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Archived Transcript for 7 November 2001: Pages
151 to 200
151
1 the ward have a sort of fear.
2 MS GIBSON: At the time -- and again it is probably
3 difficult looking back -- do you recall whether your
4 instinct at the time or your impression was that her
5 fear, after allowing her a period to settle down in the
6 ward, was something above and beyond what you would
7 expect from a child simply being in unfamiliar
8 surroundings?
9 MS HINDS: Yes. But most children are escorted by their
10 parents and if they are with the children then they sort
11 of settle in a bit more and things. So it was odd
12 circumstances that very often there was not anybody with
13 her, and her poor command of English.
14 MS GIBSON: You say in your statement to the police that she
15 remained tense throughout the night while she was awake.
16 MS HINDS: Yes.
17 MS GIBSON: Is that something you recall clearly?
18 MS HINDS: Fairly clearly, yes. She seemed frightened.
19 MS GIBSON: Do you recall if she woke up during the night?
20 MS HINDS: I think I have said in my statement that
21 I wakened her for -- to change the bed as it had been
22 wet.
23 MS GIBSON: And when she woke up at that stage, your
24 impression was that she was tense, was it?
25 MS HINDS: Yes, as far as I can remember. Yes.
152
1 MS GIBSON: You say also, again in your statement to the
2 police, that she had obvious bruising on all four limbs.
3 Can you describe what you saw in terms of bruising?
4 MS HINDS: Well, just marks on her skin that looked like
5 bruises on black skin.
6 MS GIBSON: Do you recall now where you saw those bruises?
7 MS HINDS: Limbs. I remember it -- because I did not strip
8 her completely down, it was only what I had access to
9 getting her into bed.
10 MS GIBSON: Can you assist with on which of her limbs you
11 saw the bruises?
12 MS HINDS: No, I cannot.
13 MS GIBSON: Do you recall whether or not she ate on the
14 night of her admission into hospital?
15 MS HINDS: Yes, I think I have said that in my evaluation.
16 MS GIBSON: Do you recall, at this stage, how much she ate?
17 MS HINDS: I think it was two large bowls of cornflakes. In
18 fact, I am pretty sure.
19 MS GIBSON: I think you note in the morning she ate two
20 large bowls of cornflakes but what I am talking about is
21 actually when she came in in the nighttime.
22 MS HINDS: No, but it is not normal for the night staff to
23 feed the children, it is usually handed over to the day
24 staff to do. So that was, in a sense, not the norm.
25 MS GIBSON: Again, do you remember clearly whether she had
153
1 food during the nighttime? Can you categorically say
2 she did not?
3 MS HINDS: No, I can't. No. But it would have been early
4 in the morning, which was not the norm.
5 MS GIBSON: It is just again in your statement to the police
6 you say you recall Victoria having food which she ate as
7 though ravenously hungry that night and again in the
8 morning but it seems you do not recall that very clearly
9 now.
10 MS HINDS: Well I am just aware I had given her lots of food
11 during the night, or certainly in the morning, it would
12 have been early morning because, as I say, we do not
13 normally -- the night staff do not normally feed them.
14 MS GIBSON: I just want to be clear about this because it is
15 important what you actually recall with accuracy because
16 we have your notes which were made at the time but what
17 I am concerned about is whether your recollection has,
18 perhaps, been affected by your knowledge of what
19 happened to Victoria. In your police statement you say
20 that she ate ravenously during the night, or at
21 nighttime, and in the morning, and it seems in your
22 statement to the Inquiry and in your evidence that you
23 were clear about her eating in the morning but not too
24 clear about what happened in the night. What is the
25 position and what do you actually remember?
154
1 MS HINDS: I do remember giving her cornflakes and I am sure
2 that was very early morning.
3 MS GIBSON: Are you aware that the guidelines indicate that
4 you should record a child's weight and height on
5 admission, or at least the following morning?
6 MS HINDS: Yes.
7 MS GIBSON: That was not done in the case of Victoria. Can
8 you explain why not?
9 MS HINDS: An oversight perhaps. It should have been done
10 in casualty. Very often it is put on the drug chart as
11 well, so ...
12 MS GIBSON: Would it not be your practice to look at the
13 casualty notes?
14 MS HINDS: Yes, it is.
15 MS GIBSON: And we know that Victoria was not weighed either
16 that evening or in the morning. You accept that?
17 MS HINDS: Yes I do.
18 MS GIBSON: And do you accept that if you had followed the
19 guidelines that should have happened?
20 MS HINDS: Yes, I do.
21 MS GIBSON: And were you actually aware of that guideline?
22 MS HINDS: Yes, I know that they should be weighed or
23 measured; height taken.
24 MS GIBSON: Can you explain why it did not happen in this
25 case?
155
1 MS HINDS: No, I cannot. No. It is just that she was
2 admitted very late in the night, and the weigh machine
3 is at the other end of the ward.
4 MS GIBSON: That may be the position at nighttime, but the
5 situation in the morning is different, more time to
6 carry out these tasks, and it did not happen.
7 MS HINDS: Yes, that is true.
8 MS GIBSON: Do you understand what the significance might be
9 making sure the child was weighed and measured
10 accurately at an early stage?
11 MS HINDS: Yes.
12 MS GIBSON: Perhaps you can explain why it is important to
13 do that.
14 MS HINDS: I cannot remember why I did not do it. Maybe it
15 was an oversight on my part. Just that she came in
16 fairly late and because of her potential scabies she was
17 isolated. So the purpose of that, really, is to try and
18 keep them in that separate room.
19 MS GIBSON: She came on to the ward with Kouao, the person
20 purporting to be her mother. Do you remember much about
21 your conversations with Kouao while you were filling in
22 the patient information sheet?
23 MS HINDS: I just remember that she actually was quite
24 helpful in going through it with me. She managed to
25 answer, you know, what I asked her.
156
1 MS GIBSON: Perhaps we could have a look at that sheet now
2 at volume 37-page 274.
3 You have a copy of that sheet in front of you,
4 I hope. Can you confirm first if that is your
5 handwriting on the sheet?
6 MS HINDS: Yes.
7 MS GIBSON: You say you prepared that in the presence of
8 Kouao.
9 MS HINDS: Yes.
10 MS GIBSON: You filled the form in. Can you help with what
11 the source of the information under "Immunisation
12 Record" is? "Up-to-date", would that have been Kouao
13 telling you that?
14 MS HINDS: Yes.
15 MS GIBSON: And under "Infectious Diseases" you have written
16 "Scabies".
17 MS HINDS: Yes.
18 MS GIBSON: Again what would the source of that information
19 be?
