Archived Transcript for 29 January 2002: Pages 1 to 50



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1 Tuesday, 29th January 2002

2 (10.00 am)

3 THE CHAIRMAN: Good morning ladies and gentlemen. You will

4 recall that on 18th January I heard oral submissions

5 from Mr Anthony Hudson on behalf of ITN, BSkyB and LNN

6 in support of their application for me to grant

7 permission for the video recording of Carl Manning's

8 evidence to be broadcast. I also heard from

9 Neil Garnham QC who, while adopting a neutral stance to

10 the merits of the application, summarised the arguments

11 against broadcasting that might be advanced on behalf of

12 Carl Manning, who is of course unrepresented. At the

13 time he gave evidence by video link, Carl Manning

14 indicated his opposition to such a broadcast.

15 In addition to the oral submissions, I have given

16 careful consideration to the detailed written

17 submissions on behalf of the applicants together with

18 two bundles of authorities supplied by them. I have

19 also considered the written submission from

20 Mr David Mason on behalf of the NHS bodies that he

21 represents.

22 The applicants rightly in my view place considerable

23 emphasis on the importance of the public receiving the

24 best possible information about the proceedings of this

25 Inquiry. They stress that the proceedings could be most

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1 accurately and comprehensively reported by broadcasting

2 them. They rely on Article 10 of the European

3 Convention on Human Rights which requires that any

4 restriction on the right to freedom of expression must

5 (a) be prescribed by law, (b) pursue a legitimate aim

6 and (c) be necessary in a democratic society. They

7 contend that a refusal to permit broadcast of

8 Carl Manning's evidence would be a breach of their right

9 to freedom of expression and of a potential viewer's

10 right to receive information. They argue with some

11 force that the concepts of open justice must be updated

12 to reflect the technological advances of the 20th and

13 21st centuries.

14 I have read with care their argument in support of

15 this proposition and considered the precedents set by

16 other inquiries. They emphasise that Carl Manning's

17 evidence has already been recorded and therefore

18 broadcasting of his evidence will not affect its content

19 or quality. Self-evidently that is the case.

20 Against the submissions advanced by the applicants

21 I must weigh the submissions advanced on behalf of the

22 various NHS bodies and the points made by Mr Manning and

23 Mr Garnham. In summary, the arguments against broadcast

24 are as follows.

25 Mr Garnham told me that Mr Manning was assaulted in

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1 prison following publicity given to this Inquiry at an

2 earlier stage. It is argued that in those circumstances

3 I should consider other Convention Articles that might

4 point to a different conclusion, namely Article 2, the

5 right to life, Article 3 which prohibits inhuman and

6 degrading treatment and Article 8 which guarantees

7 respect for private life.

8 It is said that it would be wrong to treat Manning's

9 evidence differently from that of other witnesses. I am

10 referred to Article 14 of the Convention which prohibits

11 discrimination in the enjoyment of other Convention

12 rights. I have to consider, so it is said, whether

13 there is any justification for a difference in treatment

14 as between Manning and other Inquiry witnesses. I am

15 asked to consider whether it is right that his evidence

16 should be liable to be broadcast as a consequence of the

17 fact that Manning is in prison and the Inquiry has

18 decided to receive his evidence in this particular way.

19 It is said that this application is not simply an

20 attempt to exercise freedom of expression. It is in

21 reality an application for permission to obtain and use

22 a copy of a video recording that has been made for the

23 Inquiry purposes.

24 Since Mr Hudson's oral submissions were delivered

25 I have received further correspondence from ITN. I have

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1 to say that that correspondence reflects the greatest

2 credit on ITN and the other applicants. It has come to

3 their attention that Dame Janet Smith, Chair of the

4 Shipman Inquiry, has now questioned whether her decision

5 to permit televising of Phase II of that Inquiry is

6 lawful, given the terms of Section 9 of the Contempt of

7 Court Act 1981.

8 I take the view, having received advice from

9 Mr Garnham, that that section is not directly relevant

10 to this Inquiry because unlike Dame Janet I am not

11 appointed under the Tribunal of Inquiry Act of 1921.

12 Nonetheless, as ITN acknowledge, Dame Janet's

13 reconsideration of the point does reduce the impact of

14 what might otherwise have been thought to be a useful

15 precedent and I am very grateful to ITN for bringing

16 this to my attention.

17 It is agreed between Mr Hudson and Mr Garnham that

18 this is a matter for my discretion. It has not been

19 suggested that the law compels one conclusion or the

20 other. It is for me to do what appears to be the right

21 thing, having balanced the competing considerations and

22 taken into account the arguments of all those concerned.

23 That is what I have done. Mr Hudson describes what

24 transpires in public proceedings as public property.

25 That might be right and it might well reinforce the

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1 right of the press to be present in this room and to

2 report the proceedings but it does not in my view of

3 itself compel a conclusion that the Inquiry should make

4 available the video recording of Manning's evidence.

5 Mr Hudson advanced his case persuasively but there

6 are two factors that I regard as particularly important.

7 Both seem to me matters that I should take into account

8 under Article 10.2 and in considering the position under

9 English domestic law. Either of these factors taken

10 alone would lead me to reject this application. Taken

11 together, they seem to me to make the case against the

12 grant of permission overwhelming.

13 First, it seems to me that I should attach

14 significant weight to the fact that Carl Manning has

15 already been the subject of an assault in prison. In

16 this context what concerns me is not the seriousness of

17 the previous assault but the risk of another, the

18 gravity of which it would not be possible to predict.

19 Television is a powerful medium and in my view the risk

20 of further assault will be increased were I to grant

21 this application. There will of course be some risk in

22 any event because of the publication of his evidence on

23 the Internet and further publicity in the written media,

24 but in my view the risk would be significantly enhanced

25 by permitting the broadcast of the video. These factors

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1 are relevant to Manning's Article 2 and Article 3

2 rights.

3 Second, in my view there would need to be powerful

4 reasons to justify treating Manning's evidence in

5 a different way from that of other witnesses. The vast

6 majority of witnesses, including Kouao, have given their

7 evidence live and in person in this room. Four

8 witnesses, of whom Manning is the last, have given their

9 evidence by video link and their evidence has been

10 recorded and the video shown in the Inquiry room.

11 Manning's evidence has been taken by way of video link

12 largely for reasons of administrative convenience, to

13 save expense and as a result of his prior agreement to

14 cooperate with this Inquiry.

15 I note that when I announced my decision that

16 television cameras would be allowed into the Inquiry

17 room for the opening statement by Counsel to the Inquiry

18 but not thereafter, no application was made by any of

19 the applicants or any other broadcasting authority. Nor

20 was there any application for permission to broadcast

21 the evidence of the other witnesses who gave evidence by

22 video link. I take the view that Manning's Convention

23 rights are involved and that there is no adequate

24 justification for permitting him to be treated in

25 a different way to the other Inquiry witnesses.

