 a large complex organisation because it becomes a

6 bureaucratic exercise and does not work.

7 MR SHELDON: But now you have a Clinical Governance

8 Committee of which you are the joint Chairman. How does

9 that committee go about getting its information?

10 DR RIORDAN: I would not want you to think that the

11 committee is not the process of clinical governance.

12 Clinical governance, as the circular describes it, it is

13 a ten year plan to set up a framework which will evolve

14 over time to allow the sort of quality assurance you are

15 talking about and I want to have to occur.

16 So the committee is merely at the moment the top of

17 that process, and its function quite frankly at this

18 moment in time is to try and get a complete system

19 working in an organic and evolutionary way. So if you

20 ask me is there a whole series of structured audits now

21 happening reporting up to a Clinical Governance

22 Committee, there is not.

23 MR SHELDON: Is that, though, the aim at the end of the ten

24 year period?

25 DR RIORDAN: The aim at the end of the ten year period, yes,

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1 is that there will be robust systems whereby at the

2 appropriate level of the organisation the quality will

3 be regularly monitored and improved but that does not

4 necessarily mean that that process will get up to the

5 clinical governance level, because in a large

6 organisation if you insist on stuff going up through the

7 hierarchy you have a recipe for paralysis.

8 So it is setting up a system that will devolve the

9 responsibility right down to the shop floor and there

10 are mechanisms for doing this which I have mentioned in

11 my statement which we believe will work, and the

12 Clinical Governance Committee is to oversee that total

13 process, not to know about the total detail.

14 MR SHELDON: So the Clinical Governance Committee, even at

15 the ten year cycle, were somebody to go to it and say,

16 "How was your hospital doing for example in training new

17 SHOs in your procedures? How is your hospital doing in

18 terms of record keeping in child protection cases?"

19 Would they be able to answer that sort of question?

20 DR RIORDAN: They would be able to refer the individual to

21 the correct part of the organisation to get the answer

22 and if the system is working well they would be

23 confident that they would get a positive answer.

24 MR SHELDON: You mentioned some of the mechanisms by which

25 you hope to achieve that in your statement, one of which

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1 I think is the system of formal consultant appraisal.

2 Is that right?

3 DR RIORDAN: Yes, that is one part of it.

4 MR SHELDON: That is not up and running yet, is it?

5 DR RIORDAN: No, it is being introduced at the moment. We

6 are in the process of introducing it.

7 MR SHELDON: One of the things that as I understand it will

8 be discussed during the course of that sort of appraisal

9 will be for example whether the consultant concerned is

10 managing his or her workload effectively. Is that

11 right?

12 DR RIORDAN: Correct.

13 MR SHELDON: So would it have been the case that had this

14 system been up and running in mid-1999, it would have

15 been a possible forum for Dr Schwartz to have used had

16 she wanted to raise her concerns about working on split

17 sites?

18 DR RIORDAN: Yes, it would have been.

19 MR SHELDON: What else are you putting in place in order to

20 get that framework that you mentioned up and running?

21 DR RIORDAN: We are providing training and support to each

22 of the clinical directorates to develop the fundamental

23 building blocks of the system. There are about five

24 different areas of -- five different techniques if you

25 like which applied coherently will produce the sort of

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1 effect that the clinical governance document is aiming

2 at, and we are gradually running a programme of training

3 people at directorate level in these techniques so that

4 they then develop the shop floor mechanisms that

5 I talked about.

6 MR SHELDON: So the responsibility will in effect be

7 devolved down to clinical directorate level?

8 DR RIORDAN: Yes.

9 MR SHELDON: So in effect it will be Dr Lachman's job for

10 example to make sure he is up to speed with the

11 standards of clinical practice within his area of

12 responsibility?

13 DR RIORDAN: Correct.

14 MR SHELDON: And he then, on the basis of the information he

15 is able to ascertain in that way, will report to your

16 committee?

17 DR RIORDAN: Correct.

18 MR SHELDON: So that you are kept up-to-date as well?

19 DR RIORDAN: Correct.

20 MR SHELDON: Now that is still in its early stages?

21 DR RIORDAN: Yes.

22 MR SHELDON: And it replaces a fairly ad hoc system of you,

23 as Medical Director, doing the best you could, talking

24 to the people you thought might be able to give you the

25 relevant information and having a look at audits as and

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1 when they arrive on your desk?

2 DR RIORDAN: Yes.

3 MR SHELDON: You speak about your quality department in

4 paragraph 17 of your statement. What is that and how is

5 that going to help you in this respect?

6 DR RIORDAN: It is a department that we have built up over

7 the years, consisting mainly of nurses who then learn

8 quality improvement techniques, so they learn about

9 audit techniques, they learn about effectiveness, they

10 learn about evidence, but in particular they learn about

11 writing what we call protocols or pathways of care in

12 which a process is dissected, used with all the

13 participants in the process -- so it is looked at very

14 critically by the individuals actually doing the work.