20 MS HINDS: Her casualty notes.
21 MS GIBSON: And under the "Dates of Admission/Reason"
22 heading, you have "Facial burns, scabies/head lice".
23 Where did that piece of information come from about head
24 lice?
25 MS HINDS: Her casualty notes.
157
1 MS GIBSON: And that would not have come from Kouao, that
2 information?
3 MS HINDS: No, I do not think so.
4 MS GIBSON: You say that she was quite helpful in filling
5 the forms out. Do you recall anything at that stage
6 about her interaction with Victoria?
7 MS HINDS: Other than she was -- she was quite helpful with
8 me but with Victoria I suppose she was stern.
9 MS GIBSON: Again, there is no recording of that in your
10 nursing notes, and you have I think already accepted
11 that it is very important to note any concerns that you
12 have, particularly where there is a case of suspected
13 child abuse. Are you quite sure that she was stern and
14 that you are not just recalling that now because you are
15 aware of the circumstances of the death?
16 MS HINDS: No, she definitely had like an off-hand manner
17 with her. She was not warm. There was no warmth there.
18 She just felt -- when I settled her into the room, there
19 did not seem to be any sort of warmth or bonding.
20 MS GIBSON: Have you come across many cases of suspected
21 abuse and perhaps actual child abuse in your career as
22 a nurse?
23 MS HINDS: Yes. Quite a few.
24 MS GIBSON: And you are aware of the need to note any kind
25 of observations. Do you accept that it is quite
158
1 a serious deficiency in this case that you did not note
2 the stern response of Kouao to Victoria, given the
3 surrounding circumstances?
4 MS HINDS: Yes. I did note other things, but yes.
5 MS GIBSON: But it is important, is it not, to note every
6 single piece of information that might be valuable in
7 building up a picture of what the relationship is like
8 between the apparent mother and daughter in evaluating
9 not just whether there has been physical abuse but
10 whether there might be potential emotional abuse?
11 MS HINDS: Yes.
12 MS GIBSON: So do you accept that there are dangers in
13 haphazard recording of these matters?
14 MS HINDS: Well it is difficult to record everything. You
15 put down sort of the format you do go through and I have
16 done that and -- there is no real space in the
17 evaluation for sort of emotional. So -- but, yes
18 I accept that ...
19 MS GIBSON: We also have a critical incident log. Were you
20 aware of that log?
21 MS HINDS: Yes.
22 MS GIBSON: And that is the place where any incidents of
23 concern go about the child. There is no entry in
24 relation to these concerns about stern behaviour of the
25 mother towards the daughter; apparent mother towards the
159
1 daughter.
2 MS HINDS: Yes.
3 MS GIBSON: That is the place where that information should
4 be recorded?
5 MS HINDS: Yes.
6 MS GIBSON: Can I ask you now to -- following filling in the
7 patient information sheet, your next step is to fill out
8 the nursing problem list and there you note her rash and
9 indications for how that should be treated. Really
10 matters relating to her physical care. Did you not
11 think it was appropriate on that nursing problem list to
12 include whether or not there should be observations by
13 nursing staff of any interactions between the mother and
14 child, as it was a case of suspected abuse?
15 MS HINDS: Yes. You would expect the nurses to know to fill
16 that out. It is just that sometimes these notes
17 occasionally get left at the end of the bedside and you
18 do not want that sort of disclosed that that is what you
19 are looking at.
20 MS GIBSON: So that list would simply deal with the physical
21 problems and the actual nursing treatment?
22 MS HINDS: Generally speaking, yes.
23 MS GIBSON: Can you have a look at your entry on the nursing
24 notes at volume 37, page 260. I think you have the
25 right volume there. It is a question of going to the
160
1 right page. Do you have that now, page 260, and at the
2 top of the page there is your note for the evening of
3 24th July. Is that correct?
4 MS HINDS: Yes.
5 MS GIBSON: You mention at the bottom of that note that:
6 "After food was offered she settled down to sleep."
7 So it looks there as if food was offered that
8 evening. You say "mum resident". What did you mean by
9 that?
10 MS HINDS: She was resident for the admission and up to the
11 approximate time of me putting the time down which is
12 23.30.
13 MS GIBSON: Would she have had the option to stay overnight
14 with Victoria?
15 MS HINDS: Yes, we offer that to all mothers.
16 MS GIBSON: And she left at about 1 o'clock in the morning.
17 Is that something you found surprising?
18 MS HINDS: Well, yes, it is quite late.
19 MS GIBSON: And would most mothers in that situation with
20 a child who had been quite badly burnt elect to stay and
21 make sure the child was settled, certainly on the first
22 night?
23 MS HINDS: Yes.
24 MS GIBSON: Would the fact that she left be a cause of
25 concern to you?
161
1 MS HINDS: I was not aware of what her other family was.
2 Some mothers do leave. Some stay.
3 MS GIBSON: Do you recall -- and if you do not please say
4 so -- whether there was any discussion with her about
5 her option to stay overnight and any explanation given
6 about why she had to go?
7 MS HINDS: I do not recall it but it would have been offered
8 to her, most probably. It generally is.
9 MS GIBSON: Then going down the page, an entry marked
10 25th July is your notes for the morning. You note there
11 that the mother left at 1 o'clock and then I think I am
12 right in reading this: "Celpil initially refused but
13 eventually taken. Refused to allow clothes to be
14 laundered." What significance did you read into that;
15 that fact that she refused to allow her clothes to be
16 laundered?
17 MS HINDS: Well they needed laundering and she held on to
18 them. She was quite adamant that she wanted to hold on
19 to her clothes.
20 MS GIBSON: Did you think that that, in the context of an
21 abuse case, was something that may be heightened your
22 concerns?
23 MS HINDS: Yes, it is a little unusual. Normally you can
24 coax children around but she was quite certain she did
25 not want them taken from her.
162
1 MS GIBSON: You say in your statement that you noted Kouao
2 was very well-dressed in contrast to Victoria.
3 MS HINDS: Yes.
4 MS GIBSON: You do not note that down on this sheet or
5 indeed on the critical incident log. Again, do you
6 accept that that observation is important and should
7 have been noted; differential appearance may indicate
8 a lack of care for the child?
9 MS HINDS: Yes. Yes, it probably should have been put in.
10 MS GIBSON: You mention that Anna slept well and her bed was
11 changed during the night as she had wet the bed quite
12 badly. Do you recall, because there is some indication
13 certainly from Kouao herself, whether at any stage
14 during your dealing with Victoria on the ward she was
15 incontinent of faeces, not simply wetting herself?
