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Archived Transcript for 7 November 2001: Pages
101 to 150
101
1 as to whether there had been physical abuse of Victoria.
2 Do you understand what I am saying?
3 DI ANDERSON: Yes.
4 MR GARNHAM: For the note it is Day 11, page 163, line 24.
5 She said in response that that may be so, she could not
6 speak for other people, but that that was not how she
7 wanted her opinion treated. On any basis of the
8 circumstances of this case and others like it that
9 reveals, does it not, a really rather serious problem,
10 that the consultant does not expect her opinion to be
11 treated as decisive but those who receive it do? That
12 is a problem, is it not?
13 DI ANDERSON: It can be conceived as a problem but it all
14 comes back to "Working Together", we are working
15 together in relation to child protection. The whole
16 purpose of "Working Together" is to be able to share
17 expertise from different agencies and we should
18 therefore be able to take the considered opinion of an
19 acknowledged expert in her field in relation to matters
20 such as this.
21 MR GARNHAM: Plainly it is right that you should take her
22 opinion into account and plainly it is something to
23 which you ought to give considerable weight but her
24 understanding was that despite her expression of that
25 opinion, further enquiries would be made about Victoria.
102
1 But both you and social services did not view the effect
2 of her opinion in the same way, did you?
3 DI ANDERSON: My understanding was that Dr Schwartz referred
4 the case back to social services with the overriding
5 opinion from her that there were no child protection
6 issues involved but that she did consider that there
7 were children in need issues to be addressed, social
8 issues to be addressed because Victoria was not
9 attending school, and so on. That would then become
10 a child in need assessment which I understand our social
11 services interpreted it and police interpreted her
12 wishes. She was quite adamant there were no child
13 protection issues in this case.
14 MR GARNHAM: She told us that her diagnosis was that there
15 was indeed scabies in this case, that was the proper
16 diagnosis of some of the marks on her, but she also said
17 that there were other marks that were not caused by
18 scabies, old marks and such like, and her contention is
19 that the matter was still open for investigation and she
20 did not expect it to close. She said that in the past
21 where such things had happened there had been
22 discussions with all those involved and is that not the
23 sensible thing to happen in this sort of situation?
24 DI ANDERSON: I want to start off by saying that Dr Schwartz
25 may be saying now that she said only some of the marks
103
1 were caused by scabies. The indications given both to
2 social services and to police child protection team at
3 the time were that all marks on Victoria's body were
4 a result of scabies, that scabies was the only cause for
5 concern with that child.
6 MR GARNHAM: It is right to say that a letter was written by
7 another doctor following Schwartz's examination that
8 said all the scratch marks were the result of scabies
9 and that there were no child protection concerns.
10 DI ANDERSON: That is correct.
11 MR GARNHAM: There is no mention in that letter about other
12 marks but does the point not remain that when police
13 were investigating a case such as this, whilst they
14 should give considerable weight to the opinion of
15 a doctor, it should not be the end of the matter?
16 DI ANDERSON: If there are severe other concerns which might
17 cause us to doubt the diagnosis in some way then I would
18 go along with that but in this case I did not think
19 there were. She had been quite adamant and the
20 information passed on to us was adamant that she had
21 discounted child abuse as in any way the cause of the
22 marks on Victoria's body.
23 MR GARNHAM: Are you not as police officers obliged to form
24 an independent judgment not just on the basis of the
25 medical evidence but on the basis of all the evidence as
104
1 to whether there was evidence here of a crime?
2 DI ANDERSON: In this particular case Victoria was taken to
3 hospital, and this is my understanding at the time then
4 and the time now still, was taken to hospital by a carer
5 who had found what she considered to be unexplained
6 marks on the child. That was the sole basis for
7 instituting the investigation. As a result of that
8 investigation being started or the decision being made
9 that there should be an investigation, a strategy
10 discussion was carried out and a course of action was
11 put in place.
12 A course of action as I understand it, I understood
13 it then, was that the child should be taken into police
14 protection to protect her for the night, photographs
15 should be taken of the marks on her body, a further
16 authoritative medical examination take place of the
17 child followed by then a memorandum interview if
18 appropriate, and then the other witnesses would be
19 interviewed.
20 MR GARNHAM: But all that comes to a stop once you get the
21 second --
22 DI ANDERSON: Yes, because as we move along that chain of
23 events because the investigation was instigated solely
24 on the basis of the marks found and not because of any
25 allegation that had been made verbally by any person,
105
1 then the moment those marks were discounted as being the
2 result of child abuse then the investigation to my mind
3 was properly stopped and the police protection lifted.
4 MR GARNHAM: I made the fatal mistake of saying that was my
5 last topic because immediately another one occurs and
6 I want to ask you about this if I may. There has been
7 some talk throughout this Inquiry about lead agency.
8 DI ANDERSON: Yes.
9 MR GARNHAM: In an investigation like this what do you
10 understand by the expression "lead agency"?
11 DI ANDERSON: The term is used frequently. I personally am
12 not very happy with the use of the word "lead agency"
13 because it suggests one agency being in total charge of
14 the inquiry. Working together in child protection means
15 we do literally work together. I would prefer -- social
16 services are normally described as the lead agency
17 within child protection investigations. I far prefer to
18 use the terminology I think "coordinating agency" in
19 that they will coordinate the activities of all the
20 agency together and make sure -- not make sure but as
21 I say pull things together into one investigation.
22 In relation to this case I think it was a joint
23 investigation and neither agency was specifically
24 required to take the lead because there were aspects
25 which affected both agencies until such time as it was
106
1 referred back to become a child in need investigation
2 when it became a sole agency matter for Brent Social
3 Services.
4 MR GARNHAM: The 1991 "Working Together" publication, the
5 one that was current at the time, says that local
6 authorities take the lead in responsibility for the
7 appointment of a chair and secretariat of the ACPC.
8 DI ANDERSON: Yes.
9 MR GARNHAM: Again I may have missed it but I do not think
10 that expression is used to describe any other of their
11 functions. It is said, let me tell you this so that you
12 understand the point, it is said that primary
13 responsibility for care and protection of abused
14 children is placed on the local authority, so that is
15 paragraph 1.10, but for myself I have been able to find
16 nothing that suggests that the local authority are lead
17 agency in any investigation where there are
18 circumstances such as this. Would you disagree with
19 that?
20 DI ANDERSON: I hope I have made it clear by saying that
21 I just do not like the expression of "lead agency".
22 MR GARNHAM: The consequence of your not liking that
23 expression is this, is it not, that the police retain
24 their duty to investigate crime whatever the involvement
25 of the local authority?
107
1 DI ANDERSON: Yes.
2 MR GARNHAM: And that was the position that obtained in
3 respect of Victoria's case?
4 DI ANDERSON: Yes.
5 MR GARNHAM: What I have to suggest to you is that what in
6 fact happened was that your team simply delegated that
7 responsibility to social services and the doctor and
8 failed to exercise any independent judgment about
9 whether or not there had been a crime and how it should
10 be investigated.