15 It is broken down and it is then built back up into what

16 is thought to be a more efficient process which is then

17 easier to monitor because it produces a structured

18 document of care, which is what the protocol is.

19 MR SHELDON: Is that a new resource available to you or

20 something with which you had --

21 DR RIORDAN: It is something we developed over ten years on

22 an experimental basis. We were one of the first

23 hospitals in the country to adopt this particular

24 approach. It is now being rolled out as widely -- it

25 gets different names: process redesign, process mapping,

22



1 care pathways. It is now being rolled out as

2 a technique across the country for improving the quality

3 of clinical care in what, as I said in my statement, has

4 become a much more broken up system in terms of

5 continuity of care of individuals because of problems

6 with hours et cetera.

7 So much more structure in the documentation and in

8 the approach to care is underlined in this approach and

9 we have been one of the first hospitals in the country

10 to do this. We were doing it in other areas of child

11 protection but I think the lessons we have learned in

12 other areas do seem to me to be applicable to the

13 problems we encountered in child protection in this

14 case.

15 MR SHELDON: Just attempting to understand how all this fits

16 together. It will be the clinical director's

17 responsibility to appraise him or herself of the

18 standards of clinical care within his or her area of

19 responsibility. In order to do that he or she will be

20 reliant on management information, as we have called it,

21 in other fields. The availability of that management

22 information, the clarity of it, will be improved by the

23 sort of work being done by the quality department,

24 namely standardised documentation, protocols and so on.

25 DR RIORDAN: Correct.

23



1 MR SHELDON: Once he or she has used those tools to gain

2 a picture of the clinical standards, he or she will

3 report to the Clinical Governance Committee, and areas

4 of concern can be identified and then addressed. Is

5 that right?

6 DR RIORDAN: Partly correct. The reporting up is part of

7 the process but an even more important part of the

8 process is immediately feeding back into the cycle of

9 improvement at local level where possible. So the first

10 move would be if something -- if documentation for

11 instance is not as good as it should be, immediately

12 taking some action locally to improve that. If it turns

13 out that it is a chronic process because of some

14 resource lack, then moving up the chain to remedy that.

15 MR SHELDON: So the clinical director's report to the

16 Clinical Governance Committee would not simply be, "We

17 have a problem with documentation"; it would be "We have

18 a problem with documentation and this is what I am doing

19 about it"?

20 DR RIORDAN: Yes.

21 MR SHELDON: That is the new system that you are in the

22 process of implementing. In respect of the old system,

23 if for example you had a consultant who was not

24 performing up to the clinical standards you would

25 expect, either because of excessive workload, strain or

24



1 a variety of other reasons, and it meant that that

2 consultant was having insufficient time to do thorough

3 reviews of cases, not around often enough to be able to

4 offer advice in cases in which he or she was needed, and

5 that children as a result in this particular example

6 were being discharged by very junior staff, how would

7 you find out about that as Medical Director?

8 DR RIORDAN: If the problem was with a particular

9 consultant, there would be a number of routes. The

10 individual themselves might come and see me and that did

11 happen on occasions. Colleagues might come and see me,

12 particularly if they thought there was a problem with

13 a colleague being stressed or indeed just being absent

14 for other reasons. Or other members of staff, through

15 the nursing network for instance, either a ward sister

16 or the Director of Nursing may come and say, "We have

17 concerns about Dr X".

18 MR SHELDON: To be clear at the outset, did Dr Schwartz ever

19 come to you and say, "I am finding my workload and

20 dealing with split sites intolerable"?

21 DR RIORDAN: No, we never had a discussion -- we did have

22 a discussion about her working on split sites and

23 I cannot remember exactly when it was.

24 MR SHELDON: Before Victoria's case?

25 DR RIORDAN: It was before Victoria's case.

25



1 MR SHELDON: Can you remember what she said about it?

2 DR RIORDAN: I can remember that she was anxious at the time

3 to get -- to concentrate her work on the Central

4 Middlesex site. She did present to me at that time

5 because of an intolerable burden of work, it was rather

6 more that it would give her a better quality of

7 professional life in terms of allowing her to work on

8 one site and to develop some research interest that she

9 wanted to develop, and I was sympathetic to what she

10 wanted to do but it did not, at the time -- was not

11 feasible to do it.

12 MR SHELDON: The resources simply were not there?

13 DR RIORDAN: The resources were not there and as I say

14 I would like to emphasise it was not presented to me at

15 that time that she was struggling in terms of the two

16 site working, it was just that it would be nicer to be

17 on one site, which I fully accept.