16 MS HINDS: I can only recall wetting.
17 MS GIBSON: You were back on duty on 25th July at 5.30 and
18 we see your records over the page at 261. Is the second
19 entry yours?
20 MS HINDS: Yes.
21 MS GIBSON: Those notes appear to be made in the morning.
22 Is that right?
23 MS HINDS: Yes.
24 MS GIBSON: Were you on duty overnight then?
25 MS HINDS: Yes.
163
1 MS GIBSON: You mention there that Victoria's eye was
2 swollen and that you called a doctor to assist with
3 that.
4 MS HINDS: Just to observe it, it is not unusual for burns
5 to swell one to two days after they have happened.
6 MS GIBSON: You note there, also, that the mother visited
7 late and did not remain. Can you clarify what you meant
8 by "late"? Were you talking about that morning or were
9 you talking about the previous evening?
10 MS HINDS: I am sure it was the previous evening, that is
11 why it was noted, because it was late. Children go to
12 bed at 8/9, particularly ones of her age.
13 MS GIBSON: Are there any sort of set visiting hours for the
14 paediatric ward?
15 MS HINDS: Yes there is, but for parents they are open
16 visiting so they can come and go as they please.
17 MS GIBSON: You also mention in your statement you found
18 Kouao to be stand-offish with you, particularly when you
19 asked her to bring in some items for Victoria,
20 a toothbrush and other personal effects. What did you
21 mean by stand-offish? Perhaps you can describe what you
22 actually saw of her behaviour.
23 MS HINDS: I felt she did not like me asking her that, that
24 she was not happy with me asking for items to be brought
25 in.
164
1 MS GIBSON: How did she indicate that unhappiness to you?
2 MS HINDS: Just her demeanour, her pose.
3 MS GIBSON: Again, this is perhaps although maybe in itself
4 quite a small matter, but in the grand scheme of things
5 another part of the jigsaw of pattern of behaviour with
6 a mother who is stern towards the child and not
7 appropriately concerned to bring small items in for the
8 child and rather stand-offish when you ask her about it.
9 Again, no recording of that. Are you given guidance on
10 the importance of recording every piece of information
11 about a child?
12 MS HINDS: Yes. We are aware of documentation and the
13 importance of it, it is just difficult to record every
14 little sort of incident and sort of every communication
15 you have with somebody.
16 MS GIBSON: You say it is difficult, and I know that you are
17 very busy, but on the ward at any one time -- I mean,
18 perhaps you can help: were there any other cases of
19 child abuse on the ward with Victoria? And it must be
20 perhaps comparatively unusual to be dealing with a case
21 of serious abuse.
22 MS HINDS: It is unusual to be dealing with serious abuse,
23 yes.
24 MS GIBSON: And this was such a case, was it not?
25 MS HINDS: Yes, it was.
165
1 MS GIBSON: So not difficult, really, to make a quick note
2 on the critical incident sheet: "Mother stand-offish
3 when asked to bring in personal items for the child".
4 It is a two second job.
5 MS HINDS: I have asked parents in the past about bringing
6 in personal things and it is not unusual for them not
7 to.
8 MS GIBSON: Maybe not to because they forget, but then when
9 they are reminded about that, to be stand-offish
10 about -- it is something a little bit strange. Most
11 parents, I would imagine, when they are in hospital are
12 bending over backwards to make sure their child is
13 comfortable.
14 MS HINDS: That is not always the case in our ward,
15 actually. It really is not. It is a grey area. Very
16 often we are putting children into adult gowns and we
17 are supplying our own shampoo and things for them.
18 MS GIBSON: But you were sufficiently concerned about this
19 case and this particular mother to recall many, many
20 months after your dealings with the case these aspects
21 of behaviour. If that was commonplace I wonder why you
22 remember?
23 MS HINDS: I remember asking her and the response -- I am
24 sure I asked the question every other week of parents
25 but I do remember asking her.
166
1 MS GIBSON: You remember her response is something unusual
2 and, again, I ask you: why was that not recorded?
3 Because your reaction about that was that there was
4 something wrong, which is why you remember.
5 MS HINDS: As I say, everything is not recorded and it is
6 the time constraint.
7 MS GIBSON: You mention at paragraph 31 of your statement
8 that both yourself and Grace Pereira witnessed Victoria
9 standing up as though to attention when Kouao entered
10 her cubicle.
11 MS HINDS: Yes.
12 MS GIBSON: Can you help with whether both yourself and
13 Grace Pereira saw the same incident or are you talking
14 about two different incidents?
15 MS HINDS: I am not certain.
16 MS GIBSON: Have you discussed this incident with
17 Grace Pereira subsequently?
18 MS HINDS: Yes.
19 MS GIBSON: And when was that?
20 MS HINDS: Not -- well, when we both discussed it I am sure
21 it was in the office when Grace said about her standing
22 and I said, "yes, I have noticed that". There was
23 probably several times after that we discussed it.
24 MS GIBSON: Are you meaning at the time in July 1999 or are
25 you meaning after you learned of her death?
167
1 MS HINDS: In July.
2 MS GIBSON: You are quite clear about that?
3 MS HINDS: Yes.
4 MS GIBSON: Again, that particular observation does not find
5 its way to any notes.
6 MS HINDS: Yes, I assumed Grace had documented it.
7 MS GIBSON: You assumed Grace had documented it but did you
8 do anything yourself to reassure that that was the case?
9 MS HINDS: No, I cannot remember.
10 MS GIBSON: You say that your recollection of Victoria was
11 that she was a happy child while she was on the ward.
12 MS HINDS: Yes.
13 MS GIBSON: And that she was given things by the nursing
14 staff. Again, was that unusual that she, I suppose,
15 became the ward favorite, if you like?
16 MS HINDS: It is not unusual. She had an engaging
17 personality. There was a lot of happiness inside her
18 and that came out. She liked to sing and dance and
19 things.
20 MS GIBSON: You mention she was friendly with the nursing
21 staff but also made friends with children on the ward.
22 MS HINDS: Yes.
23 MS GIBSON: Is it the position that she was more friendly
24 towards the staff than the children?
25 MS HINDS: Yes, possibly. Yes.
168
1 MS GIBSON: You say "possibly". I just want to know what
2 you actually remember and if you do not remember please
3 say so.
4 MS HINDS: Yes, I think that was the case.
5 MS GIBSON: So is it the position she was actually a bit
6 more shy with the other children?
7 MS HINDS: Not necessarily shy, she just seemed to attach
8 herself to nurses. She seemed to like, almost, the
9 approval of nurses.