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1 I have throughout emphasised the importance I attach

2 to the Inquiry proceedings being open and transparent.

3 This I believe has been achieved through the procedures

4 already adopted, in particular the fact that these

5 proceedings are open to the public and the fact that the

6 transcripts of evidence are published on the Internet.

7 The latter is a medium increasingly available to the

8 public and provides access to those who are interested

9 in reading the evidence.

10 The video recording of Manning's evidence will be

11 played during the course of the Inquiry's public

12 sessions, probably tomorrow afternoon I am advised, and

13 the press and the public will be able to see and hear

14 him on the screens around the room. A transcript of

15 that evidence will be published on the Internet in the

16 usual way. I note Mr Hudson's point that there are

17 members of the public who cannot get to the Inquiry room

18 and who without a television broadcast of the evidence

19 would not see the demeanour of the witness or the way in

20 which the evidence is given. That is plainly relevant

21 to my decision but in my judgment does not outweigh the

22 factors to which I have referred.

23 For those reasons I have decided to refuse the

24 application. I would add that I have proceeded on the

25 assumption that Article 10 is directly relevant to this

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1 application. In fact, I see real difficulties in

2 reading into Article 10 a requirement that the Inquiry

3 should furnish broadcasters with a copy of material the

4 Inquiry proposes using in public hearings. It seems to

5 me as a layman that the Convention simply does not go

6 that far. But be that as it may, I have decided that

7 this application should be refused.

8 Thank you very much. Mr Garnham.

9 MR GARNHAM: Thank you sir, Ms Gibson will call the first

10 witness for today.

11 THE CHAIRMAN: Ms Gibson.

12 MS GIBSON: Thank you sir. Before I begin, I have been

13 asked to mention on behalf of the Climbies that they are

14 not in the room because their translator is not here yet

15 but they are waiting in their waiting room and they do

16 not intend any discourtesy by not being present.

17 THE CHAIRMAN: That is very thoughtful, thank you very much

18 indeed for letting me have that information. I fully

19 understand.

20 MS GIBSON: If I could call Lesley Moore to give her

21 evidence.

22 MS LESLEY MOORE (affirmed)

23 MS GIBSON: Good morning.

24 MS MOORE: Morning.

25 MS GIBSON: Would you give the Inquiry your full name and

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1 professional address please.

2 MS MOORE: My full name is Lesley Moore. My professional

3 address currently is with the London Borough of Enfield,

4 Silver Street, Enfield Town.

5 MS GIBSON: You have made one statement for the Inquiry --

6 sir, it is volume 1, page 238.251 in the witness bundle.

7 I think you have a copy of that statement in front of

8 you.

9 MS MOORE: Yes I do.

10 MS GIBSON: Are there any amendments that you would wish to

11 make to the statement?

12 MS MOORE: No, not particularly. I mean it can be updated

13 a little bit.

14 MS GIBSON: We will do that in the course of your evidence.

15 Can you confirm that you have signed the statement at

16 the end and that the contents are true to the best of

17 your knowledge and belief?

18 MS MOORE: Yes.

19 MS GIBSON: You are Assistant Director for Children and

20 Families Service in the London Borough of Enfield; is

21 that correct?

22 MS MOORE: Yes.

23 MS GIBSON: You were seconded into that post I think on

24 a temporary basis on 1st July 2000?

25 MS MOORE: That is correct.

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1 MS GIBSON: And that post is due to be permanent, a recruit

2 is due to come into that post later this month?

3 MS MOORE: On 4th February, next week.

4 MS GIBSON: So you will be leaving that post at that point?

5 MS MOORE: That is correct.

6 MS GIBSON: Can I ask you firstly about some of the

7 organisational weaknesses that you mention in your

8 statement that existed in Enfield prior to

9 reorganisation. It is correct that at the time that

10 Enfield were dealing with Victoria's case that hospital

11 social workers were managed by the Assistant Director

12 for Adult Services?

13 MS MOORE: That is correct.

14 MS GIBSON: What is your view of the adequacy of that

15 arrangement that existed at that time?

16 MS MOORE: The arrangement were very clear but there was an

17 understanding that the social workers that dealt with

18 children's cases ought to be line managed within the

19 Children and Families Division and so clearly there

20 needed to be improvements to those line management

21 arrangements. But the way that the department had dealt

22 with that was to ensure that those staff in the --

23 dealing with children and families work were given

24 direct access to advice through consulting with a number

25 of key players within the Children and Families

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1 Division, so they always had at hand the appropriate

2 expertise and advice that they needed in order to carry

3 out the work.

4 MS GIBSON: Would you agree that it was less than desirable

5 that those social workers dealing primarily with cases

6 involving children were line managed by people who did

7 not have that background?

8 MS MOORE: Yes, I think that is right.

9 MS GIBSON: You describe the arrangements as not being

10 robust in your statement. In what way not robust?

11 MS MOORE: I think the delays in organising the structures

12 were difficult in themselves and had -- I mean caused

13 difficulties for the staff involved in terms of knowing

14 what was going to happen and when things would be

15 resolved and they had also got in the way of anybody

16 taking sufficiently clear responsibility for updating

17 procedures, and so that is something that once I arrived

18 we began to address even though we did not have line

19 management responsibility, because they were clearly out

20 of date and in need of updating, bringing in line with

21 current Government guidance and so on, and that had been

22 outstanding really for too long.

23 So although the staff had access to the right people

24 to give them advice about what should happen and what

25 was in current guidance, it was not readily available to

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1 them in the form of accessible written practice guidance

2 and procedure.

3 MS GIBSON: I think you would agree that the delay in

4 reorganising and making sure that they had that guidance

5 was unacceptable?

6 MS MOORE: I do not think we can argue that it was

7 acceptable. Clearly it was not and the longer it went

8 on the more difficult that got. But I can tell you that

9 story from the point at which I arrived in the course of

10 this process.

11 MS GIBSON: We know from Lesley Carr's evidence that it

12 certainly took some two years from her coming into the

13 post, her post in April 2001 for that new management

14 structure to be put in place. You came into your post

15 in July 2000. Firstly, during the period from when you

16 took up the reins can you explain the delay in sorting

17 out that reorganisation?

18 MS MOORE: Yes, I will give it a good shot. The most

19 immediate thing from my point of view when I became line

20 manager of Lesley Carr and the staff within the

21 Children's Division was that the proposals that were on

22 the table at that point about how this structure of the

23 hospital social worker teams should look in my view were

24 not correct. The proposal was to pull hospital social

25 workers out of the hospitals and relocate them in the

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1 community, which I felt was not acceptable.

2 I have experience in the past of working in

3 a hospital, I know how those services need to operate,

4 the close communication that needs to happen on a daily

5 basis between the medical team and social workers and so

6 on, and so in that sense you could say that I was

7 responsible for putting the plans that were beginning to

8 emerge at that time on hold.