18 MR SHELDON: That is the way she presented it to you in the

19 context of that conversation. Did you hear from any

20 other members of staff, either peers or more junior

21 staff, that they were finding Dr Schwartz was not around

22 as much as they would like or expect?

23 DR RIORDAN: No. Again, I was aware that the Paediatric

24 Department as a whole was -- what shall I say -- working

25 as a cohesive unit but were all working hard to keep the

26



1 system going. Over that particular time I was aware

2 that we could -- we would like to have had more

3 paediatricians and that people working hard to maintain

4 a system. But nobody was saying to me this system is on

5 the verge of breaking down or is dangerous.

6 MR SHELDON: But you were aware, firstly, that you would

7 like more paediatric consultant cover and you were aware

8 of Dr Schwartz's view that she would rather work on one

9 site than two?

10 DR RIORDAN: Yes, I was. I should perhaps say that in

11 context I was also aware that in probably every other

12 department in the hospital I had similar pressures and

13 in some other areas I had actual clinical risk issues

14 that I was trying to deal with.

15 MR SHELDON: But this specifically has been an area which

16 has been revisited, has it not, since Victoria's case?

17 DR RIORDAN: Yes, it has.

18 MR SHELDON: If we could have volume 45H please,

19 page 208.515. We can see the minutes of a meeting that

20 took place on 27th June 2001 and I note from the front

21 sheet that you were not there but it is a meeting to

22 which you refer in your statement.

23 If we turn over to page 517, we can see that

24 enclosed with this paper, which I presume is

25 Dr Lachman's progress report referred to over the page,

27



1 was a summary of the action required to stabilise the

2 situation but increasing consultant sessions at CMH to

3 provide a safe daily presence in the acute area.

4 So we are back to the issue raised before, albeit in

5 the context of scarce resources everywhere of more

6 consultant paediatrician cover at CMH.

7 DR RIORDAN: Yes.

8 MR SHELDON: We are assisted with the detail of those

9 proposals by a paper written in September 2000 by

10 Dr Lachman which is in volume 45I at page 11. Perhaps

11 we could look at that, please. If you wanted to,

12 Dr Riordan, you might want to turn back to page 9, just

13 so you can identify the document that we are looking at.

14 We went through it with Dr Lachman yesterday. It is

15 a paper that he wrote dated 12th September 2001. Before

16 we go to the detail of it, was this a matter that was

17 considered at the Strategy and Performance Group that

18 you refer to at paragraph 2 of your statement?

19 DR RIORDAN: I do not remember whether it was or not.

20 I would have expected normally -- well, whether it was

21 considered before it was proposed to the board

22 I certainly do not know. What I can say is that in

23 terms of developing the proposal for the consultant

24 post, that would have gone through the Strategy and

25 Performance Board at some stage.

28



1 MR SHELDON: Have you ever seen this before?

2 DR RIORDAN: Yes, I have.

3 MR SHELDON: If we look at page 11 under heading number 2,

4 "Consultant Sessions at CMH", we can see that in effect

5 two problems are identified. Firstly, in the first

6 line, "adequate consultant cover at the CMH" but then in

7 addition about three lines up from the bottom of that

8 paragraph the observation that the named doctor for

9 child protection was employed for six sessions only,

10 which as we understood from Dr Lachman yesterday equates

11 to about three days a week.

12 So it would appear that the proposals that were

13 being considered were to address two issues. Firstly

14 lack of consultant cover overall, but in addition the

15 position of the named doctor and the fact that he or she

16 was there not all the time. Is that right?

17 DR RIORDAN: Yes.

18 MR SHELDON: The proposals that were put forward are

19 summarised underneath with a number of bullet points,

20 and it effectively equates, as we discovered yesterday,

21 to about two-thirds of an extra consultant post, about

22 another eight sessions and within that Dr Schwartz, who

23 was the named doctor, would be moving to the CMH

24 full-time, is that right?

25 DR RIORDAN: Yes, that is correct.

29



1 MR SHELDON: Dr Lachman said that those proposals were

2 approved almost straight away.

3 DR RIORDAN: They were approved very quickly in terms of the

4 current mechanisms for getting new consultants approved.

5 I cannot remember exactly how quickly it took to get

6 formal approval because there were about four different

7 hurdles that have to be crossed before the funding is

8 released.

9 MR SHELDON: He certainly did not give us the impression he

10 was fighting a particularly difficult battle in this

11 respect.

12 DR RIORDAN: Not at all, quite the contrary.

13 MR SHELDON: As I understand it, Dr Schwartz has come into

14 that new full-time post as of 1st January this year, is

15 that right?