10 MS GIBSON: She attached herself to adults. Did she become
11 very warm towards a nurse who was caring for her very
12 quickly?
13 MS HINDS: Yes, she liked to sort of show you what she could
14 do. She could sing and dance and curtsey and twirl in
15 her dress.
16 MS GIBSON: Would it be a fair description to say she was
17 positively looking for affection from adults?
18 MS HINDS: Yes, you could say that. Yes.
19 MS GIBSON: Are you given any training as a nurse or are you
20 aware of attachment, disorders and signs of anxious
21 attachment in children as being a possible indicator of
22 abuse?
23 MS HINDS: I have not been given any formal training in it
24 but ...
25 MS GIBSON: Not any formal training but do you have any
169
1 basic awareness?
2 MS HINDS: Yes.
3 MS GIBSON: Where does that awareness come from? Is it
4 something you pick up or something you are given basic
5 training about?
6 MS HINDS: Something you are aware of from having worked
7 with children.
8 MS GIBSON: And what is the significance of that?
9 MS HINDS: It may be them looking for love that they have
10 not been able to get from whoever is looking after them
11 or their parents, or ...
12 MS GIBSON: Did you do anything to share that particular
13 concern with anybody about her attaching to adults?
14 MS HINDS: Well I think most people in the ward were aware
15 of it by her actions and just noting the way that she
16 played in the ward and that.
17 MS GIBSON: Thank you very much Miss Hinds. If you wait
18 there, there may be more questions.
19 THE CHAIRMAN: Thank you Miss Gibson. Mr Mason, please.
20 MR MASON: Thank you Miss Hinds. You have volume 37 there.
21 Just look at page 275. Now I hope that is the critical
22 incident log; is that correct?
23 MS HINDS: Yes.
24 MR MASON: Would you have been aware of that document when
25 you were on duty and what was written in it?
170
1 MS HINDS: Yes.
2 MR MASON: If you look at the note, the first entry of that
3 note refers to -- it is a note by Grace Pereira and she
4 refers to the master and servant relationship that she
5 noted. Is that the standing to attention that she spoke
6 to you about?
7 MS HINDS: Yes I think so, yes.
8 MR MASON: Would it be fair to say that you would have been
9 aware that Mrs Pereira had in fact made a note of those
10 concerns?
11 MS HINDS: Yes, I thought she had.
12 MR MASON: So having been aware of the contents of that log,
13 would there be any point, in your opinion, in to
14 repeating the same sort of observations?
15 MS HINDS: Maybe I had no strength to, but it is
16 duplicating.
17 MR MASON: One small matter. It may be a slightly odd way
18 of introducing a small bit of evidence but, Miss Hinds,
19 there is reference in Lucy O'Toole's(?) statement of
20 a couple of photographs having been taken of Victoria, a
21 polaroid, while she was on the ward. And Miss Hinds --
22 it has been found and Miss Hinds produced it this
23 morning. The nurses put it in a frame and Mr and
24 Mrs Climbie now have that. So this photograph does
25 exist of Victoria in the dress that Miss Hinds refers to
171
1 in her witness statement.
2 THE CHAIRMAN: Well I am grateful Mr Mason for that
3 information. I am grateful to the nurses who have found
4 the photograph and given it to Mr and Mrs Climbie. I am
5 sure they will value it very greatly. With Mr and Mrs
6 Climbie's permission, I think I and my colleagues would
7 like the opportunity to see it some time, if we may
8 please, though of course we will return it right away.
9 MR MASON: Thank you, sir.
10 THE CHAIRMAN: Miss Hinds, you have been very helpful.
11 Thank you very much indeed.
12 MS GIBSON: Thank you, sir. Mr Sheldon will take the next
13 two witnesses.
14 MR SHELDON: Sir, with your permission, Christine Keating,
15 please.
16 THE CHAIRMAN: Thank you very much.
17 MISS CHRISTINE BRIGID KEATING (sworn)
18 MR SHELDON: Good afternoon. Miss Keating, could you
19 confirm your full name, please?
20 MS KEATING: Christine Brigid Keating.
21 MR SHELDON: And your current professional address?
22 MS KEATING: North Middlesex Hospital.
23 MR SHELDON: I understand you have made a statement for use
24 by this Inquiry, is that right?
25 MS KEATING: Yes.
172
1 MR SHELDON: I think a copy of that is being put in front of
2 you.
3 Sir, for your note it is in volume 6, page 156.
4 Miss Keating also made a very brief statement to the
5 Crown Prosecution Service. That is in bundle 46,
6 page 134.
7 Miss Keating can you have a look at that statement
8 and confirm that it is your signature on the last page
9 of it?
10 MS KEATING: Yes, it is.
11 MR SHELDON: And are you happy that the facts and matters in
12 that statement are true?
13 MS KEATING: Yes.
14 MR SHELDON: You became a registered general nurse in 1994,
15 is that right?
16 MS KEATING: That is right.
17 MR SHELDON: You received your diploma in childrens' nursing
18 in 1997.
19 MS KEATING: Yes.
20 MR SHELDON: You have been working on the Rainbow Ward of
21 the North Middlesex Hospital since about August 1998.
22 Would I be right in that?
23 MS KEATING: Yes.
24 MR SHELDON: Firstly as an agency nurse, then as a Grade E
25 staff nurse and then since October 1999 a Grade F nurse.
173
1 MS KEATING: That is correct.
2 MR SHELDON: As far as the training in child protection that
3 you have received, you made reference in your statement
4 to a yearly seminar on child protection run by the
5 Trust.
6 MS KEATING: That is right.
7 MR SHELDON: Is that the one run by Dr Rossiter?
8 MS KEATING: Yes.
9 MR SHELDON: You say in your statement, paragraph 6, that
10 you attended that seminar in March 1999/2001. Have you
11 been twice?
12 MS KEATING: Yes.
13 MR SHELDON: I see, so you went in March 1999 and March
14 2001.
15 MS KEATING: I am sure it was 1999. It may have been 1998
16 but I think it was 1999.
17 MR SHELDON: Is the seminar the same each year?
18 MS KEATING: It is an updated seminar each year, so more
19 information.
20 MR SHELDON: And one of the principal things it covers is an
21 understanding of the Trust child protection guidelines?
22 MS KEATING: Yes.
23 MR SHELDON: I wonder if you could be shown a copy of those.
24 They are in volume 39, starting at page 221. These are
25 the guidelines you were referring to, are they?
174
1 MS KEATING: Yes.
2 MR SHELDON: I take it that you have been on two seminars
3 covering them. You are reasonably familiar with them?