9 The other thing that was happening was that there

10 were plans to restructure and reorganise services across

11 the whole Social Services Department, so it was not just

12 a question of throwing the hospital teams up in the air

13 and deciding where they may land in a better place, but

14 also all the teams right across the community in Adults

15 and Children's.

16 At the time when I arrived and over that summer

17 period, July, August, September, there were a series of

18 group management teams it is called, the senior

19 management team meetings, specifically on the issue of

20 how to paint a more appropriate picture across the

21 group, and the other influences on that were that there

22 had been a joint review of the department which had made

23 recommendations about strengthening policy and

24 commissioning functions and there were all sorts of

25 internal and external drivers to rethink just about

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1 everything, and so it was quite a complex task.

2 In the meetings that we had over that summer period,

3 there were difficulties within the senior management

4 team about agreeing what that structure should look

5 like, although we were beginning to resolve those

6 difficulties by the beginning of autumn, October.

7 At that time we were pulled up in our tracks by two

8 things. Firstly, the director at that time, Easeman,(?)

9 became suddenly ill, he was taken ill at a corporate

10 management team meeting, quite seriously ill, and was

11 then off sick for quite a substantial period of time

12 and, as is the way of things, there was then within

13 a matter of moments a very major financial crisis there

14 for us to deal with in relation to the rest of the

15 group, that simply, to take you through that, there was

16 a projected overspend of about -- I am struggling to

17 remember the amount but it was a considerable amount of

18 overspend, and we had to then divert all attention of

19 the remaining senior management team without a director

20 to addressing that budget crisis.

21 That took up the time between the director becoming

22 sick and the Christmas period. An awful lot of quite

23 extreme measures were put in place, eligibility criteria

24 were tightened, there were political issues in relation

25 to implementing that, and to be honest with you the

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1 whole of the senior management group's time was taken up

2 in dealing with the practicalities of that and putting

3 that straight so that we did not end up without the

4 money to run a service.

5 That was put straight over those months and in

6 the January of 2001 an interim director was brought into

7 post to cover and from January 2001 we began, having got

8 the worst of the financial crisis out of the way, to

9 revisit the structural reorganisation and it was the

10 priority to do that, we were acutely aware of the impact

11 that the delay in dealing with it was having on all

12 staff, including the hospital social workers, and we

13 then worked very quickly in the early months to agree

14 a structure which made sense across the group and was

15 financially viable and possible to actually implement.

16 We did that and we implemented it in April 2001,

17 which was I believe as fast as we could humanly function

18 from that point on.

19 So from April 2001 the Children and Families social

20 workers came under Children and Families Division. The

21 only thing that I would add to that is that I was not in

22 a position prior to April 2001 to offer adequate line

23 management arrangements to the extra hospital team

24 because there was not sufficient resource within the

25 division to do that and so it would have been short

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1 sighted of me to have made a special case, or a separate

2 case if you like to bring in that small group of social

3 workers at an earlier point than the general

4 restructuring.

5 MS GIBSON: So the picture is really that when you came into

6 post you were aware of the problems within the Hospital

7 Service, that those social workers within the Hospital

8 Service had been waiting for restructuring for some time

9 and were in some state of drift in terms of their

10 guidance and procedures?

11 MS MOORE: That was the case across the whole of the

12 department. It was not something that just affected the

13 hospitals. There were difficulties for staff across the

14 group. One could argue that there were particular

15 difficulties for the hospital social workers but my

16 belief is that they were dealt with in an adequate way,

17 in that they did have access to advice and consultation

18 and what we did was strengthen the availability of

19 staff. We ensured that specialist child protection

20 reviewing officers were actively involved in cases at

21 the hospital, and later in the autumn, when Lesley Carr

22 moved from her post, another manager was given the task

23 of a particular liaison role with those staff and met

24 with them frequently and gave them specific advice about

25 cases.

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1 MS GIBSON: As you said earlier in your evidence, you were

2 keen to retain the service at the hospital and for it

3 not to be based elsewhere.

4 MS MOORE: Absolutely.

5 MS GIBSON: Was there any problem for you in making sure

6 that that view prevailed?

7 MS MOORE: No.

8 MS GIBSON: So when you came into post, reversal of any

9 previous decision to base social workers elsewhere was

10 not a particular problem?

11 MS MOORE: There had not been a decision to locate them

12 elsewhere. There was a proposal that was in the making,

13 with a proposed report to the senior management team,

14 and I pulled that report and said that I did not agree

15 with the content and that it was not a step that we

16 should be taking, it was not a sensible step.

17 MS GIBSON: And was part of the reason for looking at that

18 option an issue of cost saving?

19 MS MOORE: Absolutely not. In fact, it would be -- it is

20 more expensive for us to have the service that we have.

21 MS GIBSON: I understand that, but I meant the alternative

22 proposal, the one to base --

23 MS MOORE: The proposal to base them outside?

24 MS GIBSON: Yes.

25 MS MOORE: I do not think it was a matter of cost. I think

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1 it was a matter of expediency to some extent, that there

2 were extreme pressures on front line staff within

3 Children and Families who undertook assessment work. It

4 is the least popular area of social work for all social

5 workers to be working on the front line dealing with

6 child protection. It continues to be difficult to

7 retain staff in those teams but it was particularly

8 acute at that time and I think the thinking was to do

9 with making the best use of available resources rather

10 than cutting costs as such.

11 MS GIBSON: Prior to you coming into post, and you have

12 explained the reasons for the delay after that, what did

13 you understand to be the reason for the fact that these

14 particular issues had not been resolved more rapidly?

15 MS MOORE: I can only give you half an answer to that but

16 I will do my best. There had been a gap in the cover

17 for the Assistant Director Children and Families post.

18 The substantive post holder had been seconded to another

19 post outside of Enfield towards the end of 1999. Then

20 for a short period the Assistant Director post was

21 covered by a temporary person who moved on. So I think

22 from I believe -- from memory from January to March 2000

23 there was a temporary AD. Then there was no AD until

24 I came -- there was a gap between April and the

25 beginning of July when I arrived.

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1 So in terms of the senior management arrangements

2 for the Children and Families Division, they were less

3 than adequate and being covered in a way best as people

4 could manage but clearly not sufficient. To what extent

5 that got in the way of the senior management team making

6 robust decisions about what the new structure should

7 look like I cannot really answer I am afraid. But

8 I think the configuration of the structure across the

9 department and the financial pressures on the department

10 were difficult to reconcile.

11 MS GIBSON: It seems from your evidence that once the

12 decision was taken to take action on bringing the

13 Hospital Service under the wing of Children and Families

14 rather than moving it out of the Adult Division, that

15 that happened within a few months from I think, was

16 it January 2001 through to April 2001?