11 DI ANDERSON: No, I think Rachel Dewar acted quite properly
12 in deferring to the opinion of a very senior consultant
13 paediatrician in this case, someone who would
14 undoubtedly have been called to give evidence in
15 subsequent cases if it had actually been taken.
16 MR GARNHAM: I have no further questions sir.
17 THE CHAIRMAN: Let us carry on and we will take a break
18 after Mr Egan.
19 MR EGAN: As a result of something that has been raised, it
20 would assist me if you might take the break now.
21 THE CHAIRMAN: Then we will break and would 12 o'clock be
22 a satisfactory time?
23 MR EGAN: Fine.
24 (11.45 am)
25 (A short break)
108
1 (12 noon)
2 MR EGAN: Mr Anderson, you were asked some questions about
3 the interpretation of multiagency work and particularly
4 the expression "lead agency". I do not want to ask you
5 any questions about that but just for reference and to
6 assist the Inquiry, you were asked by Mr Garnham about
7 any reference to the social services being the lead
8 agency and could I ask to be put on the screen "Working
9 Together", volume 25, page 265, dealing with part 4, the
10 role of the agencies involved.
11 Sir, this is an exercise that those who represent
12 this officer and others merely do to assist the Inquiry
13 so that you can identify -- they are probably there
14 already.
15 THE CHAIRMAN: I am grateful to you.
16 MR EGAN: If one looks at page 265 and if you could scroll
17 to 4:
18 "Local authorities are under a statutory duty to
19 investigate where they have a reasonable cause to
20 suspect that a child is or is likely to suffer
21 significant harm or is subject to an emergency
22 protection order or police protection", I am giving all
23 of it for context. "The social services department
24 carried out these responsibilities on behalf of the
25 local authority. They do not do this alone and of
109
1 necessity call on the expertise of other agencies and
2 professionals", and I interpolate that the police are
3 clearly included in that category.
4 "Part 5 of this guide outlines the process for
5 handling individual cases from referral and
6 investigation through the child protection process to
7 removal of the child named from the Child Protection
8 Register. This section illustrates how the Social
9 Services Department takes the lead role in managing
10 individual cases but also relies on the assistance and
11 cooperation of professionals in other agencies. The
12 Social Services Department also carries responsibility
13 for managing key parts," and it goes on to deal with
14 that.
15 The role of the police is described for your
16 reference, sir, at paragraph 4.11 to 4.17 and I am not
17 going to go through that in detail but it is merely that
18 Mr Anderson had used that expression and the reference
19 to that in "Working Together" and obviously Part 5 deals
20 with individual cases which the Inquiry can look at in
21 due course. At any rate you have given your evidence
22 about that consideration.
23 DI ANDERSON: Yes.
24 MR EGAN: On that morning I think in fact you started duty
25 rather early, did you not? Have you had reference to
110
1 your duty status, volume 45-page 40? At 7 o'clock on
2 15th July, 7 am.
3 DI ANDERSON: I believe so.
4 MR EGAN: I think that although the entry -- and I will give
5 it, it can be referred to if necessary: "On duty office
6 re CRIS correspondence," do you have any actual
7 recollection of looking at this particular CRIS report
8 that morning?
9 DI ANDERSON: No I have not and I know I did not because in
10 relation to other matters this CRIS report has been
11 examined by a consultant who can interrogate the machine
12 and it is quite clear I did not look at that report
13 before the 16th. I do not know why, having said that.
14 I know I came on duty early that morning.
15 MR EGAN: This was of course before you went to Bushey.
16 DI ANDERSON: It was. I can only assume that I had
17 something else to do that morning. The entry on there,
18 "engage CRIS", I think is a generic entry, what I would
19 normally be involved with in the morning in the office,
20 and it is almost instinctive to write my duty state when
21 I first arrive at work.
22 MR EGAN: Just two further matters please. Firstly, dealing
23 with contact with children before memorandum interviews,
24 clearly there has been inquiry, a deal of evidence.
25 I want to ask you about one particular matter. It was
111
1 put to another witness, Sergeant Smith, that an
2 important part of contact pre a memorandum interview
3 would be the question of transparency, in other words
4 that nothing was being hidden and that nothing underhand
5 was going on, transparency presumably illustrating that
6 point.
7 DI ANDERSON: Yes.
8 MR EGAN: But of course in addition to transparency there
9 would also be, would there not, in your experience the
10 need for any contact with a child prior to a memorandum
11 interview to be accurately recorded?
12 DI ANDERSON: Indeed.
13 MR EGAN: A short entry in a pocket book or a CID diary
14 would probably not be sufficient, would it, if it was
15 being examined by other professionals in the course of
16 court proceedings?
17 DI ANDERSON: It would certainly be subject of a long debate
18 in court I would think, probably likely to be thrown
19 out.
20 MR EGAN: If such contact was to be properly recorded in the
21 spirit of for example the reasoning behind memorandum
22 interviews, it would need to be formally recorded on
23 tape.
24 DI ANDERSON: Ideally, yes.
25 MR EGAN: Finally, you were asked a number of questions
112
1 about the statute, Section 46, and you have given your
2 understanding of it in relation to whether the officer
3 should see the child or could cause the child to be
4 informed and cause the carer to be informed and also the
5 separation between designated officer and the
6 investigating officer or the officer in the case. You
7 gave the explanation that it could of course illustrate,
8 or it could be designed to deal with police officers
9 without any special skills for examining children
10 working together with a designated officer, because at
11 the very least the statute requires a designated officer
12 to be of a certain type of class of officer.
13 DI ANDERSON: Yes.
14 MR EGAN: That was your understanding?
15 DI ANDERSON: That is correct.
16 MR EGAN: Whether or not you are right as a matter of
17 statutory interpretation is another matter. Can I ask
18 you about that in relation to whether it is acceptable?
19 The general accepted practice in Brent was to cause the
20 child or the carer to be informed by the social
21 services?
22 DI ANDERSON: I think that would be deemed to be an
23 acceptable practice within Brent. It would have been
24 really a matter of which was most practicable.
25 MR EGAN: Provided that was done at any rate, whether it is
113
1 now regarded to be correct or not, a junior officer
2 would not be criticised for it?
3 DI ANDERSON: No.
4 MR EGAN: An important part of that function would perhaps
5 be, or an important part of that decision would be the
6 desire of investigating officers to keep away from the
7 child before the memorandum interview?
8 DI ANDERSON: Yes, that would be part of the rationale.
9 MR EGAN: Like everyone else, everyone said finally and has
10 been wrong about it.
11 You were asked about Dr Schwartz's opinion and the
12 attitude of the police to that. It is necessary perhaps
13 to look with a little care in view of the questions that
14 you were asked about what was actually said and put to
15 the police at the time. If one examines the CRIS
16 report, and I know you have looked at it with some care,
17 if one examines the CRIS report, is there apparently any
18 qualification in the opinion given to you by Dr Schwartz
19 or given about Victoria by Dr Schwartz?