16 DR RIORDAN: Correct.

17 MR SHELDON: For those of us who are not involved with the

18 paediatric care in hospitals and who heard the evidence

19 of Dr Schwartz, we may have come to the conclusion that

20 it seemed fairly obvious that she was being asked to do

21 an awful lot, even allowing for her commitment, energy

22 and everything else one might expect. Would you agree

23 that being named consultant for two sites significantly

24 distant from each other in London is too much for

25 a consultant?

30



1 DR RIORDAN: It certainly sounds like it to me, although

2 I am not particularly familiar with the workload

3 involved in being a named doctor, which Peter Lachman

4 is. But if he says it is too much then I would accept

5 that.

6 MR SHELDON: One is left with the impression from the

7 evidence that we have heard this morning and yesterday

8 afternoon that although this was clearly a difficulty

9 and a problem and it would seem from this morning's

10 evidence one that Dr Schwartz drew to your attention at

11 least in a different context, it took the tragedy with

12 which we are concerned to push this issue far enough up

13 the Trust's agenda for something to be done about it.

14 Is that a fair assessment of the situation?

15 DR RIORDAN: The tragedy certainly sharpened our minds and

16 clarified what -- yes, got us to the point faster,

17 I accept that.

18 MR SHELDON: That might be thought to be an unsatisfactory

19 state of affairs, might it not; that it takes a tragedy

20 like this before what might manifestly be seen to be an

21 unsatisfactory state of affairs is addressed?

22 DR RIORDAN: I accept that. It is also -- I do accept that,

23 but it is perhaps part of real life that when a tragedy

24 occurs one is focused on something and does something

25 about it within a context where one is struggling all

31



1 the time with balancing difficult priorities and

2 understanding that the picture you have painted of

3 a doctor who -- I forget the words, but is being asked

4 to do a lot was the way I think you phrased it -- a lot

5 of my colleagues are still being asked to do an awful

6 lot and in lots of fields. So what the tragedy did

7 obviously was to highlight a particular doctor being

8 asked to do an awful lot in an area of particular

9 sensitivity and vulnerability and I accept that we

10 should have spotted it sooner.

11 MR SHELDON: This doctor, as you say, had a conversation

12 with you about this issue albeit in a different context

13 and, as you say, not framed in the sense of "I am unable

14 to do my job adequately, children may therefore be at

15 risk" but in a slightly different context. Given that

16 and given your post as Medical Director, if there was

17 a problem within Paediatrics and there was a problem

18 with insufficient levels of care in child protection

19 cases, very junior doctors discharging children and so

20 on, is that not something you should have known about?

21 DR RIORDAN: I guess it is and I think what I was pointing

22 out in the earlier part of my evidence is that in order

23 to know about it one needs robust systems that are

24 structured in order to allow it to happen, which at the

25 time they were not.

32



1 MR SHELDON: You would have needed, would you, in the

2 position you were in, either Dr Edwards to have come and

3 told you about it or the happy coincidence that somebody

4 decided to do an audit of this particular area of the

5 Trust's business at the relevant time?

6 DR RIORDAN: Yes.

7 MR SHELDON: And neither of those things happened?

8 DR RIORDAN: Or -- as I say the third failsafe would have

9 been the ACPC, which my understanding is it was

10 a mechanism for reviewing these things at regular

11 intervals, I could have also expected that to have

12 pointed out some problems to me.

13 MR SHELDON: One of the other difficulties with which we

14 have been acquainted at the time in relation to the

15 paediatric care of children with suspected abuse was the

16 level of training given to staff and also their

17 familiarity with the guidelines that they were supposed

18 to use.

19 Now if you could have volume 40, page 56. There is

20 a copy of the guidelines that we were told were enforced

21 at the time. This is a child protection pack,

22 Dr Riordan. If you turn over the page to page 57 and

23 look at the very bottom of the page you will see it is

24 produced by Dr Schwartz in April 1997. She confirmed to

25 us it was what was current at the time with which we are

33



1 concerned with.

2 Over the page to page 58 there is reference in the

3 left-hand column to both interagency Child Protection

4 Guidelines and procedures which should be available in

5 all departments, and also internal Child Protection

6 Guidelines which should also be available within all

7 departments.

8 First of all, were you even aware that there was

9 a child protection pack in operation at the time?

10 DR RIORDAN: No.

11 MR SHELDON: Even taking into account the numerous different

12 fields with which you must necessarily be concerned as

13 Executive Medical Director, is it not reasonable to have

14 required you at some stage to have enquired what if any

15 guidelines staff were working from in relation to child

16 protection matters in the Trust?

17 DR RIORDAN: Quite honestly I would not see that as part of

18 my role. I would have expected with a former mechanism

19 like the ACPC and designated named doctors with

20 responsibility and with a clinical director with

21 a knowledge of that area, I would have expected that to

22 be their responsibility and the fact that they exist --

23 I would expect this to exist. I would not expect to

24 know about it.