4 MS KEATING: Reasonably.
5 MR SHELDON: Were they kept on the ward?
6 MS KEATING: Yes.
7 MR SHELDON: Whereabouts?
8 MS KEATING: Kept in the office in a child protection
9 folder.
10 MR SHELDON: You had ready access when you needed them?
11 MS KEATING: Yes.
12 MR SHELDON: There is only one aspect I wish to refer you to
13 at the moment and it is on page 241. Hopefully that
14 page is headed "Children's Wards", is it?
15 MS KEATING: Yes.
16 MR SHELDON: About two-thirds of the way down there is
17 a numbered paragraph 2 which reads:
18 "Information relevant to child protection including
19 accidents on the ward, parental visiting, decisions of
20 a planning/strategy meeting or case conference should be
21 recorded on form CP6. Accidents should also be recorded
22 on risk management forms."
23 Were you aware of that requirement?
24 MS KEATING: Yes.
25 MR SHELDON: I think it is right that also in addition to
175
1 the form CP6 you operated something called a critical
2 incident log; is that right?
3 MS KEATING: Yes.
4 MR SHELDON: So is the position if you did come across
5 anything on the ward that you thought was relevant to
6 child protection, you would either put it on a CP6 form
7 or you would note it on a critical incident log?
8 MS KEATING: The majority of the time back then we would
9 have put it on the critical incident.
10 MR SHELDON: I see. Turning to your experiences of
11 Victoria. You remember, I take it from your statement,
12 two occasions upon which you came into contact with her?
13 MS KEATING: That is correct.
14 MR SHELDON: The first was on night shift of 30th July 1999;
15 is that right?
16 MS KEATING: Yes.
17 MR SHELDON: That is a shift that runs from 7.30 in the
18 evening until 8 o'clock in the morning the next day, is
19 it?
20 MS KEATING: Yes.
21 MR SHELDON: You would have been one of four or five nurses
22 on that shift, one of whom would have been in charge?
23 MS KEATING: Yes.
24 MR SHELDON: Were you in charge?
25 MS KEATING: No.
176
1 MR SHELDON: You would be allocated on duty a number of
2 children for whom you have particular responsibility?
3 MS KEATING: Yes.
4 MR SHELDON: But presumably you would help out with other
5 children as and when appropriate?
6 MS KEATING: Absolutely, yes.
7 MR SHELDON: How many children would you be allocated on
8 a normal shift?
9 MS KEATING: About four or five, maybe six.
10 MR SHELDON: On this occasion one of the children you were
11 allocated was Victoria.
12 MS KEATING: Was Victoria, yes.
13 MR SHELDON: The first thing I understand is you received
14 a handover from the day shift nurses.
15 MS KEATING: Yes.
16 MR SHELDON: During the course of that handover are you
17 brought up to date on all the children on the ward or
18 only those to whom you have been specifically allocated?
19 MS KEATING: We are given a general handover of all the
20 children on the ward, then we do a bedside handover
21 where we go around to each child and we are handed over
22 individual nursing care for each child. But we go
23 around as a group.
24 MR SHELDON: I see; the first stage is a handover in the
25 nurses' office; is that right?
177
1 MS KEATING: Yes.
2 MR SHELDON: That encompasses all the children on the ward.
3 MS KEATING: Yes.
4 MR SHELDON: So if there were, for example, child protection
5 concerns about a particular child, then all the nurses
6 would be made aware of that at the initial handover even
7 if they were not the allocated nurse?
8 MS KEATING: Yes.
9 MR SHELDON: During the course of the handover for a child
10 to whom you were allocated you would look at the patient
11 information sheet, would you?
12 MS KEATING: The nurse handing over would, yes.
13 MR SHELDON: Would she show the patient information sheet to
14 you?
15 MS KEATING: No.
16 MR SHELDON: So would you ever see the patient information
17 sheet?
18 MS KEATING: The patient information sheet, they are all
19 left in the same folder in the office.
20 MR SHELDON: I see. Would you during the course of the
21 handover be shown the critical incident log or form CP6,
22 whichever it was, that was being completed in relation
23 to a child to whom you were allocated?
24 MS KEATING: Yes, I probably would see it and handover
25 information was written on the back of the form but not
178
1 necessarily being handed around to each individual to
2 be ...
3 MR SHELDON: Could you be shown volume 37, please, page 275.
4 This is a copy of the critical incident log sheet in
5 relation to Victoria.
6 MS KEATING: Yes.
7 MR SHELDON: Do you recall whether you saw this sheet?
8 I realise it would not have all the entries on it we now
9 see, but do you recall whether you saw that sheet at
10 handover on 30th July?
11 MS KEATING: To the best of my memory I looked at it after
12 handover that night.
13 MR SHELDON: Just looking at that sheet -- and we will not
14 try and pick our way through all of it but you would
15 have seen for example in relation to the entry on
16 25th July 1999, three lines down, that a master and
17 servant attitude had been observed, and mum kept
18 pointing a finger at her. That is one of the things you
19 would have been aware of, yes?
20 MS KEATING: Yes.
21 MR SHELDON: You would also have known from the entry on
22 26th July 1999 that a referral had been made to social
23 workers; yes?
24 MS KEATING: Yes.
25 MR SHELDON: And that -- second line -- "doctors [and
179
1 I presume that is] and nurses to contact social work
2 department again if it is thought that injuries are
3 non-accidental and CP forms have been completed stating
4 this". So you are aware of that too?
5 MS KEATING: Yes.
6 MR SHELDON: You would also have been aware, given the entry
7 on the 29th July 1999, that Anna had said that she had
8 taken a kettle herself and poured it over her forehead;
9 you remember that too?
10 MS KEATING: I do not remember reading that part of it but
11 I would have read the back of the folder that was on.
12 MR SHELDON: But you would in any event have known there was
13 a fairly important role for any nurse allocated to
14 Victoria at that time?
15 MS KEATING: Yes.
16 MR SHELDON: And that role included keeping a close eye on
17 her behaviour and any interaction with her mother, yes?
18 MS KEATING: Yes.
19 MR SHELDON: Recording anything that might seem relevant to
20 child protection issues on a critical incident log
21 sheet?
22 MS KEATING: Yes.
23 MR SHELDON: And given the entry for the 26th July, if you
24 thought that there was evidence to support
25 non-accidental injury, then the social worker should be
180
1 informed too?
2 MS KEATING: Yes.
3 MR SHELDON: So having made yourself aware of that
4 information and those obligations you then went out on
5 to the ward and started caring for Victoria?