17 MS MOORE: Yes.

18 MS GIBSON: So in terms of sorting out budgeting issues and

19 pay issues from moving the staff, no change in terms and

20 conditions for workers or anything complex to resolve?

21 MS MOORE: No.

22 MS GIBSON: Do you not think looking back that it would have

23 been better practice to have ensured that there was more

24 focus on that structural change which at the end of the

25 day took a few months to resolve?

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1 MS MOORE: We were not unfocused on it. There were cost

2 implications in terms of having sufficient management

3 cover within Children and Families to provide adequate

4 management arrangements and that was not available prior

5 to the restructuring of the whole group. What I could

6 not have condoned was a sort of Sellotape job on the

7 basis that there were particular problems with the

8 hospitals which was then equally inadequate if not more

9 inadequate because there was not sufficient management

10 available. There was sufficient management available

11 prior to April 2001.

12 We know -- I do not disagree with the argument that

13 it was not ideal but there was line management available

14 from the Adults Division. I did not have the capacity

15 to provide that until money was released from other

16 parts of the department, so I think it was the right

17 course of action. I accept that it added to delays

18 which had already been far too long but I did not have

19 an alternative at the time.

20 MS GIBSON: In looking at the impact of that cumulative

21 delay on the morale of staff and again focusing on the

22 Hospital Social Work Service, what would you say was the

23 effect on that service?

24 MS MOORE: I think the morale of staff had improved

25 somewhat, in that when Lesley Carr became involved there

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1 was some focus of attention and some thinking with them

2 about what should happen. I do accept that the

3 prolonged uncertainty will have -- is the other side of

4 that coin but I should say that the morale across the

5 group was not good. It was not something that we could

6 turn round quickly.

7 What we were aware that we needed to do was get

8 structures right and that that would improve the morale

9 of staff and ultimately that is what has happened, that

10 in creating a sensible approach to things in making

11 correct decisions about how we can deal with scarce

12 resources and best relocate teams and so on, we have

13 developed an increased faith in the senior management

14 team if you like from staff about being able to sort of

15 create some order, and we had to live with the

16 frustration of how long that took, but it would not have

17 been sensible to overreact and do something too quickly,

18 which then turned out to be something that needed to be

19 changed. I think that again would have affected morale

20 far more badly.

21 MS GIBSON: So in essence what you are saying is that what

22 you inherited when you came into the post was the result

23 of previous management neglect and it took time to sort

24 out those issues?

25 MS MOORE: It did take time to sort them out, yes.

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1 MS GIBSON: And where would you say responsibility lay for

2 what you inherited?

3 MS MOORE: Well, that is a difficult question. I mean

4 I guess it lay with the senior management team. I know

5 that there were difficulties there.

6 MS GIBSON: What were those difficulties?

7 MS MOORE: The pressures on them in terms of managing

8 a service within a restricted budget and trying to

9 deliver the required statutory services within extreme

10 pressures and the difficulties of coming up with

11 a structure which met new requirements from government

12 and external auditors and inspectors at the same time.

13 I think there were difficulties in how to resolve that.

14 MS GIBSON: Can I turn now to look at the organisation as it

15 is now and how that delivers a service. You say that

16 the hospital social work teams now liaise with the teams

17 providing assessment in the community and that is

18 a day-to-day liaison. Has there been a tightening up in

19 that respect of previous arrangements?

20 MS MOORE: We have welcomed that team into the division and

21 we do things as a "we" and so they have been swept in to

22 the new social work centre, which has been radically

23 reorganised, specialist teams have been created. They,

24 the hospital teams, have the strongest links with the

25 two assessment teams because the nature of the work is

23



1 quite similar, and there needs to be a flexibility of

2 working arrangements so that in instances where the

3 hospital were not able to cover a particular case then

4 the staff from the assessment teams would kind of step

5 in.

6 There is a lot of joint work with the managers in

7 that they meet regularly together and they are actively

8 involved in all the events that we run in terms of

9 updating procedures and training and management

10 processes generally.

11 MS GIBSON: You say in your statement that the deputy team

12 manager for the hospital team attends management

13 meetings at the social work service centre. With what

14 sort of frequency do those meetings take place?

15 MS MOORE: The frequency is of the managers' attendance at

16 management meetings. I could not put my hand on my

17 heart and swear to you that this is correct but

18 I understand it to be approximately fortnightly. Those

19 managers meet more regularly, but I am not aware that

20 the hospital team manager joins every week, but can

21 I put a health warning on that answer?

22 MS GIBSON: Can you assist with what the purpose of those

23 meetings is?

24 MS MOORE: Management meetings take place regularly to keep

25 everybody up to speed with a number of events, external

24



1 events in terms of expectations on them in relation to

2 the work from myself and other external pressures and

3 issues. They deal with -- they have regular meetings

4 which focus on child protection issues in which the

5 staff from the Child Protection and Review Unit are

6 involved, where they look at children who are either on

7 the register or complex cases where there are

8 investigations going on, so there is a practice focus to

9 some of the meetings.

10 Part of the meeting is involved in allocating work

11 so that where cases that are of Enfield children that

12 need longer term work need allocating, those are brought

13 into the Social Work Service. So it is a mixture of

14 functions.

15 MS GIBSON: What is done to ensure that there is clarity

16 between the roles of the hospital social work team on

17 the one hand and those teams in the community who they

18 may have to pass assessment over to?

19 MS MOORE: Could you ask me that again?

20 MS GIBSON: What is done to ensure that there is clarity of

21 responsibility as between the hospital team and the

22 investigation and assessment teams within the community?

23

24 MS MOORE: I think there is a much better and improved

25 understanding of one another's roles, simply because of

25



1 the increased contact. The other thing on a more formal

2 basis is that we have somebody working on procedures and

3 one of the things that they have done is establish

4 written protocols between each of the teams so there are

5 now clear kind of understandings about who does what and

6 when they do it and at what point cases transfer from

7 one team to another.

8 MS GIBSON: I want to ask you now about the response to

9 Victoria's death and also where you see the errors lying

10 in the way that this case was managed. We know that

11 a report was commissioned by an independent consultant,

12 Vicky Golding, and in response to the recommendations

13 coming out of that report you commissioned a more

14 detailed report from Caroline Campbell which came out

15 in January 2001 with a series of recommendations that

16 were then put into effect. That was progressed

17 alongside the updating of ACPC procedures across the

18 borough.

19 You say at paragraph 7 of your statement that you

20 discovered at one point that Dr Rossiter had launched

21 new guidelines for medical staff compatible with I think

22 it was the old ACPC procedures. Why is it, given that

23 to some extent you were taking on responsibility for

24 coordinating implementation of new guidelines, why was

25 it that Dr Rossiter was in a position where she was

26



1 working on her own and doing something independently

2 rather than in coordination with Enfield?