25 MR SHELDON: So in the absence of anything, so if you do not

34



1 hear anything you can safely assume there are

2 guidelines, they are available and they are being used

3 adequately?

4 DR RIORDAN: I certainly would not make that assumption

5 about any set of guidelines, and this if you like

6 illustrates why clinical governance is being brought in.

7 There are shelves in every hospital in the country full

8 of guidelines about every conceivable problem, many of

9 them are this thick or thicker, and as a mechanism for

10 ensuring quality they are not terribly effective. They

11 do need to be done to codify what should happen and to

12 use as an educational resource, but in terms of staff,

13 every member of staff familiarising themselves with

14 every pack of guidelines of this detail of this sort, it

15 is just not practical and I personally did not see it as

16 my role to go around and say, "Do you know about this

17 guidelines, that guidelines" and so on.

18 It is a fundamental point of medical management

19 here -- which I keep coming back to -- which is why this

20 sort of approach, while it is important for the people

21 managing as I say to codify what they are doing, is not

22 the way of actually ensuring that proper standards are

23 adhered to because people do not read these guidelines.

24 MR SHELDON: That might be a slightly depressing, certainly

25 for us but perhaps particularly for Dr Lachman who has

35



1 spent the last three months writing 130 pages of

2 guidelines that we went through in some detail

3 yesterday.

4 DR RIORDAN: They are an excellent educational resource.

5 The difference between Dr Lachman's guidelines and this

6 is that in there he has a protocolised document of care

7 which when it is audited will allow people to see

8 whether the guidelines are being followed or not. The

9 problem about standard old-fashioned guidelines is they

10 say what should be done but they do not provide

11 a mechanism for ensuring that it is done.

12 I have given up reading them years ago because

13 I know for people who write guidelines they put them on

14 the shelf, so that is why I have spent the last

15 ten years working with the Quality Department saying let

16 us get the key points of a particular guideline for

17 a particular member of staff into the working document

18 where it is there in front of them when they are doing

19 their day's work, and then let us also build into that

20 system a way of auditing in real time -- and I quote

21 you -- examples in other areas of our work where this

22 happens and works, and where guidelines have sat on

23 shelves gathering dust and not been implemented.

24 MR SHELDON: So it is not an entirely pessimistic picture

25 you paint. It is not that guidelines are not followed,

36



1 it is that you have to have the right sort of guidelines

2 and they have to be short on verbiage and heavy on

3 practical documents you can get into the habit of using

4 on a daily basis?

5 DR RIORDAN: Yes, and the other point I am making is that

6 people like me cannot spend time going through the

7 guidelines and being familiar with them, it is not part

8 of my job.

9 MR SHELDON: That is not what I wanted to ask you. I wanted

10 to know whether you knew they even existed. Because

11 what you say about guidelines I am sure is right and

12 borne out of long experience, but one might have thought

13 that this is a difficult and complex area, that there

14 are difficult issues such as for example the

15 relationship with Social Services and the protocols that

16 have to be followed to ensure that children do not slip

17 through the net.

18 You have to know what happens with police

19 protection, you have to know what an emergency

20 protection order is, you have to know how to make

21 a referral, and staff, when they are looking after

22 children and these issues arise, need to know where to

23 go to find that out and so you have to have something

24 down to tell them, have you not?

25 DR RIORDAN: I fully agree.

37



1 MR SHELDON: So did you not want to know whether there was

2 something down to tell them?

3 DR RIORDAN: No, whether I was correct or not, I had

4 confidence in Dr Schwartz and Dr Edwards that systems

5 existed to do this, to make staff aware of their

6 responsibilities. Now, the systems were not perfect as

7 I have said; with the methodology we are now using we

8 have better systems. On the other hand, my reading of

9 the earlier evidence was that people ordinarily speaking

10 had a high level of awareness of the actual, certainly

11 the diagnosis of child abuse and were aware of what

12 their particular role was.

13 MR SHELDON: Yes, but what they did not have a high

14 awareness of, I might suggest to you, is either this

15 pack or the guidelines that are referred to in it. We

16 asked Nurse Graham about it, she said no interagency

17 ones on the ward and cannot remember any agency ones.

18 Dr Beynon said never seen this or anything else in the

19 way of guidelines. Dr Dempster neither, although

20 unsurprisingly she was only there for a day. But none

21 of the key people seem to be aware of guidelines as to

22 how to deal with a child abuse case. That is

23 unsatisfactory, is it not?