20 DI ANDERSON: No.
21 MR EGAN: We know and we referred yesterday to Dr Dempster's
22 letter, a very well known document, I give the reference
23 at volume 5-page 12 -- we know that Dr Dempster's letter
24 which the social services were asking the hospital to
25 write refers to Dr Schwartz having decided that her
114
1 scratch marks are all due to scratches, and you have had
2 that matter read out to you by Mr Garnham. It is also
3 right, is it not, that the letter went on to say, "Thus
4 it is no longer a child protection issue"?
5 DI ANDERSON: That is the case in that letter I believe,
6 yes.
7 MR EGAN: That was a particular part of the medical opinion
8 which was given to the police, is it not?
9 DI ANDERSON: Yes.
10 MR EGAN: Not only that all were down to scratch marks or
11 were all due to scabies but that it is no longer a child
12 protection issue. Would you in your experience expect
13 medical experts to address the reasons for giving such
14 an opinion that it was no longer a child protection
15 issue?
16 DI ANDERSON: No, not particularly. I wonder whether the
17 interpretation of the letter is to emphasise that there
18 are still issues but not child protection issues.
19 MR EGAN: To take an example, never mind about what is being
20 said now, but the diagnosis, a diagnosis of
21 non-accidental injury would be a very important medical
22 opinion by a doctor, would it not?
23 DI ANDERSON: Yes.
24 MR EGAN: And had that been given on 15th July, for example
25 Dr Schwartz was of the opinion that either some or all
115
1 of the injuries were non-accidental injuries, that would
2 have been an integral part of her opinion, would it not?
3 DI ANDERSON: Yes.
4 MR EGAN: And you would have acted on it, would you not?
5 DI ANDERSON: Yes indeed.
6 MR EGAN: Looking at what her opinion was on the 15th,
7 namely that they were not non-accidental injuries --
8 there is no way of avoiding the double negative, they
9 were not non-accidental injuries -- was that an equally
10 important and integral part of her opinion?
11 DI ANDERSON: Yes it was.
12 MR EGAN: In those circumstances, if her opinion was that
13 they were not non-accidental injuries, they were all
14 explained by scabies and there was no longer a child
15 protection issue, however that is put, was there
16 a crime?
17 DI ANDERSON: No, there was not. The instigation of the
18 crime in evidence-in-chief was based on the unexplained
19 injuries which subsequently became explained.
20 MR EGAN: That is all I ask.
21 THE CHAIRMAN: I am grateful to you Mr Egan.
22 I only have a small number of questions I would like
23 to ask you. I will follow on from where Mr Egan
24 helpfully pointed, if I may, to the document "Working
25 Together." I wonder if we could have page 265 and
116
1 page 266 up. I want to make sure that we understand
2 each other. Page 266, the section that Mr Egan referred
3 to.
4 DI ANDERSON: I do not have the bundle.
5 THE CHAIRMAN: That is coming. It is the section Mr Egan
6 referred to as being the police responsibilities. It is
7 the first paragraph under "Police". If you can
8 highlight the first paragraph so the witness can see it.
9 It would be easier if I read it:
10 "The police involvement in the cases of child abuse
11 stems from their primary responsibility to protect the
12 community and to bring offenders to justice. Their
13 overriding consideration is the welfare of the child.
14 In the spirit of working together the police focus will
15 be to determine whether or not a criminal offence has
16 been committed, to identify the person or persons
17 responsible and to secure the best possible evidence in
18 order that appropriate consideration can be given as to
19 whether criminal proceedings should be instituted.
20 Failure to conduct child abuse investigations in the
21 most effective manner may mean that the best possible
22 protection cannot be provided for a child victim."
23 Is it your view that your section carried out their
24 responsibilities under this section of "Working
25 Together"?
117
1 DI ANDERSON: Yes, I believe they did.
2 THE CHAIRMAN: I hesitate only because I do not quite
3 understand what the police did that was unique to the
4 police role in this case.
5 DI ANDERSON: The police in agreement with social services
6 set in train a course of action as agreed by the
7 strategy discussion. That course of action referring
8 back to paragraph 4.11 would have been to determine
9 whether a criminal offence had been committed. The
10 allegation brought to our notice was based solely,
11 certainly it is my understanding solely on the fact that
12 the child had some unexplained marks on her. It was not
13 based on any other account that went with any allegation
14 or accusations that had been made but solely on those
15 injuries. They are what instigated the investigation,
16 and the course of action put in place jointly by the
17 police and social services led at a very early stage to
18 the injuries being discounted as having been
19 non-accidental. That having been the case, the reason
20 for the investigation was no longer present.
21 THE CHAIRMAN: You will understand I think we have been
22 round the track several times and I think I understand
23 the point you have made. You are an experienced senior
24 detective.
25 DI ANDERSON: Yes.
118
1 THE CHAIRMAN: Do you think that the police could and should
2 in their independent and separate responsibilities
3 within "Working Together" have done more than they did?
4 DI ANDERSON: I don't think so sir, no, because this is
5 a case which we used the expertise of others as we
6 should do and that expertise negated any further
7 investigation.
8 THE CHAIRMAN: What you did was to allow other people to
9 make the decisions for you.
10 DI ANDERSON: The fundamental information that was required
11 in relation to this case was whether or not that child
12 had been deliberately injured and the diagnosis of
13 someone who is in post as the named doctor for child
14 protection, someone who lectures on science and symptoms
15 of child abuse, was that these were not non-accidental
16 injuries and this is the fundamental piece of evidence
17 as far as I am concerned because it was the evidence
18 which most influenced us.
19 THE CHAIRMAN: If this child or young person had not been
20 seven but 17, as an experienced detective would you have
21 conducted this matter in exactly the same way?
22 DI ANDERSON: No. I think the child or the person would
23 have been spoken to.
24 THE CHAIRMAN: Why is it that you think it is right that the
25 child should not have been spoken to?
119
1 DI ANDERSON: The explanation given by Rachel Dewar and
2 clarified by Mr Smith this morning was the fear of
3 jeopardising a future memorandum interview if there was
4 one carried out.
5 THE CHAIRMAN: Do please help me because I do not understand
6 why it is that the police were content to allow the
7 social worker to interview both the carer and the person
8 who was thought to be the parent and the child but the
9 police were not. Why was it appropriate for the social
10 worker to do this and not the police?
11 DI ANDERSON: The social worker would, if involved at all
12 with the memorandum interview, would not have been
13 leading on the interview. She would have been present
14 probably only as an appropriate adult capacity.
15 THE CHAIRMAN: I understand that but I thought that your
16 concern, and I have to put this to you as the most
17 experienced detective, was the issue of contamination
18 and yet you were happy to allow a social worker to
19 interview the person who had taken the child to the
20 hospital, the person who was thought to be the parent
21 and the child.
22 DI ANDERSON: I think interview is the wrong word. The
23 intention would have been I am sure from Rachel Dewar to
24 Michelle Hines that an initial clarification would be
25 sought by social services, nothing more than that, and
120
1 any full scale interviews would have been done by police
2 at a later date.