3 MS MOORE: That is not something I can easily answer. As

4 well as being Assistant Director of Children and

5 Families I have a role as Chair of the Area Child

6 Protection Committee. Amongst the committee's members

7 is a paediatrician whose responsibility it is to liaise

8 with her colleagues working within the borough.

9 The committee commissioned effectively the writing,

10 the updating of procedures and the person that we

11 employed did her work in a collaborative way and

12 prepared drafts in consultation with key players across

13 all the agencies, and in the process, in making contact

14 with staff at the North Middlesex Hospital, discovered

15 that Mary was rewriting, updating their own single

16 agency guidance, which was absolutely fine. I mean each

17 individual agency has a separate section within our

18 joint procedures which sets out their own internal

19 procedures. But the issue for us was about

20 compatibility. I think the problem was more one of

21 timing, that there had not been sufficiently proactive

22 communication about the work that Mary was doing at that

23 time.

24 I am just trying to remember the sequence of events

25 but I know that when we took this up with the North

27



1 Middlesex and said "Hang on a minute, we are now

2 updating and although the final drafts are not ready we

3 need to ensure that your single agency procedures are

4 compatible with the new procedures", we had no problem

5 then in getting agreement with the staff to ensure that

6 there was a process for putting straight any

7 incompatibilities and a list of incompatibilities was

8 drawn up and work is ongoing to ensure that that is put

9 straight.

10 The Area Child Protection Committee procedures that

11 we launched yesterday in fact are not finally finished

12 and in a sense no dynamic line set of procedures is

13 finally finished. There are still some single agency

14 procedures, not just the ones that Mary Rossiter has

15 been involved in updating, there are other single agency

16 procedures which still need finalising, and we are

17 actively involved with the hospital staff in resolving

18 that.

19 We also have worked quite closely with Haringey on

20 this because obviously there is a very close

21 relationship there, and what the assistant director in

22 Haringey and I have agreed is that once their Child

23 Protection Procedures are updated this year and the

24 Medical Procedures are updated for both North Middlesex

25 and Chase Farm and possibly other hospitals as well,

28



1 that there is a process of joint training that is done

2 with staff in the North Middlesex between Enfield and

3 Haringey Social Services.

4 MS GIBSON: It does seem from the outside to be undesirable

5 to say the least that even after Victoria's death

6 agencies are not working fully together, one agency is

7 taking some unilateral action in terms of guidelines.

8 Where would you say responsibility for that

9 miscommunication lies?

10 MS MOORE: I guess it lies within the Area Child Protection

11 Committee.

12 MS GIBSON: Have you looked at why the message did not get

13 through to Dr Rossiter through the paediatrician who

14 sits on the ACPC?

15 MS MOORE: I have not specifically looked at it. I have

16 talked to the paediatrician on the committee but because

17 we have not had a particular difficulty in resolving it,

18 we have had a series of meetings to resolve it and it

19 was a question of timing, it is not something that

20 I have actively pursued as a particular problem I have

21 to say.

22 MS GIBSON: What is done now to ensure that such

23 miscommunication does not occur in the future?

24 MS MOORE: Well, I have to say that I think there will

25 always be miscommunications of this sort of nature, and

29



1 that where agencies are willing to kind of address the

2 misunderstandings and put them right I do not see that

3 as a particular problem. I do not know that you can

4 legislate to prevent all misunderstandings happening.

5 Interagency working is very complicated. Understanding

6 all the channels of communication between each of the

7 players is incredibly complicated and whilst we need to

8 ensure that we work hard at communication and work hard

9 at that we have certainly been doing in Enfield, I think

10 that there will always be misunderstandings. The

11 problem arises when there is a reluctance on one side or

12 the other or both to actually resolve those

13 misunderstandings.

14 MS GIBSON: Looking at that particular example, there may be

15 some very simple solutions for dealing with that, for

16 example to make sure that there is someone perhaps on

17 the ACPC who is the coordinator for guidance that people

18 have to go through when they are going to write some new

19 guidance.

20 MS MOORE: We have that in place, we have somebody that is

21 commissioned to do that and the North Middlesex staff

22 are clear who that person is and what her role is.

23 MS GIBSON: But that does not seem to have worked in this

24 particular instance.

25 MS MOORE: It is certainly working now. As soon as that

30



1 person -- it was that person that identified the issue

2 and as soon as she did we have begun to address it and

3 communication is open and functioning and working with

4 both Haringey and with the North Middlesex to sort that

5 out.

6 MS GIBSON: Can I ask you now about the errors in Victoria's

7 case, and perhaps if you could give us your own summary

8 of where you feel errors occurred in the way that the

9 Enfield service handled the case?

10 MS MOORE: I do not believe any errors occurred in terms of

11 the practice of the staff involved. The deficits at the

12 time were procedural. There were out of date procedures

13 both within the hospital social work department for

14 children and families and in a broader context in terms

15 of the up-to-dateness of Child Protection Procedures in

16 a broader sense.

17 My sense is that given those deficiencies, that the

18 staff involved in Victoria's case acted appropriately.

19 Within 24 hours of receiving the referral from the ward

20 a referral had been passed on to Haringey according to

21 arrangements that were in place at the time, and indeed

22 the referral had been accepted by Haringey as a child

23 protection case. An awful lot of effort was made by our

24 social worker to convey information and there was an

25 awful lot of activity around that.

31



1 I am aware that there has been concern expressed in

2 this Inquiry about -- and criticism of us about not

3 interviewing Victoria. There is absolutely no doubt in

4 my mind that if there was any doubt on Haringey's part

5 about whether they were going to interview Victoria,

6 that our social worker Karen Johns would have

7 interviewed her, but there was no doubt about it.

8 Best practice as I understand it is that you do not

9 send a string of different social workers to make

10 relationships with children and interview them. You

11 certainly do not if there is an acceptance of a referral

12 by one authority and they, in acceptance of

13 responsibility, interview that child in that case. As

14 I have already said, I cannot emphasise strongly enough,

15 if there had been any request by Haringey for us to do

16 that interview then Karen has been unequivocal about her

17 response which would have been to do so.

18 So I think we are aware that the management

19 arrangements in the sense that I have outlined already

20 and the procedural guidance that was available needed to

21 be improved but in that context I do not think that

22 there were any deficits in terms of the way that our

23 staff undertook their work, and I believe that they were

24 thorough in what they did and clear in what they

25 conveyed.

32



1 MS GIBSON: In that you would seem to depart to some extent

2 from the report of the independent consultant. For

3 example, at -- perhaps we do not need to go to this but

4 at volume 2, page 167, she discusses the limited nature

5 of the initial assessment conducted by Karen Johns and

6 certainly, as you have identified, that was part of the

7 arrangement with Haringey and Enfield, but she did

8 suggest that at the least Karen Johns should have seen

9 Kouao to discuss Social Services' involvement, not in

10 terms of a formal interview but it would have been good

11 practice to have informed her and possibly to have

12 considered a joint interview with Kouao and the doctors

13 to clarify the nature of the injuries.