24 DR RIORDAN: It is, but the mechanism for making their

25 awareness -- I keep coming back to this -- the mechanism

38



1 is not production of a pack like this which is important

2 as an overall resource, the mechanism is to get

3 something in the working documentation close to the

4 place of work. So a proper discharge form sitting on

5 the ward would overcome -- the fact they do not know

6 there is a guideline, if there is a proper discharge

7 form they know they have to fill in which guides them

8 through it, that in my view is the approach rather than

9 say, "Do you know the guidelines? Have you been through

10 them?" Because I promise you you will turn people off

11 because there are too many guidelines. You will turn

12 people off. So you say to doctors, "Are you familiar

13 with the guidelines of X, Y?" They will say no because

14 they do not carry them around in their head.

15 MR SHELDON: But what they should be familiar with are the

16 appendices in which the forms they need to fill out are

17 contained?

18 DR RIORDAN: They should be familiar with the key principles

19 that are for their particular role and then the system

20 should enable them to have access -- to be reminded of

21 those key principles when they are dealing with a case.

22 That is the idea.

23 MR SHELDON: The difficulty with that though Dr Riordan in

24 light of the evidence that we heard yesterday is that it

25 is not simply a question of being au fait with the key

39



1 principles, interests of the child, listening to the

2 child, this sort of thing, because there are, as we

3 heard yesterday, now instituted a number of reasonably

4 complicated and specific procedures. For example, we

5 found that making a referral and chasing the referral up

6 is a seven stage process: you make a call, you write

7 a letter ten days after discharge, you do something

8 else. It is not just enough to say as well as they know

9 basically the key principles, they have to know the

10 procedure, otherwise Dr Lachman has been wasting his

11 time and we may find ourselves in the same position

12 again.

13 DR RIORDAN: No, I am sure he has not. They have to know

14 the key principles and they have to have clear processes

15 for achieving the key objectives, which is I think what

16 that seven stage process is. Now, I am not familiar

17 with the process.

18 MR SHELDON: No, but you would expect them to be.

19 DR RIORDAN: Yes, and I would further predict that if it is

20 a complicated process, first of all people will, as they

21 begin to use it and monitor it, will find that it may

22 need simplification in order to be put into effect

23 100 per cent, and this is what this continuous approval

24 methodology I am talking about, this is the principle

25 that underlies it.

40



1 So what I am saying is Peter Lachman has made a good

2 start in putting these sort of things into place. There

3 is now a continuous job to be done of allowing the staff

4 to work through these key areas of work, look at their

5 work, see whether it is working and, if it is not,

6 change it. That is not me saying, "Here is the

7 process", that is them saying, "This is our process, we

8 are looking at it" and if it has seven stages it may

9 well be too cumbersome, it may need review, and a quick

10 cycle of audit on that will show whether it is or not.

11 It may be the only way to do it, I do not know.

12 MR SHELDON: And you will want to be hearing about that in

13 the Clinical Governance Committee, will you not, from

14 him, and you will want to be asking him, "How are these

15 new procedures working?"

16 DR RIORDAN: Exactly, and I would see my role as then

17 saying, "If it is not working, let us change the

18 methodology. Let us not just blame the people and say

19 they were just too careless and did not do it". It is

20 usually a system problem when a guideline is

21 persistently ignored.

22 MR SHELDON: Can we look briefly now at the question of

23 note-taking and documentation. I appreciate that in

24 your position this is not something that you are going

25 to be able to monitor in every ward in the hospital in

41



1 every specialisation, but as Medical Director is one of

2 the things that you are concerned to know how well

3 documentation is kept, how well notes are kept, and key

4 points in the care of a patient recorded?

5 DR RIORDAN: Yes.

6 MR SHELDON: And pre-clinical governance, how did you find

7 out?

8 DR RIORDAN: From time to time we would have audit --

9 actually hospital audits of note-taking, which we would

10 then feed back in meetings and broadly speaking remind

11 people and encourage people that -- that we would nearly

12 always find it was inadequate and we would just keep

13 reinforcing the message, it is important to write better

14 notes.

15 Now over the years -- I have been working as

16 a consultant since 1975, in hospital since 1964 -- over

17 the years, despite the fact that notes still have

18 glaring deficiencies in them, I can tell you that they

19 are vastly better than they used to be. Unfortunately

20 the fact that they have improved is not good enough

21 because at the same time as they have improved, the

22 continuity of medical care has deteriorated because of

23 hours of work et cetera.

24 So there is a problem and the old-fashioned method

25 of just auditing it and urging people to do better was

42



1 of limited success, which again is why I believe firmly

2 that the approach we are now adopting of structuring the

3 notes so that they can be audited day by day on the ward

4 by the staff concerned gives you a vast improvement.

5 We have evidence in areas where we have high levels

6 of protocols to show the documentation is vastly better.

7 We also have evidence to show that with structured

8 documentation nurses spend more time with the patient

9 and less time writing.

10 MR SHELDON: Is this something that is taken genuinely

11 seriously by the Trust, because as you say it is

12 something that always comes up, each time you do the

13 audit it is unsatisfactory, and one wonders the extent

14 to which one shrugs one's shoulders and says oh well,

15 doctors and their notes, it is always a problem, and it

16 is not really taken as seriously as it needs to be.