3 THE CHAIRMAN: I think that you went to Brent, to the team
4 in 1996.
5 DI ANDERSON: That is right.
6 THE CHAIRMAN: In 1996 it just happens that there was an SSI
7 inspection of Brent in its child protection.
8 DI ANDERSON: There had been one just before I arrived.
9 THE CHAIRMAN: Were you familiar with the report?
10 DI ANDERSON: I saw extracts from it, not the whole report.
11 THE CHAIRMAN: If we could put up on the screen 14, it is in
12 bundle 14/O26, I wonder if this refreshes your memory.
13 I want to read four brief paragraphs, paragraphs 7.6 to
14 7.9:
15 "Inspectors noted that in a significant number of
16 cases included in the sample for inspection either
17 emergency protection orders were applied for or more
18 usually police powers of protection were taken.
19 "Between 1st January 1996 and 19th September 1996
20 26 emergency protection orders and two applications for
21 extension were made. Between 1st October 1995 and
22 30th September 1996 Brent police exercised their powers
23 of protection on 116 occasions.
24 "Inspectors also noted from discussion with the
25 senior solicitor in the borough that it was the practice
121
1 to instigate care proceedings as soon as an emergency
2 protection order was taken.
3 "These figures were significantly high, although it
4 was the view of the police officers and social workers
5 that emergency powers were used expeditiously. Examples
6 drawn from the case sample do not support this
7 proposition and case examples to illustrate this point
8 were shared with the SSD."
9 Were you aware of these sections of the report?
10 DI ANDERSON: This is in fact the part of the report that
11 was drawn to my attention by social services to explain
12 that 116 figure at paragraph 7.7 there and I was able to
13 do so by the fact that the figures which they had
14 obtained from the police were in fact inaccurate. They
15 had asked for details of how many police protection
16 orders, for want of a better expression, had been taken
17 out and they had simply been given a bald figure of the
18 number of occasions children had been taken to police
19 protection.
20 The overwhelming majority of those cases had not
21 been cases where child protection was the issue, these
22 were cases for example where a young missing person had
23 been found and no parents were available at home. In
24 other words they were taken as means to allow a young
25 person to remain at a police station prior to being
122
1 taken somewhere else. The accurate figure I cannot
2 remember off the top of my head but I think it was
3 something under roundabout 30, not 116.
4 THE CHAIRMAN: I am grateful for that explanation and
5 I readily accept it without any hesitation but
6 presumably it made you think that in future you ought to
7 be quite clear about the grounds for using police
8 protection in respect of children and maybe particularly
9 children that were not on the streets.
10 DI ANDERSON: Yes indeed, and I think throughout my time,
11 not trying to enhance my own image, throughout my time
12 with Brent I think the use of the power of police
13 protection has not been abused. On many occasions we
14 have disagreed or refused to take out police protection
15 when requested to by social services and on frequent
16 occasions I have been asked to act as the arbiter in
17 arguments between social workers and my officers when
18 requesting police protection.
19 More recently and as a result of this Inquiry there
20 has been a specific exercise undertaken within Brent
21 Social Services or ACPC to reiterate the importance of
22 consideration for emergency protection orders and not
23 using powers of police protection. I think there have
24 been cases where the cases where we have refused to take
25 them have been cases where social workers have attempted
123
1 to use power of police protection as a short cut and
2 that is when we have refused and problems have arisen.
3 THE CHAIRMAN: So in this particular case in respect of
4 Victoria did you say to PC Dewar or indeed your
5 sergeant, "I need to be satisfied that the right course
6 of action is being taken"?
7 DI ANDERSON: I did not say that to them but in the
8 circumstances as I was given them I was quite happy this
9 was an appropriate case for a power of police protection
10 to be taken.
11 THE CHAIRMAN: A couple more questions for clarification.
12 First of all, I think I am right, I would like to get it
13 clear, that you represented the police on the ACPC?
14 DI ANDERSON: Yes.
15 THE CHAIRMAN: The memorandum of practice as I understand
16 it, the guidance, says that that is normally done by an
17 OCU commander, in this case Chief Superintendent Cox.
18 Why did that not happen?
19 DI ANDERSON: I do not know the precise reasons but I think
20 general practice throughout the Met was that that
21 responsibility was almost invariably delegated to the
22 local CPT DI.
23 THE CHAIRMAN: Secondly, I believe I am right in saying but
24 please correct me, that you actually conducted the
25 internal management review for the police in respect of
124
1 the part 8 review.
2 DI ANDERSON: Yes I did.
3 THE CHAIRMAN: Could you explain to me why you were asked to
4 do this?
5 DI ANDERSON: It was a matter of expediency. The decision
6 to hold a part 8 review within Brent was made very
7 hurriedly when it was found that the borough had not
8 been included within the part 8 review for Haringey and
9 all agencies very quickly had to produce a management
10 report, as quick as they could. In those circumstances
11 I produced one and I have to say I can honestly say
12 I think I was as objective as anyone could have been in
13 the report I put together. It was purely factual and
14 nothing else.
15 THE CHAIRMAN: I am not going to question your objectivity.
16 I am basically asking your appropriateness as to how it
17 could be that you were thought to be the appropriate
18 officer to do this.
19 DI ANDERSON: I think it was just practicality of getting
20 someone else to do it in the short timescale available.
21 THE CHAIRMAN: I quite follow that. Could it be that this
22 was not regarded as a very important matter?
23 DI ANDERSON: Anything but. It was regarded as very, very
24 important.
25 THE CHAIRMAN: Well, the Metropolitan Police is quite a big
125
1 service.
2 DI ANDERSON: Yes.
3 THE CHAIRMAN: Expediency could have gone in other
4 directions.
5 DI ANDERSON: Yes, it probably could have done.
6 THE CHAIRMAN: Do you think it would have gone in other
7 directions with advantage?
8 DI ANDERSON: If I may say so only from the point of view
9 that I would not be answering these questions with you
10 now if it had done.
11 THE CHAIRMAN: Well, that may be just one aspect of it.
12 MR GARNHAM: I only have one final question and that is one
13 that I omitted to put, I was asked to put by
14 Metropolitan Police. Mr Anderson, would you agree that
15 over the period that you were attending DI team managers
16 meetings, the meetings we looked at earlier, that there
17 is no reference in any of them to your raising any
18 concerns about transport?
19 DI ANDERSON: There is not and that is a matter which
20 I always treat as a fairly low priority to be honest.
21 I felt there were other matters that were more
22 important. It was a bonus to get some transport
23 eventually.
24 MR GARNHAM: Thank you very much. Thank you Mr Anderson.
25 Miss Gibson will take the next witness.
126
1 MS GIBSON: The next witness is Breda Cuddihy.
2 MISS BREDA CUDDIHY (sworn)
3 MS GIBSON: I wonder if you could give the Inquiry your full
4 name and professional address.
5 MISS CUDDIHY: Breda Cuddihy, North Middlesex Hospital,
6 operational service manager for critical care.