14 MS MOORE: I think what Karen did was in the context of the

15 arrangements that were in place at the time, that

16 arrangements had been made for better or for worse that

17 Haringey cases would be referred directly to Haringey

18 and she made every effort to provide sufficient

19 information to Haringey to enable them to understand the

20 nature of the referral they were receiving and there was

21 no dispute from them about what the case was and what

22 their role should be within it.

23 The practice was and remains that where you are

24 dealing with a child protection case that joint planning

25 goes on to decide who is going to do what in terms of an

33



1 investigation, and that took place. Karen attended

2 a strategy meeting the day after and the joint planning

3 of the investigation took place straight away.

4 At that time there was no urgency in as much as

5 Victoria was safely placed within the hospital and

6 Haringey were accepting responsibility, so I stand by

7 what I have said really. I believe that we did, Karen

8 on the advice she had at the time from Cynthia Lipworth

9 did what they were required to do.

10 MS GIBSON: The system however is one where there was plenty

11 of scope for misunderstanding, particularly in those

12 type of cases where child protection had not been

13 confirmed.

14 MS MOORE: I do not think there was any misunderstanding at

15 all. I think Karen was absolutely aware of what she was

16 dealing with. She knew that this was a child protection

17 case. She was pressing the doctors to confirm it and

18 confirm their view in the context of knowing that where

19 medical staff are clear about a diagnosis, that that

20 carries some weight, but she was very clear with

21 Haringey and they understood absolutely that she was

22 making a child protection referral. That is why

23 a strategy meeting was called. Everybody knew what

24 territory they were in. There was no doubt about were

25 we assessing a child in need or were we thinking about

34



1 a Section 47 investigation under the Children Act. It

2 was absolutely clear.

3 MS GIBSON: Looking now at the position of cover within the

4 hospital, we know that in February 2000 Lesley Carr

5 wrote to Haringey to inform them that from that point

6 onwards Enfield social workers would be offering

7 a limited service to Haringey because of the volume of

8 work generated by Haringey referrals.

9 For example, in February 2000 the hospital social

10 workers were carrying 36 cases, 24 of those were

11 Haringey cases and 12 Enfield. Is it your view that the

12 volume of work that Enfield social workers were

13 conducting was too high?

14 MS MOORE: I think it was too high. I think that there were

15 insufficient staff to cover it and they felt that they

16 could not deliver an adequate service to those children.

17 What is required within hospital social work is a lot of

18 intensive work over a short period of time, so the

19 nature of the case load is very different to a case load

20 of a social worker carrying perhaps more long-term cases

21 in the community, and as was instanced by the case of

22 Victoria, that there needs to be an almost full-time

23 attention to some cases. So to be carrying a case load

24 of over 12 cases per worker would mean that there were

25 some cases which did not receive speedy enough and

35



1 adequate enough attention.

2 MS GIBSON: What is your view of the way that the system is

3 functioning now, given that there are separate Haringey

4 social workers working within the hospital, Enfield now

5 are just carrying responsibility for your own cases?

6 MS MOORE: We are now in a much better state. I would not

7 go as far as to say it was perfect. There are still

8 issues about sorting out accommodation. I am not

9 up-to-date with the position in terms of providing

10 adequate accommodation at the hospital for the Haringey

11 staff in terms of office equipment and all the things

12 that they need, and I know that the Haringey social

13 workers have started work but have had to start work

14 based in the Tottenham office and doing a lot of moving

15 between the hospital and the office site, so I cannot

16 bring you bang up-to-date with the kind of office

17 accommodation issues but what I do know is that we have

18 worked quite closely with Haringey around the internal

19 procedures that we have implemented for the hospital

20 staff and that they are happy to use these as guidance

21 while they are producing their own and that the systems

22 are actually working as well as they can do in this

23 period of change.

24 MS GIBSON: And is the aim that their guidance will, where

25 possible, mirror your guidance so that hospital staff

36



1 are really only having to deal with one process?

2 MS MOORE: Yes, absolutely.

3 MS GIBSON: Turning now to strategy meetings, we know that

4 you put arrangements in place to tighten up strategy

5 meetings through the guidance and that you now have

6 a child protection reviewing officer who attends those

7 meetings. Can you summarise what the purpose of that

8 post is?

9 MS MOORE: The purpose of the post?

10 MS GIBSON: Yes, or what the reviewing officer --

11 MS MOORE: Or that particular function?

12 MS GIBSON: What that particular function is.

13 MS MOORE: The particular function is to ensure that the

14 person managing the investigation is somebody with child

15 protection expertise and experience and also somebody

16 who will bang on doors if things do not go properly so

17 that if there were a problem in terms of the handover of

18 a case or the failure of a particular agency to act in

19 the way that they committed themselves to act or

20 anything like that, that there would be somebody who is

21 very used to banging on my door or anybody else's door

22 that needs to be banged on to kind of get those problems

23 sorted out.

24 So it is about expertise, it is about having

25 somebody who knows the most up-to-date position in terms

37



1 of best practice and procedure and guidance and all

2 those requirements who has experience also of seeing

3 children through the whole child protection process and

4 out the other end and so understands the implications of

5 the decisions that they are making and so on, and has

6 access to best practice experience from other parts of

7 the department.

8 So it is really about strengthening expertise and

9 also freeing up the staff within the hospital to do the

10 thinking about the planning rather than having to manage

11 the process. The reviewing officer takes the role of

12 managing the strategy meeting and ensuring that

13 decisions are followed through and having another

14 strategy meeting if that is required.

15 MS GIBSON: So it is the reviewing officer's responsibility

16 to check that recommendations are followed up?

17 MS MOORE: Absolutely.

18 MS GIBSON: What is done higher up the management structure

19 to ensure that strategy meetings are effective?

20 MS MOORE: They are monitored in terms of -- we are in the

21 process of finalising what we call a quality assurance

22 strategy across the division, which involves all sorts

23 of monitoring activity by all sorts of people. There is

24 an active monitoring of strategy processes from the

25 child protection reviewing unit to ensure that

38



1 follow-through happens. There is auditing of cases that

2 regularly goes on to ensure that decisions are followed

3 through and that children are safeguarded, and there are

4 other auditing mechanisms, semi-independent, with

5 managers from one part of the service auditing other

6 people's things.

7 So there are a whole range of things that we are

8 beginning to establish and we have a much stronger

9 management information system which is developing all

10 the time in terms of generating regular data about

11 children going through various processes within the

12 division.

13 MS GIBSON: Can I ask you about psychosocial ward rounds.

14 Again, why did it take so long to resolve this

15 particular issue? I appreciate you were not in post but

16 it was indicated that you would be put in a position

17 where you could respond to these questions.