17 DR RIORDAN: Well, I think the Director of Nursing and

18 I take it passionately in the sense that we understand

19 the problem of trying to get doctors particularly to

20 write notes and we understand that the methodology of

21 audit broadly speaking does not work, and we have been

22 campaigning for ten years to develop this structured

23 system that I keep talking about which improves

24 documentation demonstrably and reproduceably and

25 continually.

43



1 MR SHELDON: So the sort of documentation that we were

2 looking at yesterday with Dr Lachman where there are

3 revised forms, it is clear what information is supposed

4 to go where and it is measurable whether or not that

5 information is put in, that is a hospital-wide approach,

6 is it?

7 DR RIORDAN: It is. It is one -- we have not got it in

8 every area of the hospital yet because righting the

9 pathways and educating people to use them is a complex

10 process, and as I have said, it is also time-consuming

11 because it involves the actual individuals who

12 understand the job taking time out, or being given time

13 out to sit down and analyse the process, write the

14 protocol and then work their way through a number and

15 revise it. But it is time well spent and we have

16 a policy of encouraging this in every department.

17 It is a cultural change for hospitals that have not

18 done it before and having come from one hospital where

19 it was moderately developed but still developing to one

20 where it is a new thing, one finds that takes a long

21 time to get people to move from an old system to a new

22 system.

23 MR SHELDON: And this is something again that you will be

24 asking, if he does not tell you, Dr Lachman on the

25 Clinical Governance Committee, how these new forms are

44



1 filled in, are they filled in adequately?

2 DR RIORDAN: Absolutely.

3 MR SHELDON: And how many people are signing body charts for

4 example?

5 DR RIORDAN: Absolutely.

6 MR SHELDON: And if he did not tell you, you will ask him,

7 will you?

8 DR RIORDAN: Yes.

9 MR SHELDON: That is how it is now going to work, is it?

10 Rather than waiting for the audits to come to you, if

11 there is no audit you will say it is about time we found

12 out how good the documentation was in this area?

13 DR RIORDAN: Yes. Once the system has bedded down I will

14 ask him to define for me some what we call key

15 variances, which are the key areas of that document that

16 must be filled in, and if they are not they are a marker

17 for poor quality or poor work. What we will be doing

18 for all these pathways is asking each area to identify

19 key variances, then to monitor them and then report them

20 up to the Clinical Governance Committee.

21 MR SHELDON: Can we turn now to look at the response of the

22 Trust after Victoria's death and immediately thereafter.

23 We have already looked in part at this in the context of

24 the conversations you were having about increasing

25 paediatric consultant cover and Dr Schwartz's transfer

45



1 recently implemented to the single site.

2 Why did it take so long and I think the first

3 reference we have to that is the June 2000 meeting. Why

4 did it take so long to start having this conversation?

5 DR RIORDAN: Sorry?

6 MR SHELDON: Well Victoria died in February 2000.

7 DR RIORDAN: Yes.

8 MR SHELDON: You say in paragraph 8 of your statement that

9 the Trust Executive was made aware of the circumstances

10 of her death in April 2000 when the police came to take

11 statements.

12 DR RIORDAN: Yes.

13 MR SHELDON: It is not until 18 months or so later that you

14 are looking at how to improve consultant paediatric

15 cover in the CMH. Why did it take so long?

16 DR RIORDAN: Because we were not aware at that stage that

17 the primary issue was consultant cover. The problem was

18 originally brought to my attention as a result of

19 a leaked report to the press before the murder trial and

20 the initial problem I had to deal with was of one of my

21 doctors, who in my view was and is an excellent

22 paediatrician and a competent child protection doctor,

23 even though she made significant errors in this case,

24 but as a general statement I still believe that to be

25 true.

46



1 I was faced with the position that this doctor was

2 being pilloried in the national press as not knowing the

3 difference between scabies and serious child -- physical

4 child abuse. So my immediate concern at that time was

5 first of all to establish, did I have a totally

6 incompetent doctor on my hands, in which case I would

7 have had to have suspended her, or a dangerous doctor?

8 So that was one of the tasks I set myself, was to

9 establish that by an informal mechanism, knowing that

10 there was -- there were formal inquiries going on, both

11 in terms of child protection and in terms of the murder

12 trial.

13 My other concern was to provide psychological

14 support to somebody who was being put under very serious

15 pressure by this adverse publicity and my other concern,

16 frankly, was that if I did not do that for her as an

17 individual, and I had a responsibility to her as an

18 individual, I would be left in a position where I would

19 not have somebody to do the child protection work that

20 she was doing; in other words, what you are describing

21 as an inadequate situation would have become a totally

22 uncovered situation.