7 MS GIBSON: Could you be provided with a copy of the witness
8 statement you made for the Inquiry at volume 6, page 42.
9 If you could have a look at that, your signature appears
10 at the end of that document, is that correct.
11 MISS CUDDIHY: Yes.
12 MS GIBSON: Are the contents of that statement true.
13 MISS CUDDIHY: Yes.
14 MS GIBSON: Is there anything you wish to alter in your
15 statement?
16 MISS CUDDIHY: No.
17 MS GIBSON: Thank you. It is right, is it not, that you are
18 the operational services manager for critical care and
19 that has been from November 1996?
20 MISS CUDDIHY: That is correct.
21 MS GIBSON: And that responsibility includes the Accident
22 and Emergency department at North Middlesex.
23 MISS CUDDIHY: That is correct.
24 MS GIBSON: The lead nurse is directly accountable to you in
25 the A&E Department?
127
1 MISS CUDDIHY: Yes.
2 MS GIBSON: You say in your statement that at this
3 particular time there was no section of the Accident and
4 Emergency department with dedicated paediatric
5 facilities.
6 MISS CUDDIHY: As compared to now, new A&E development we
7 have actually got dedicated facility within the new
8 department, in which paediatrics is isolated away from
9 adult, whereas in the old department it was an adjunct
10 to the treatment area. There was facilities but they
11 were much smaller and just attached to the treatment
12 area.
13 MS GIBSON: Yes, and you deal with that in your statement.
14 Did the system that was in place at the time of
15 Victoria's admission to North Middlesex, did it present
16 any problems in dealing with children who presented at
17 accident and emergency?
18 MISS CUDDIHY: No, not at all.
19 MS GIBSON: You say there were no designated paediatric
20 Accident and Emergency nurses at that time. Is that
21 still the case?
22 MISS CUDDIHY: With the new development we have actually got
23 dedicated facilities with dedicated nurses to work
24 within that area.
25 MS GIBSON: Are they trained as paediatric nurses?
128
1 MISS CUDDIHY: The senior nurses are trained. They hold the
2 RSCN qualification. However in the old department we
3 did have nurses trained to the same level with RSCN
4 qualification.
5 MS GIBSON: Perhaps you can explain the distinction between
6 the different qualifications.
7 MISS CUDDIHY: RSCN is a registered sick children's nurse
8 qualification. The majority of registered sick
9 children's nurses also hold the general nursing
10 qualification. It is an additional qualification to
11 work with children. You don't necessarily have to have
12 it but obviously the more senior people we would expect
13 to hold that qualification.
14 MS GIBSON: So the position is that then back in 1999 there
15 were nurses.
16 MISS CUDDIHY: Yes.
17 MS GIBSON: With that qualification.
18 MISS CUDDIHY: Yes.
19 MS GIBSON: Is that still the position?
20 MISS CUDDIHY: Yes.
21 MS GIBSON: You deal with guidelines and protocols in
22 respect of children, particularly in relation to child
23 protection concerns. What is done to ensure that staff
24 are made aware of those protocols?
25 MISS CUDDIHY: All new staff, dealing with nursing staff,
129
1 all the new staff that join the department go through
2 a two week induction programme and within that two weeks
3 the child protection guidelines are -- they are shown
4 where they are, where they are located, how to fill in
5 the forms and how to use them, and then that is followed
6 up by a 6-month orientation period with a mentoring
7 programme, and it is part of their ongoing development.
8 All the junior doctors, we have two intakes for the
9 junior doctors twice a year and there is an induction
10 programme for the doctors, and within the first two days
11 child protection procedures are identified to them and
12 explained to them. Additionally Dr Rossiter comes, the
13 junior doctors have child protection teaching every
14 Wednesday, and during those sessions Dr Rossiter will
15 come and go over the child protection procedures with
16 them, and other paediatricians will also come in and
17 give lectures on general paediatric protocols.
18 MS GIBSON: Thank you for that. If I can ask you in
19 relation to agency staff, what is done to ensure that
20 agency staff are aware of your protocols?
21 MISS CUDDIHY: Given that agency staff merely work once in
22 the department, they are never in charge of the
23 department. They are generally made aware that there is
24 policies and procedures and if they have any concerns
25 working in the department they would refer to the nurse
130
1 in charge either of the section that they are working in
2 or in charge of the actual department. It is not
3 envisaged that they would actually be working directly
4 with the child protection protocols themselves.
5 MS GIBSON: What would happen if an agency member of staff
6 was on duty for example either in the reception area or
7 as the triage nurse?
8 MISS CUDDIHY: It is very unlikely that an agency nurse
9 would work in triage. It is standard practice in the
10 department for our own staff to actually triage, to
11 carry out that role within the department.
12 MS GIBSON: You say very unlikely, but what would be the
13 position if that did in fact happen?
14 MISS CUDDIHY: I have said mostly agency nurses present only
15 once and certainly if it was a new agency nurse, no, we
16 would not have been able to assess their competency to
17 carry out that function as a triage nurse. However,
18 over a period of months where you build up and you get
19 to know agency staff and you gain and you can assess
20 their competency, it may be that if they have
21 undertaken the EMB 199 training, they would be allowed
22 to function in that role. By then they would certainly,
23 because they would be a regular in the department they
24 would have been made very much aware of the child
25 protection procedures, plus where the Child Protection
131
1 Register was, so they could actually carry out the
2 triage function properly, because they would need to be
3 informed about the Child Protection Register in order to
4 carry out the triage function.
5 MS GIBSON: You mentioned training and the Wednesday
6 training sessions. Would it be the case, as I think you
7 say in your statement, that those training sessions may
8 include child protection? You say that at paragraph 16.
9 Is it matter of chance whether or not the programme that
10 a particular doctor is following included child
11 protection, with Dr Rossiter or would that invariably
12 happen for all of the doctors?
13 MISS CUDDIHY: Categorically Dr Rossiter will come and
14 lecture on child protection issues without reservation;
15 as long as I have worked in the department that has
16 happened.
17 MS GIBSON: That is the position for doctors on the
18 department?
19 MISS CUDDIHY: Yes.
20 MS GIBSON: You say in your statement that nurses are I
21 think in effect free to attend those protected training
22 sessions on the Wednesdays.
23 MISS CUDDIHY: Yes.
24 MS GIBSON: Is there any requirement for nurses in Accident
25 and Emergency to attend child protection training?
132
1 MISS CUDDIHY: All of the senior staff in the department
2 have attended. The paediatric department run a number
3 of training programmes, multidiscipline training
4 programmes, and all the senior staff working in the
5 department have attended a two or three-day course.
6 Additional to that, as part of the development of staff
7 within Accident and Emergency, it is at work training
8 basically, and we now have a clinical facilitator, which
9 actually helps develop staff and teaches them about
10 child protection issues.
11 MS GIBSON: So just to be clear, would any nurse, however
12 junior in your department, receive child protection
13 training at some stage in their programme?