18 MS MOORE: Yes. Before I became aware of it I can only

19 speculate about why it took so long, and the

20 speculations are that there were an awful lot of

21 meetings about the problems about the meetings and that

22 these took place in the context of a department overall

23 that tended to operate like that, that there were

24 certainly more discussions about issues than there were

25 decisions about issues, and that has changed quite

39



1 radically over the last 18 months and a year. And that

2 in those regular meetings and discussions some of the

3 issues did not get resolved.

4 What was needed was a decision. Once I was aware

5 that there was a problem, a decision was made and the

6 meetings have resumed. I think that the department is

7 learning all the time about that practice culture about

8 decisions not being made and is making decisions. The

9 senior management team gives clear messages and all

10 managers are now making decisions in a way that perhaps

11 was not happening over a period of time.

12 MS GIBSON: Looking at the chronology, it does seem to be an

13 extraordinarily long period of time before any decisions

14 were made. The problem first flagged up in

15 December 1997 and then social workers stopped attending

16 I think in February 1998 for a few weeks but did not

17 actually go back after a few weeks to attendance.

18 MS MOORE: I think that is right and I know that the line

19 managers of the service at the time, the middle

20 managers, were not aware that this was going on. They

21 were aware that there was a problem but were not aware

22 that it had not been resolved, and why that happened

23 I am afraid I cannot explain that. I think Cynthia in

24 her evidence accepted some responsibility for that and

25 accepted that the situation should have been resolved

40



1 a long time ago.

2 When staff from the Children and Families Division

3 who were giving advice and were involved in various

4 meetings attended those meetings and recorded those

5 meetings, the sense was that the discussions occurred

6 but because there was not an actual line management

7 responsibility, they again did not take that and pushed

8 the issue across to adults who should have been the ones

9 that made the decision. So --

10 MS GIBSON: So would you say in part of it it is probably

11 a symptom of the organisational weakness you began your

12 evidence with?

13 MS MOORE: Yes.

14 MS GIBSON: We know that a letter was received by you from

15 Dr Rossiter on 22nd May which appears at 43A,

16 page 354.511 of the bundle, and again we do not need to

17 go to that letter but that was about social workers not

18 attending the meeting. From that period in May 2001 how

19 long did it take you to resolve the issue of attendance

20 at psychosocial ward meetings?

21 MS MOORE: The social work staff resumed attending on

22 18th June and have been attending regular meetings since

23 then.

24 MS GIBSON: So it took a matter of weeks for the thing to be

25 sorted out? Did you meet any resistance.

41



1 MS MOORE: No.

2 MS GIBSON: What is done given what we have heard about the

3 problems with psychosocial rounds, with social workers

4 feeling deskilled, that they were not given an active

5 part to play in those meetings, to ensure that meetings

6 are properly structured so that everyone can make

7 a valuable contribution?

8 MS MOORE: I am sorry, I cannot answer that question.

9 I have not been made aware that there are ongoing

10 problems of the nature that was described in the past.

11 MS GIBSON: It does seem from the evidence we have heard

12 that part of the problem was that social workers felt

13 they were not being given enough status in those

14 meetings, that they could not make their contribution

15 properly. Given that, it would seem that it would be

16 management's responsibility to look at those meetings

17 and make sure that there was a structure in place for

18 them to be effective.

19 MS MOORE: My understanding is that the manager in place in

20 the hospital now has undertaken that and I have not

21 heard that there is an ongoing problem of the nature

22 that was described historically.

23 MS GIBSON: What is done higher up the management chain to

24 monitor those meetings, if anything, to check that

25 social workers do attend and that they are productive?

42



1 MS MOORE: There is not a monitoring arrangement of those

2 meetings.

3 MS GIBSON: Do you think that perhaps that might be

4 something that would be of value?

5 MS MOORE: I think we have an awful lot of systems for

6 monitoring activity around children and those are the

7 most important areas to monitor. We are not at this

8 point in the business of monitoring processes which are

9 conducted between the adult professionals dealing with

10 those children. There has not been the necessity that

11 I am aware of to do that. If there were a repeated

12 problem of conflict between the professionals at the

13 hospital, monitoring may be one way of looking at that.

14 There may be other ways that we would address it. It

15 would depend what the causes were. But the main purpose

16 of management monitoring at present is focused on

17 activity that we require social workers to do in order

18 to safeguard children and there are numerous mechanisms

19 for doing that.

20 MS GIBSON: Thank you very much. I have no further

21 questions.

22 THE CHAIRMAN: Thank you Ms Gibson. Mr Verdan?

23 MR VERDAN: I have no questions.

24 THE CHAIRMAN: Thank you. Ms Moore, some questions from me,

25 if I may. One of your colleagues clearly took the view

43



1 that the social work element from the hospital could be

2 covered better by social workers not being based in the

3 hospital but by being based in a team outside the

4 hospital. You took a different view and thought the

5 social worker should be in the hospital. What did you

6 think were the compelling arguments for the social

7 workers being in the hospital?

8 MS MOORE: The way that hospitals work, things move and

9 change from day to day, and as we have identified

10 already, the key in multiagency, joint agency working is

11 about communication and the key to good communication is

12 about effective working relationships and those are

13 achieved through day-to-day contact with staff. There

14 are often lots of changes of staff within hospital

15 teams, within nursing teams, within the medical teams

16 there are arrangements by which people work for a fixed

17 period of time and then are moved to a different ward.

18 So you cannot make a relationship for six months and

19 hope that that will be the same person that is working

20 for the subsequent six months, you have to be ever

21 present and working on those professional relationships

22 all the time. I do not think that is easy to do from

23 a separate office base. You would need to be able to

24 appear on the ward within five minutes, not five hours,

25 when something comes up, and if it is not five minutes,

44



1 then a kind of a sense that you are down the corridor or

2 in the next building and can be available fairly

3 quickly.

4 It is a different -- it is about a different speed

5 and it is about a different way of joint working which

6 cannot be achieved -- there is also an issue about, one

7 of the issues that came up in the problems about the

8 psychosocial meetings were about credibility of social

9 work staff and one of the ways that people develop

10 credibility is through observing one another work, and

11 doing joint pieces of work together, and again if you

12 are not available unless called in and when you are

13 called in you do a small piece of work and then you go

14 back somewhere, you are simply not as visible, and so

15 your credibility is much harder to demonstrate, if you

16 like.

17 THE CHAIRMAN: So there are huge advantages in having the

18 social workers in the hospital because of the speed of

19 communication and yet you say in your statement that

20 Karen Johns, the hospital social worker, only learnt of

21 the death of Victoria in August 2000. She died

22 in February 2000. You say in your statement that just

23 by chance you discovered that when the ACPC arrangements

24 were being rewritten, you discovered Dr Rossiter was

25 rewriting the hospital ones; and there was no question

45



1 of the compatibility and the speed of reaction as far as

2 Victoria was concerned, that she was in hospital for

3 13 days and was not seen by a hospital social worker.