23 Now as I say, the deficiencies that have since come

24 out in detail with the detailed scrutiny at that time

25 I was unaware of and I saw my role at that time as

47



1 dealing with these other issues first.

2 MR SHELDON: Certainly I see that, and I do want to come on

3 to your dealings with Dr Schwartz on an individual basis

4 in just a moment, but it was something that you said at

5 the outset of that answer which I would like to clarify

6 with you, which is that it was at the criminal trial

7 where you read in the press that there were difficulties

8 with the way in which the hospital had handled the

9 situation.

10 What I wonder is whether or not you did not know

11 much earlier than that. I mean the police came

12 in April 2000. You would have known from your own

13 notes, the hospital's own notes, that the child had been

14 admitted with suspected non-accidental injury, they had

15 been under police protection and been discharged home

16 the next day into the hands of the people that

17 eventually killed her. Now is that not enough

18 information for you to think we need to take an urgent

19 look at our child protection systems?

20 DR RIORDAN: Well, I did not think that. What I did was

21 I took advice from our risk manager who had collected

22 all the information for the police and I took advice

23 from the other paediatricians as to whether there was an

24 immediate problem that required urgent attention.

25 MR SHELDON: An immediate problem with Dr Schwartz?

48



1 DR RIORDAN: With child protection in Central Middlesex and

2 Dr Schwartz.

3 MR SHELDON: I see, you did ask that first question as well?

4 DR RIORDAN: Yes.

5 MR SHELDON: We can contrast that approach, though, with for

6 example the approach taken by Haringey which has been

7 criticised for not taking management decisions quickly

8 enough in other forums, but as soon as news of

9 Victoria's death reached them the Assistant Director

10 ordered an audit of child protection cases in the

11 district offices which was on her desk by April 2000.

12 So she was entirely aware at that stage of what the

13 position was on the ground and one can contrast that,

14 cannot one, with the position with the CMH, which seems

15 to have been "wait for the Brent Part 8 report to come

16 out and see what we are told to do".

17 DR RIORDAN: It may seem like that. It was, as I say,

18 partly -- it was based on advice from people on the

19 ground that the system while it may not be perfect was

20 not dangerously flawed, and it was based on a view that

21 me personally, investigating in that sort of detail ...

22 I mean, I believed then and I still think I need some

23 convincing otherwise, that me doing a detailed audit in

24 a top down way of what happened in the context that

25 I have just described was not going to be helpful. Now

49



1 this may be difficult to put across but it is what

2 I believe.

3 MR SHELDON: It would not be helpful because of the

4 psychological impact it may have on the principal member

5 of staff concerned?

6 DR RIORDAN: Partly for that reason, yes. In fact largely

7 for that reason, I guess.

8 MR SHELDON: One might suggest that there are more important

9 considerations, might not one, Dr Riordan? One might

10 say, "what I have to do as a matter of urgency is to

11 make sure this is not likely to happen again"?

12 DR RIORDAN: Yes. And I did have discussions with

13 particularly Dr John Loftus, and I did -- again, I am

14 sure I had discussions with Peter Lachman about are

15 there things we need to do immediately that need to be

16 done? Now that is -- yes, I accept that I could have

17 adopted a different approach, but I did not, and if I am

18 going to be criticised for that I will take the

19 criticism.

20 I did what I did which was my best judgment at the

21 time. While it may not look good on paper I think it

22 was a reasonable thing to do in the circumstances in

23 which I found myself.

24 MR SHELDON: There was at least one audit done afterwards

25 which we looked at with Dr Lachman yesterday. Perhaps

50



1 you could have a look at it now. It is volume 45I,

2 page 16. It is an audit which deals with 56 child

3 protection cases in the Central Middlesex between

4 I think May to September 2000 of which 39 could be found

5 and so 39 were looked at in detail. I do not want to

6 deal with the contents in detail with you because

7 Dr Lachman dealt with them with us yesterday. Are you

8 able to tell us who commissioned this report? Was it

9 you or your committee?

10 DR RIORDAN: No, I have not seen this report. This would

11 have come from either Dr Lachman or Dr Loftus. This --

12 or the ACPC. I do not know.

13 MR SHELDON: I wonder, pausing there, the extent to which

14 the fact you had not seen it might be thought to be

15 either revealing or concerning, because now we are in

16 the new clinical governance situation where you and your

17 committee are concerned to monitor clinical standards.

18 We have here a survey of child protection cases which

19 might be thought to be a fairly hot topic within the

20 hospital at the moment and something at least reasonably

21 close to the top of your agenda.

22 It comes up with some worrying conclusions, not

23 least the fact that only 39 out of 56 of the sets of

24 records could be found, and although Dr Lachman said we

25 have to look behind the audit before we can accurately