14 MISS CUDDIHY: On a one to one with clinical facilitator,
15 ongoing from the staff who are working senior staff
16 working in the department, and more formally they would
17 be put on to the in-house training courses, so yes.
18 MS GIBSON: That is in-house but what is done in respect of
19 ensuring that the nurses working in Accident and
20 Emergency have training as soon as they start working in
21 Accident and Emergency?
22 MISS CUDDIHY: Within the first week every nurse who
23 commences work in our Accident and Emergency department
24 have a period of two weeks supernumerary Newham where
25 they are not actually working in the department. That
133
1 two week period allows for training of staff in all
2 aspects of A&E, giving them an overview of all the
3 protocols, including the child protection protocols, the
4 NAI register, and an overview of how they actually
5 manage this process within the department. So that is
6 the first step and that is within the first two weeks of
7 their employment at the North Middlesex A&E.
8 MS GIBSON: As part of that initial induction programme, are
9 they actually required to read the child protection
10 guidelines?
11 MISS CUDDIHY: They are all given a copy, not individual
12 copies, we hold copies in the department, but it is
13 expected that they will read them but, you know, I am
14 sure they do. I mean, hand on heart I could honestly
15 say every member of staff is very acutely aware of child
16 protection in the A&E Department.
17 MS GIBSON: Aside from being given the guidelines, is
18 anything done to ensure that A&E staff are conscious of
19 possible signs and indicators of child abuse, things to
20 look out for?
21 MISS CUDDIHY: It is within the document, there is actually
22 clear guidance within the document that identifies for
23 them to look at, but I think a lot of the A&E nurses
24 actually can pick things out. You know, it is instinct.
25 A lot of them can pick things up fairly quickly. They
134
1 can identify. One of the key things and key functions
2 around triage is the information that is provided by the
3 person, the adult accompanying for example, an adult
4 accompanying a child, making sure that the history given
5 is consistent with the presentation symptoms, and
6 through their training they are able to make an
7 assessment that you know it is consistent or
8 inconsistent.
9 MS GIBSON: Is anything done to evaluate knowledge of child
10 protection issues in terms of either testing staff on
11 ongoing assessment --
12 MISS CUDDIHY: Not particularly in child protection issues
13 or in assessment but there is a programme we call PDS,
14 Personal Development System, where each member of staff
15 has a mentor and that mentor will assess three or four
16 times a year skills and ability and issues that they may
17 have around their own ability. You know, if the mentor
18 picks up that maybe they are not performing a particular
19 function as well as maybe they could be during that
20 period then there is an opportunity to address this, and
21 if there was a child protection issue highlighted then
22 it would be addressed more formally in that arena, but
23 if there was something on a day-to-day basis it would be
24 picked up by any senior member of staff and dealt with
25 there and then.
135
1 MS GIBSON: Can I now ask you about the triage nurse and the
2 system for checking the Child Protection Register. You
3 say in your statement that the triage nurse, talking
4 about 1999 now, would check a small register kept in the
5 triage room, and then if the child's name was shown on
6 that they would then check on the main Child Protection
7 Register which was kept in the treatment area.
8 MISS CUDDIHY: Yes.
9 MS GIBSON: Can you tell us what the distinction is between
10 the small register and the main Child Protection
11 Register?
12 MISS CUDDIHY: The small register just has the name of the
13 child with very little detail. The main register has
14 the details that are provided by social services. So
15 when the information is provided by social services it
16 is transcribed from the form sent in by social services
17 which is kept separately, and that is the main register,
18 on to a smaller workable system for the triage nurse.
19 MS GIBSON: To be clear, every name in the small book is
20 contained in the main register?
21 MISS CUDDIHY: Yes, definitely.
22 MS GIBSON: At that time certainly the main register was not
23 on computer.
24 MISS CUDDIHY: No.
25 MS GIBSON: Did that lead to any problems in keeping the
136
1 records up-to-date?
2 MISS CUDDIHY: No. As soon as the information is received
3 within the A&E Department then the register was updated
4 and --
5 MS GIBSON: Was there ever any delay in you receiving that
6 information from social services that you were aware of.
7 MISS CUDDIHY: Not that I am aware of, but the post being
8 the post I am sure there is always sometimes a lapse in
9 sending out and actually receiving, but not that I am
10 aware that it caused any specific problems, but you know
11 there is obviously that time factor from sending it out.
12 MS GIBSON: Can you tell us whether that register is now on
13 computer?
14 MISS CUDDIHY: We are working towards -- we are nearly
15 there. It is not yet on computer but we have made a lot
16 of strides into getting it.
17 MS GIBSON: What would you say would be the improvements
18 once you have access to it on computer?
19 MISS CUDDIHY: Again, talking about the time lapse, the
20 information is managed directly by social services. It
21 is timing. So patients that are on the register and
22 taken off -- the accuracy of the information, it is not
23 just about children going on to the register, it is
24 children that are removed from the register, because we
25 have to send paperwork back. So there is obviously
137
1 security, the confidential issues. It is managed
2 probably in a safer way.
3 MS GIBSON: Thank you. Can you give us some indication of
4 when it is anticipated that the register will be on
5 computer?
6 MISS CUDDIHY: The hardware is bought. We have now got --
7 we are just waiting on a link cable to be put in place
8 and as soon as that is in place, which should be very,
9 very next few weeks hopefully, it should be in place.
10 MS GIBSON: You say at paragraph 19 of your statement that
11 the Child Protection Register is checked in respect of
12 all children who go through Accident and Emergency.
13 MISS CUDDIHY: Yes.
14 MS GIBSON: At what stage does the check take place?
15 MISS CUDDIHY: After the assessment.
16 MS GIBSON: So it is straight after the assessment in every
17 case?
18 MISS CUDDIHY: Yes.
19 MS GIBSON: We know that in this case the referral to the
20 paediatric ward took place in accordance with the
21 protocol, that it went to the Paediatric Registrar.
22 What systems do you have in place to ensure that that
23 happens in every case?
24 MISS CUDDIHY: It is part of the guidelines and it is about
25 staff understanding the guidelines and systems. It is
138
1 quite clearly documented and staff will follow that.
2 MS GIBSON: Can I ask you in relation to the child
3 protection forms, CP1 to 6, those are sent on from
4 Accident and Emergency to Dr Rossiter.
5 MISS CUDDIHY: CP4 is the specific A&E document.
6 MS GIBSON: And that is the one where any A&E concerns are
7 recorded.
8 MISS CUDDIHY: Yes.
9 MS GIBSON: What is done to ensure that that is received in
10 the paediatric department and at what stage is it
11 transmitted?
12 MISS CUDDIHY: As soon as the consultation has been
13 completed, if the child has been admitted it goes with
14 the child for the handover. If the child is being
15 discharge a copy of the A&E notes is photocopied
16 straightaway with the CP4 form and we have an internal
17 post system, and it is put into the internal post for
18 the attention of Dr Rossiter.
19 MS GIBSON: Is anything done to check that the internal post
20 system functions and it is received by Dr Rossiter, if
21 there are concerns?