4 It does not exactly convey the justification of the

5 speed of reaction that you are talking about.

6 MS MOORE: Well, the responsibility for the procedures lay

7 with staff outside of the hospital. We could not base

8 our procedure writer within the hospital. I am not

9 suggesting that we do that. I certainly accept that

10 there could have been more efficient communication from

11 hospital based staff about those procedures and it may

12 indeed be that the staff concerned with writing the

13 procedures were aware of this before I was, so I do not

14 know that that was particularly a problem about the

15 speed of communication from the hospital staff.

16 THE CHAIRMAN: Yes, but you are telling me that the

17 principal benefit of having social workers in the

18 hospital is because of the speed of communication. What

19 I have put to you is that in your statement you say the

20 first time that the social worker involved knew that

21 Victoria had died was in August 2000 when Victoria died

22 in February 2000. That does not seem to me to justify

23 your statement about ease of communication.

24 MS MOORE: The case became the responsibility of Haringey

25 Social Services. It was not an open case to Enfield.

46



1 At the point at which they took it on, which was the day

2 after we referred it, which was very speedy, there was

3 no ongoing communication about it. I think there was --

4 I think those are separate points.

5 THE CHAIRMAN: Well, I thought that actually Victoria was

6 the responsibility of the hospital, not just Haringey,

7 and I thought that the communication between the

8 hospital and Haringey was via the hospital social

9 worker. So I cannot quite understand why it is that the

10 social worker would have been thought to have no

11 interest in the fact that a patient that she had been

12 involved with had died in the circumstances in which she

13 had died.

14 MS MOORE: I am not aware that the medical team -- at what

15 point the medical team knew of Victoria's death.

16 THE CHAIRMAN: Right, let me ask you something else then.

17 As you have described hospital social work, and you have

18 defended with some vigour what happened from the Enfield

19 social work point of view, did they not do nothing more

20 than act as a post box? Anybody could have actually put

21 the communication from the doctor to Haringey. What was

22 the actual added value of having a hospital social

23 worker there?

24 MS MOORE: When I was talking about having Enfield social

25 workers based within the hospital I was talking about

47



1 them providing a service to Enfield children. I am not

2 disagreeing with you that the arrangements at the time

3 for Haringey children residents were not sufficiently

4 robust. We know that there should have been social

5 workers based within the hospital as there are now

6 dealing with those children.

7 Effectively you are right, that the role that Karen

8 played was largely a post box one, although what she did

9 do was understand the nature of the concerns that were

10 being expressed in a way and I guess conveyed those in

11 a very clear sense, that they were child protection

12 concerns, and I think that is a little bit more than

13 a post box. She worked very hard to get information

14 from the medical team in order to give Haringey the best

15 possible referral.

16 THE CHAIRMAN: Well, as I understand it, from evidence we

17 have heard, although the hospital is based in Enfield

18 the majority of patients come from Haringey.

19 MS MOORE: Yes, they do.

20 THE CHAIRMAN: Is it not therefore important that the role

21 of the hospital social worker, particularly I guess in

22 every case but as we are interested in child protection

23 cases, is very clear?

24 MS MOORE: Yes, absolutely.

25 THE CHAIRMAN: Did you think it was clear?

48



1 MS MOORE: At the time?

2 THE CHAIRMAN: Yes.

3 MS MOORE: No, I do not think it was sufficiently clear.

4 I think what I said at the beginning was that in the

5 circumstances of the what I would say were inadequate

6 procedures and inadequate clarity, that Karen did the

7 best that she could do, but I am not defending the state

8 of clarity or procedural guidance, nor the arrangements

9 between the two authorities in terms of who would do

10 what, and both of us have worked hard to put right those

11 inadequacies subsequently, but I am certainly not trying

12 to defend them.

13 THE CHAIRMAN: Well, then obviously I misheard you and I am

14 glad that you have corrected me because I thought that

15 actually as I said earlier on you put up a fairly robust

16 defence about everything that happened from the Enfield

17 end of this.

18 MS MOORE: I was not defending the poor state of the

19 procedures and the arrangements and the management

20 arrangements, absolutely not. I was defending the

21 social worker's actions in the context of rather

22 inadequate arrangements.

23 THE CHAIRMAN: Well let us look at the social worker's

24 responsibilities. I did not understand, and this is why

25 I am asking you about what are the benefits of putting

49



1 social workers in hospitals, I did not understand why

2 you thought it was poor practice that a social worker

3 should pop on to the ward and talk to, have a chat with

4 Victoria and meet the person they assumed was her parent

5 in order to improve the communication between the

6 hospital and Haringey. What is the impediment of

7 a hospital social worker going on the ward and chatting

8 to a patient and communicating the result of that?

9 MS MOORE: Within child protection practice, in my

10 experience, and it is the belief of others, that in

11 interviewing children we need to be very careful about

12 how we do that. If a child has been abused they are not

13 readily going to necessarily disclose that. If they are

14 required to see more than one professional then that is

15 not going to enhance their ability to tell us about what

16 is happening to them, particularly if they are fearful,

17 as clearly this child was.

18 It is something in my own experience in talking to

19 children that they often convey a sense that social

20 workers keep changing. I do not disagree with you that

21 somebody should have interviewed this child and

22 interviewed them quickly. All I am saying to you is

23 that it was Karen Johns' belief that that was going to

24 be a task that was going to be undertaken promptly by

25 another authority who had agreed to take that

50



1 responsibility on.

2 THE CHAIRMAN: Yes, well I did not say -- I did not elevate

3 this interview. I said a social worker going on to the

4 ward and having a chat with Victoria and with the

5 parent. As for this business of the number of people,

6 the reality is that the ward staff change every eight

7 hours. I mean I just do not follow your argument at all

8 I have to say, but even if I do not follow your

9 argument, let me ask you another thing then.

10 If the social worker refers the matter to Haringey,

11 what you seem to be saying is that is the end of their

12 responsibilities, they have no responsibility whatsoever

13 to follow this up to make sure that something actually

14 happens. They put the letter in the post, send it on

15 a fax machine, whatever it is, and say, "Thank goodness

16 I have done that, on to the next job, I do not have to

17 worry any more about that" while there is a little girl

18 in a ward upstairs for 13 days who has not been seen,

19 whereas what you seem to be saying is, "Nothing to do

20 with me or us".

21 MS MOORE: I know that Karen did quite a lot of follow-up

22 after the referral was made and after indeed she had

23 attended the strategy meeting, so it was more than

24 putting a letter in the post as you said. She did do

25 a number of things, which are outlined in the case