6 MS KEATING: Yes.
7 MR SHELDON: So we can take it from your answers to those
8 last questions that where you say in paragraph 13 of
9 your statement, four lines down: "I think I was also
10 told social services were involved in Victoria's
11 case...", that the real position is you knew that social
12 services were involved in Victoria case?
13 MS KEATING: Probably I read it afterwards, I read it after
14 handover. I was probably told that in handover so
15 I said I think I was told that in handover.
16 MR SHELDON: I see. So when you go out onto the ward and
17 introduce yourself to the child you are looking after,
18 the first thing you do is a bedside assessment; is that
19 right?
20 MS KEATING: Yes.
21 MR SHELDON: You would check medication charts, update the
22 parents if they are there, and devise a care plan for
23 the night?
24 MS KEATING: Yes.
25 MR SHELDON: Did you do that in relation to Victoria?
181
1 MS KEATING: Yes.
2 MR SHELDON: I know the parent was not there, but devising
3 the care plan and checking the charts.
4 MS KEATING: Yes.
5 MR SHELDON: Would you look at the notes?
6 MS KEATING: I probably would not have had a chance to look
7 at the critical incident log at that time, I would have
8 left that until it was a bit quieter and then read it.
9 But I would have had a look at her in the afternoon
10 shift and handover.
11 MR SHELDON: Let us turn to how she seemed to you that
12 night. I can only find one entry from you in the notes.
13 It is in volume 37 at page 267. Could you turn to that,
14 please. The second note up from the bottom on page 267,
15 is that your handwriting?
16 MS KEATING: Yes.
17 MR SHELDON: Could you read what you say there?
18 MS KEATING: "Unsettled night. Very upset at times.
19 Looking for food early nocte. Incontinent x 1.
20 Antibiotics as prescribed. Missed midnight dose as she
21 was upset going to sleep. Cepe for undisturbed.
22 Pyrexial. Paracetamol and (indecipherable) Itching ++
23 at times".
24 MR SHELDON: So we can take it from that that one of the
25 first things you noticed when you took over her care was
182
1 she seemed very hungry or very anxious to be fed?
2 MS KEATING: Yes.
3 MR SHELDON: You describe in your statement that after a bit
4 of research she came up with the word "bread".
5 MS KEATING: Yes.
6 MR SHELDON: And asked you for some bread. Did you give her
7 any?
8 MS KEATING: I cannot remember.
9 MR SHELDON: Do you recall whether you fed her that night at
10 all?
11 MS KEATING: I probably did.
12 MR SHELDON: That was despite knowing she had been eating
13 quite a bit that day?
14 MS KEATING: She had had a bedtime snack as well.
15 MR SHELDON: It seems from that note she may have been
16 fairly cheerful at that point prior to going to bed.
17 MS KEATING: Yes.
18 MR SHELDON: But you recall that during the night she became
19 very upset?
20 MS KEATING: Yes.
21 MR SHELDON: And when you went to see her you discovered she
22 had wet the bed; is that right?
23 MS KEATING: That was later on. She had become upset
24 earlier as well because she was scratching a lot and she
25 was getting frustrated with it and then later on she was
183
1 wet.
2 MR SHELDON: You just indicated scratching, and you
3 indicated scratching her arm. Is that because that is
4 where you recall her scratching.
5 MS KEATING: I do not particularly recall where she
6 scratched, no. I am just scratching my arm.
7 MR SHELDON: So she was upset early in the night shortly
8 after going to bed and that seemed to be because she was
9 in discomfort and itching. But you recall her being
10 upset later and on that occasion discovered she had wet
11 the bed. Is that right?
12 MS KEATING: Yes.
13 MR SHELDON: When you say "upset", what do you mean?
14 MS KEATING: She became very distressed. Obviously she was
15 wet and it was cold and she became upset/distressed.
16 MR SHELDON: Crying?
17 MS KEATING: Crying, yes. She became very agitated and
18 started scratching at herself.
19 MR SHELDON: Just so we are clear on one point: did Kouao
20 visit at any stage during that night?
21 MS KEATING: I do not recall her visiting, no.
22 MR SHELDON: Did anything happen during that night that you
23 thought should have gone in the critical incident log?
24 MS KEATING: I perhaps should have written she was
25 incontinent overnight because they had been recording
184
1 her behaviour during the night. But it was written in
2 the multi-disciplinary which the doctors would have had
3 access to the next morning, so, no.
4 MR SHELDON: So you thought recording it where you did would
5 probably be sufficient?
6 MS KEATING: Yes.
7 MR SHELDON: You did not, for example, think that the
8 incidents of distress you thought were such in light of
9 what you knew about her case as to raise child
10 protection concerns or be significant in the child
11 protection context?
12 MS KEATING: I did not, no.
13 MR SHELDON: Was that because you thought that they were
14 incidents of distress of a type that you might commonly
15 see amongst children on the ward?
16 MS KEATING: Yes.
17 MR SHELDON: Three minor points about her presentation that
18 night before we move on. You have already indicated
19 that she was itching and you say in your CPS statement
20 that she was itching before she went to bed, as I think
21 you have indicated today, and that she was given
22 anti-itching medication. In your statement to the
23 Inquiry you say she was itching her face and hair.
24 MS KEATING: Yes.
25 MR SHELDON: You are not saying, I take it, that her itching
185
1 was restricted to her face and hair, are you?
2 MS KEATING: Not that I can recall. I remember when she was
3 wet she was scratching everywhere. She just seemed to
4 be getting very agitated.
5 MR SHELDON: Were you told at the handover to take any
6 precautions when caring for Victoria so you did not get
7 scabies?
8 MS KEATING: No.
9 MR SHELDON: Next point: you have noted she wet the bed on
10 one occasion and you noted in your note "incontinence
11 times one". Was she ever incontinent to faeces whilst
12 she was under your care?
13 MS KEATING: No.
14 MR SHELDON: Lastly: did you ever observe her to self-treat
15 with either Hibitane or Hibiscrub while she was on the
16 ward?
17 MS KEATING: No.
18 MR SHELDON: Moving on to the second occasion you came into
19 contact with her, which was some time, you say in your
20 statement, the following week.
21 MS KEATING: Yes.
22 MR SHELDON: Can you be any more precise than that?
23 MS KEATING: I cannot, no.
24 MR SHELDON: You recall an incident when you were dressing
25 Victoria's head wounds in the treatment room.
186
1 MS KEATING: I think that was what I was doing, yes. We
2 were dressing her head wounds.
3 MR SHELDON: That was in the company of another nurse, was
4 it?