22 MISS CUDDIHY: To this day I have not been advised or
23 alerted to any concerns or any issues that Dr Rossiter
24 has not received her post.
25 MS GIBSON: We know in this case that this reference and
139
1 perhaps we need not go to it but for the record it is at
2 volume 37, 243, that Victoria had been admitted to
3 Central Middlesex Hospital prior to her admission in
4 North Middlesex Hospital. Whose job would it be to
5 follow up that earlier admission and to obtain
6 information about it?
7 MISS CUDDIHY: I would suspect -- I would suspect once she
8 would have been admitted on to the ward that it would be
9 part of -- I am not quite sure because I do not know the
10 procedures from within the wards. Certainly from an A&E
11 perspective we, if she was only attending A&E, it is not
12 standard practice for A&E's to contact A&E staff
13 directly. It probably would be good practice within
14 other teams to follow up.
15 MS GIBSON: If in A&E you receive information, perhaps the
16 triage nurse learns from the person bringing the child
17 in or from some other source that that child has been
18 admitted to another hospital, and perhaps there is
19 concern about suspected abuse, what is done to highlight
20 that fact that the child has been admitted to a hospital
21 before, because there may be important and significant
22 information which needs to be transferred?
23 MISS CUDDIHY: If the information is provided by the adult
24 or the carer, that information is documented on the A&E
25 card, and once the referral is made to the Paediatric
140
1 Registrar then it would be followed up by the Paediatric
2 Registrar or the paediatric team.
3 MS GIBSON: You mention a system that is in place for a
4 health visitor to come in to check through all of the
5 cards of children coming in to A&E and that is on
6 a daily basis.
7 MISS CUDDIHY: Yes.
8 MS GIBSON: Was that in place in 1999 as well?
9 MISS CUDDIHY: Yes.
10 MS GIBSON: Those health visitors pick up on any cases of
11 children returning perhaps frequently to A&E?
12 MISS CUDDIHY: Yes, or even pick up on something maybe that
13 they, because of their own particular skills and
14 knowledge when they may know the child or they may have
15 their own -- on their assessment of the information on
16 the card, they may choose to follow it up for their own
17 particular reasons.
18 MS GIBSON: Perhaps you cannot assist with this but do you
19 know how they carry out that function?
20 MISS CUDDIHY: I am not sure actually. I know it occurs but
21 it is probably best answered by a member of the
22 paediatric team.
23 MS GIBSON: Do you know if there is any system in place to
24 check with hospitals generally if a child has been
25 admitted say to one paediatric or to one Accident and
141
1 Emergency as here in Central Middlesex and then North
2 Middlesex to pick up returns to hospital beyond North
3 Middlesex alone?
4 MISS CUDDIHY: No. Because you can phone up but there may
5 be some confidentiality issues about enquiring about
6 information without actually appropriate, you know, from
7 an A&E perspective I suspect that there may be
8 procedures once the child is admitted if children are
9 being admitted but not from A&E.
10 MS GIBSON: The reason I ask, obviously it is felt
11 appropriate to look for returns of children coming back
12 frequently and I imagine the purpose is for example if
13 a child is being over presented to hospital there may be
14 child abuse concerns?
15 MISS CUDDIHY: Absolutely.
16 MS GIBSON: But if they are presented to a number of
17 different hospital because the carer wants to avoid
18 discovery, I wondered if you were aware of any system in
19 place to check on that?
20 MISS CUDDIHY: Not that I am aware of, but there may be
21 within the health visitor service. There possibly is, I
22 am not quite sure of their roles and functions outside
23 of the A&E Department.
24 MS GIBSON: Thank you very much. If you would wait there.
25 THE CHAIRMAN: Thank you. Mr Mason.
142
1 MR MASON: Just one matter. You were here yesterday I
2 believe when Meriel Clarke was being asked about her
3 personal experience of nurse training in scabies and she
4 was also asked about whether she thought that other
5 nurses were trained in dealing with scabies. She said
6 she was not and she thought it was perhaps unlikely that
7 other nurses were, particularly now with the condition
8 becoming less common. Does her experience fit with
9 yours?
10 MISS CUDDIHY: Yes.
11 MR MASON: Thank you.
12 THE CHAIRMAN: Just one question if I may. If you look at
13 paragraph 17 of your statement, in the middle of that
14 paragraph you refer to the form CP4 designed for A&E
15 nurses to record their concerns. Do you know if that
16 was used at all in the case of Victoria?
17 MISS CUDDIHY: I am not sure actually.
18 THE CHAIRMAN: I did not know whether you could answer.
19 Thank you very much for giving your evidence very
20 clearly. I am grateful to you.
21 MS GIBSON: You may go now. I note it is almost one o'clock
22 and I wonder if that would be a convenient moment to
23 break.
24 THE CHAIRMAN: You may have heard my tummy rumbling. Thank
25 you very much for that. Let us make a decision, let us
143
1 get back here at 1.30. We will rise until 1.30.
2 (12.55 pm)
3 (The short adjournment)
4 (1.30 pm)
5 THE CHAIRMAN: Miss Gibson.
6 MS GIBSON: Thank you sir. The next witness is Lucy Hinds.
7 Miss Lucy Hinds (sworn)
8 MS GIBSON: Thank you Miss Hinds. Could you begin by giving
9 the Inquiry your full name and professional address,
10 please.
11 MS HINDS: Lucy Hinds, North Middlesex Hospital but working
12 through an agency.
13 MS GIBSON: Thank you. You have provided a statement to the
14 Inquiry which is found in the witness bundle at
15 volume 6, page 133. If you could have a look at that
16 statement and can you check that you have signed that
17 statement at the end?
18 MS HINDS: Yes.
19 MS GIBSON: Are the contents of that statement true?
20 MS HINDS: Yes.
21 MS GIBSON: Thank you. Is there anything that you wish to
22 add or alter to that statement at this stage?
23 MS HINDS: No.
24 MS GIBSON: You have also made a statement to the Crown
25 Prosecution Service in respect of the criminal
144
1 proceedings. Sir, for your reference that is found at
2 volume 46, page 96.
3 You were an agency staff nurse at grade D. Was that
4 also the position in July 1999?
5 MS HINDS: Yes.
6 MS GIBSON: You say in your statement that you were aware of
7 the hospital's Child Protection Guidelines.
8 MS HINDS: Yes.
9 MS GIBSON: I wonder if you could be provided with a copy of
10 those guidelines at volume 39, page 221. Do you have
11 the guidelines there?
12 MS HINDS: Yes.
13 MS GIBSON: Could you have a look at page 242. Just
14 generally in respect of those guidelines, have you read
15 through all of those guidelines?
16 MS HINDS: Yes.
17 MS GIBSON: Are you aware of the importance of keeping
18 records of all indications of child abuse?
19 MS HINDS: Yes.
20 MS GIBSON: When you were given the guidelines, were you
21 directed to read them, or was that on your own
22 initiative?