5 MS KEATING: That is correct.
6 MR SHELDON: In paragraph 24 of your statement you recall
7 Victoria talking to you about her itching head. It is
8 recorded there. I realise it cannot be a precise record
9 of what she said, but the gist of it is, is it not, that
10 she was telling you she had poured boiling water from
11 a kettle over her own head to stop itching?
12 MS KEATING: Yes.
13 MR SHELDON: You had asked her, had you, how she had come by
14 the wounds to her head?
15 MS KEATING: I think so. I think we had said "how did this
16 happen", either myself or my colleague.
17 MR SHELDON: I take it from the next paragraph of your
18 statement, where you record -- "Victoria told this story
19 in a sing song fashion, with her head going from side to
20 side, as if to indicat that she had told the story so
21 many times that she was bored [by] it" -- that the way
22 in which she told you made you suspicious?
23 MS KEATING: Yes. She told it very song-like, like she had
24 learned it before.
25 MR SHELDON: Regardless of the way in which that story is
187
1 told, the story itself is such as to generate suspicion,
2 is it not?
3 MS KEATING: Yes.
4 MR SHELDON: We know certainly from what the other nurse
5 said as you record in paragraph 26 that the other nurse
6 did not believe her.
7 MS KEATING: Yes.
8 MR SHELDON: Did you believe her?
9 MS KEATING: No.
10 MR SHELDON: Perhaps I should put it directly. Did you
11 think, from observing her on that occasion, that she had
12 been coached to give a false account of the manner in
13 which she had come by her injuries?
14 MS KEATING: Coached I do not know but she certainly had the
15 story off in a rhyme and it could be she repeated it so
16 many times or she had been told to say it, I do not
17 know.
18 MR SHELDON: Were these suspicions and concerns, what you
19 felt then, or by looking back what you have decided must
20 have been the case?
21 MS KEATING: I think I did not believe it then and certainly
22 looking back on it I know it to be the case.
23 MR SHELDON: Because there is no record of that conversation
24 in the notes, is there?
25 MS KEATING: No.
188
1 MR SHELDON: I take it from that that when you came to make
2 your statement, because it is not in your CPS statement,
3 either you had an independent recollection of that
4 conversation --
5 MS KEATING: Yes.
6 MR SHELDON: -- despite the fact it had taken place two
7 years ago?
8 MS KEATING: Yes.
9 MR SHELDON: Given that you have an independent recollection
10 of it and it was so long ago, can I take it you regarded
11 it at the time as something unusual and/or significant?
12 MS KEATING: I remember it at the time being unusual.
13 MR SHELDON: The fact that a child about whom there are
14 child protection concerns is giving an account of her
15 injuries that you do not believe, that is important in
16 a child protection context, is it not?
17 MS KEATING: Yes.
18 MR SHELDON: Why is there no note of it in the critical
19 incident log?
20 MS KEATING: Regrettably I did not record it in the critical
21 incident log. I should have done.
22 MR SHELDON: Why did you not tell the social worker?
23 MS KEATING: I do not know again. I do not know why I did
24 not. Regrettably I did not.
25 MR SHELDON: But you are sure it happened?
189
1 MS KEATING: Yes.
2 MR SHELDON: You are aware -- I have shown you the section
3 in the Child Protection Manual of the obligation to make
4 a note of this sort of thing.
5 MS KEATING: Yes.
6 MR SHELDON: So quite candidly and creditably you said that
7 was a defect in your nursing practice that day.
8 MS KEATING: Yes.
9 MR SHELDON: Did you bring what she had said to the
10 attention of any nursing staff or any medical staff?
11 MS KEATING: I do not directly recall bringing it to the
12 attention of anybody but at handover we would have had
13 a general discussion about anything that Victoria had
14 said. So I presume that I would have -- we would have
15 mentioned it, we would have discussed it at some level
16 either in the ward round or handover, but I do not
17 directly recall writing it down, so I did not.
18 MR SHELDON: We know that there is at least one reference to
19 the fact that Victoria had been admitted to the Central
20 Middlesex Hospital shortly prior to coming to North
21 Middlesex.
22 Sir, for your note one such reference is volume 37
23 page 243.
24 Did you know, Miss Keating, that Victoria had been
25 at Central Middlesex Hospital a couple of weeks
190
1 previously?
2 MS KEATING: I have a vague recollection of it. I do not
3 know whether I learned that afterwards, after she had
4 died, or beforehand.
5 MR SHELDON: But you do not recall any efforts by anybody on
6 Rainbow Ward to get hold of her ward notes from Central
7 Middlesex Hospital to find out what had gone on while
8 she was there?
9 MS KEATING: I do not recall it, no.
10 MR SHELDON: Dr Reynders says in his witness statement --
11 I do not need to take you to it, it is paragraph 15 sir
12 for your note -- that after Victoria had left Rainbow
13 Ward there was a lengthy discussion about her case.
14 Unfortunately he does not say who was involved in those
15 discussions or that discussion. Were you?
16 MS KEATING: No.
17 MR SHELDON: Do you recall ever discussing Victoria's case
18 with anybody after she left prior to the investigations
19 into her death in this Inquiry?
20 MS KEATING: I have no knowledge.
21 MR SHELDON: No-one ever asked you for your views on the
22 case or your input into it, social services, the police,
23 anyone like that?
24 MS KEATING: Not that I can recollect, no.
25 MR SHELDON: Now of course it is right to say, Miss Keating,
191
1 that your witness statement to this Inquiry was prepared
2 after you knew what happened to Victoria and the
3 terrible circumstances in which she died.
4 MS KEATING: (Nods).
5 MR SHELDON: Is it possible in light of that knowledge you
6 may have attached more significance to some of the
7 observations that you record in this statement now than
8 you accorded to them at the time?
9 MS KEATING: Probably not. I think for this, because I had
10 somebody else writing my statement for the CPS
11 statement, we were told to write factual information,
12 and for preparing this statement I had somebody to help
13 me write it.
14 MR SHELDON: Because that might be one explanation, might it
15 not, for why, for example, the conversation about
16 Victoria pouring the water over her head did not find
17 its way into the notes, by which I mean you did not
18 think it particularly important then but knowing what
19 you now know you can see it is important now?
20 MS KEATING: That could be one way, yes.
21 MR SHELDON: You gave an answer to me earlier -- and this is
22 the last point I need to deal with -- in relation to
23 scabies and how you were not told to take any
24 precautions when nursing Victoria on 30th July to avoid
25 catching it yourself. That is the position, is it?
192
1 MS KEATING: Yes.
2 MR SHELDON: Was she not being nursed in isolation at that
3 point?