23 MS HINDS: Not formally, no. I would have looked at them on
24 my own.
25 MS GIBSON: You have not attended any formal child
145
1 protection courses but were you aware from your
2 experience what signs of abuse were?
3 MS HINDS: Yes. I have a general idea, yes.
4 MS GIBSON: You mention in your statement signs of abuse
5 including bruising, scars and withdrawn behaviour.
6 MS HINDS: Yes.
7 MS GIBSON: Can you help with what other indications of
8 abuse might be?
9 MS HINDS: Well, the hunger aspect when she initially came
10 in, and her bed wetting, her behaviour initially was, as
11 I said, withdrawn. She looked frightened. She looked
12 scared. They would all be indicative of some form of
13 abuse.
14 MS GIBSON: You say, in your statement, you have not
15 attended any child protection courses.
16 MS HINDS: Yes.
17 MS GIBSON: How do you acquire awareness that these are
18 possible indicators of abuse?
19 MS HINDS: A lot of it is intuitive. If you have been
20 working with children you know how they act on a sort of
21 daily basis, and their sort of interaction with people.
22 And then the obvious; how she looked.
23 MS GIBSON: You have not attended courses, but were such
24 courses actually available to you in respect of child
25 protection at that time, July 1999, or before?
146
1 MS HINDS: In a sense it would have been available to me but
2 as an agency nurse I could be there one week and not
3 there the next. So as it was I did work there on
4 a continuous basis but I was not actually offered.
5 MS GIBSON: We know with Victoria that you put her in
6 a separate room because of scabies, your concern about
7 scabies. Had you had any experience of scabies prior to
8 this case?
9 MS HINDS: Yes, I have had an experience of scabies, yes.
10 MS GIBSON: And what is your knowledge of the way in which
11 scabies is spread?
12 MS HINDS: Direct contamination or close contact.
13 MS GIBSON: Did you take any precautionary measures in
14 respect of Victoria?
15 MS HINDS: Well, that is why she was isolated.
16 MS GIBSON: Did you take any measures yourself to protect
17 yourself from contracting scabies?
18 MS HINDS: I cannot remember but generally speaking I would
19 have worn gloves initially but I know she was -- it was
20 said she had been treated several times and this was the
21 cause of the dry skin, so that was an indicator that she
22 would not have been infectious -- well, as infectious,
23 but we needed to take the precautions.
24 MS GIBSON: These events are some time ago. Do you remember
25 when you first learned about the circumstances of
147
1 Victoria's death?
2 MS HINDS: Yes, I do remember. Yes.
3 MS GIBSON: Can you tell us when that was?
4 MS HINDS: I think it was the day after she died.
5 MS GIBSON: And how did you learn of her death?
6 MS HINDS: Because she had been brought in through A&E and
7 then the next day it was said that she had died.
8 MS GIBSON: We know in his statement Dr Reynders refers to
9 discussions amongst staff at the hospital following
10 Victoria's death. Do you recall any discussions about
11 Victoria, following your knowledge of her death?
12 MS HINDS: Not with any clarity, no. Well, yes, but not
13 with any clarity.
14 MS GIBSON: So the position is you recall there were
15 discussions. You do not recall with any clarity, but
16 can you help us with what the content of those
17 discussions would have been?
18 MS HINDS: No, not directly. I have only sort of vague
19 recollections of it now.
20 MS GIBSON: Perhaps you could tell us what you do recall of
21 discussions following Victoria's death. Firstly, can
22 you recall who you discussed this with?
23 MS HINDS: No.
24 MS GIBSON: Was it the general topic of discussion on
25 Rainbow Ward?
148
1 MS HINDS: When it came to light that it was Victoria that
2 had died, I remember recalling that yes, I had looked
3 after her when she had been in the ward in August.
4 MS GIBSON: And when you learned that she had been admitted
5 to your Accident and Emergency Department and had died,
6 did you at that stage know of the circumstances of her
7 death and that abuse was suspected and indeed later --
8 MS HINDS: Yes, I remember that being talked about.
9 MS GIBSON: Did you learn at a later stage that Kouao and
10 Manning had been convicted of her murder?
11 MS HINDS: Yes.
12 MS GIBSON: Do you accept that it may be possible that in
13 the light of that knowledge about the terrible
14 circumstances in which she died some of your
15 recollection of what has happened has been affected by
16 that knowledge?
17 MS HINDS: I am unsure about that, to be honest.
18 MS GIBSON: Do you recall events relating to Victoria
19 clearly?
20 MS HINDS: While she was on the ward?
21 MS GIBSON: Yes.
22 MS HINDS: Yes.
23 MS GIBSON: In your Crown Prosecution statement -- sir, for
24 your reference it is at volume 46, page 96. Perhaps
25 actually it would be helpful if you had a look at that
149
1 at this stage. You say in that statement on admission
2 you remember Anna, as you then knew Victoria, as being
3 "somewhat frightened and tense".
4 MS HINDS: Yes, that is true.
5 MS GIBSON: We do not find any reference in the nursing
6 notes to her being frightened and tense. Can you
7 explain why not?
8 MS HINDS: Well I think they give other indicators of --
9 that would indicate that things were amiss with her bed
10 wetting and being hungry.
11 MS GIBSON: But did you not think that in accordance with
12 the protocols for child protection it would be important
13 to record the fact that she was, in your view,
14 frightened and tense?
15 MS HINDS: Yes, maybe I should have done.
16 MS GIBSON: Do you accept that might have been a shortcoming
17 on your part?
18 MS HINDS: Yes.
19 MS GIBSON: And are you quite clear you have not been
20 influenced by knowledge of what has happened to Victoria
21 subsequently when you say in your statement to the
22 police that your recollection is that she was frightened
23 and tense?
24 MS HINDS: No, I remember her being frightened and tense.
25 MS GIBSON: Perhaps you can describe to the Inquiry what you
150
1 mean by that and what you actually observed about her
2 demeanor that made you think that she was frightened.
3 MS HINDS: She just had a sort of fearful look in her eyes,
4 and the way she sort of presented herself.
5 MS GIBSON: Is there anything else about her behaviour that
6 evening that caused you concern?
7 MS HINDS: Well, as I say, her bed wetting, her large
8 appetite.
9 MS GIBSON: You say in your Crown Prosecution statement that
10 you initially thought that Victoria's behaviour was down
11 to or due to her new surroundings in the hospital, the
12 effect of the burns and her poor command of English.
13 MS HINDS: Yes.
14 MS GIBSON: You use the word "initially" implying you
15 changed your mind about this at some stage. Can you
16 help firstly if that is what you meant by initially?
17 MS HINDS: I think initially she was like that but she did
18 settle into the ward and she became quite accustomed to
19 it and the nurses around it and she just perhaps felt
20 more secure there. She adapted to her surroundings,
21 secure surroundings.
22 MS GIBSON: Do you now attribute her being frightened and
23 tense to those factors or to something beyond that?
24 MS HINDS: It is probably a combination of both: what had
25 happened to her and most children when they come into
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