4 MS KEATING: She was being nursed in isolation because of
5 her burns. She had open wounds and it was just to
6 prevent an infection of those, so we reduced her
7 exposure to other children on the ward.
8 MR SHELDON: So it was nothing to do with scabies?
9 MS KEATING: That is what I understood. Nothing to do with
10 scabies.
11 MR SHELDON: Thank you very much.
12 THE CHAIRMAN: Thank you very much, Mr Sheldon. Mr Mason.
13 MR MASON: Miss Keating, a couple of quick questions if
14 I may. You were asked whether or not you should have
15 mentioned Victoria's account of how she received her
16 burns to a social worker. Do you recall ever speaking
17 to a social worker about Victoria while she was an
18 in-patient?
19 MS KEATING: No.
20 MR MASON: At the time did you think that this account was
21 important enough that you should go and actively seek
22 out a social worker to inform him or her about this
23 story?
24 MS KEATING: I think at the time I presumed that it had
25 already been documented and recorded. It was a story
193
1 Victoria had told a lot, so no, I did not go to a social
2 worker with it, no.
3 MR MASON: Thank you.
4 THE CHAIRMAN: Thank you. Miss Keating, just tell me: is
5 there food on the ward at night?
6 MS KEATING: Yes.
7 THE CHAIRMAN: How do you actually get food for a child?
8 MS KEATING: There is usually breakfast cereals and there
9 may be some sandwiches left over from earlier on and
10 there are facilities to make toast.
11 THE CHAIRMAN: So a child who is hungry could be provided
12 with something quite quickly?
13 MS KEATING: Yes.
14 THE CHAIRMAN: In your experience, was there anything
15 exceptional about Victoria's condition and care, other
16 than what you have already said, that you would like to
17 say or have you actually covered all the things that you
18 wanted to cover? I do not want you to go away and
19 think, "I wish I had a chance to say something more".
20 There is no more?
21 MS KEATING: I do not think so, no.
22 MR SHELDON: Thank you very much indeed.
23 Sir, with your permission the next witness is
24 Millicent Graham.
25 MISS MILLICENT MARIE GRAHAM (sworn)
194
1 MR SHELDON: Good afternoon.
2 MS GRAHAM: Good afternoon.
3 MR SHELDON: Would you confirm your full name.
4 MS GRAHAM: Millicent Marie Graham.
5 MR SHELDON: Miss Graham, you have made a statement for use
6 by this Inquiry, a copy of which I think is going to be
7 put in front of you. Sir, for your note it is volume 6,
8 page 119. Miss Graham has also made a statement to the
9 CPS, in bundle 46, page 94, and the transcript of her
10 evidence at the Central Criminal Court is bundle 49,
11 page 135 onwards.
12 Miss Graham can you have a look at the last page of
13 that statement and confirm that it is your signature at
14 the bottom?
15 MS GRAHAM: Yes, it is.
16 MR SHELDON: Are you happy that the facts and matters in
17 that statement are true?
18 MS GRAHAM: Yes.
19 MR SHELDON: You have been a nurse on Rainbow Ward since
20 1987, is that right?
21 MS GRAHAM: Yes.
22 MR SHELDON: You are currently a Grade E staff nurse?
23 MS GRAHAM: Yes.
24 MR SHELDON: You detail in your statement at paragraph 2 the
25 hours you commonly work and you work on a part-time
195
1 basis, do you not?
2 MS GRAHAM: Since 1988, yes.
3 MR SHELDON: So were those hours that you describe in
4 paragraph 2 the hours you were working in July and
5 August 1999?
6 MS GRAHAM: Yes.
7 MR SHELDON: When you commonly come on duty in the morning,
8 the first thing that happens is you receive a handover
9 from the nurses on the night shift; is that right?
10 MS GRAHAM: Yes.
11 MR SHELDON: And during the course of that handover you are
12 made aware of the information contained in the patient
13 information sheet as well as anything that may be in the
14 critical incident log relating to any child. Is that
15 right?
16 MS GRAHAM: We are given the child's age, name and diagnosis
17 and we are made aware of anything that might be on the
18 critical form at the back and then when we get time we
19 read it later.
20 MR SHELDON: I see. So you are given during the course of
21 the handover a verbal summary of the important points,
22 then you will look at it in detail when you get the
23 opportunity?
24 MS GRAHAM: But anything that cannot be said at the bedside
25 is usually said in the handover.
196
1 MR SHELDON: Is that in respect of all the children or just
2 the children you are allocated?
3 MS GRAHAM: All the children, in handover of all the
4 children.
5 MR SHELDON: But you are allocated five or six children in
6 a particular shift for whom you have particular
7 responsibility?
8 MS GRAHAM: Once we have had walk around and seen all the
9 children, we are allocated our separate patients.
10 MR SHELDON: But the way in which the handover would work is
11 such that if there were child protection concerns about
12 any child on the ward, you would be made aware of them
13 whether he or she was one of your allocated patients or
14 not?
15 MS GRAHAM: Yes, everyone gets the same handover in the
16 morning.
17 MR SHELDON: Once you had been allocated a group of
18 children, you would do an assessment of those children
19 at the bedside; is that right?
20 MS GRAHAM: Yes.
21 MR SHELDON: That would involve devising a care plan and
22 explaining to them how they were going to be looked
23 after that day?
24 MS GRAHAM: Yes.
25 MR SHELDON: Would you commonly look at the clinical notes
197
1 during the course of that assessment?
2 MS GRAHAM: We usually look at what has been written by the
3 night staff or whoever has handed over to us.
4 MR SHELDON: You probably heard reference being made more
5 than once this afternoon to the hospital's child
6 protection guidelines which are in volume 39 and
7 I wonder if they could be put in front of you.
8 Page 241, please. Before we come on to the detail of
9 those, you are familiar with those guidelines, I take
10 it?
11 MS GRAHAM: Yes.
12 MR SHELDON: Because you, in common with Miss Keating, have
13 also been on two of Dr Rossiter's child protection
14 seminars; 1997 and 1999?
15 MS GRAHAM: Yes.
16 MR SHELDON: And these guidelines are covered during the
17 course of those seminars; is that right?
18 MS GRAHAM: They are constantly being updated.
19 MR SHELDON: Have a look at page 241, please, and paragraph
20 numbered 2 about two-thirds of the way down the page:
21 "Information relevant to child protection, including
22 accidents on the ward, parental visiting, decisions of
23 a planning/strategy meeting or case conference should be
24 recorded on form CP6."
25 Were you aware of the obligation on nurses to record
198
1 matters significant to child protection?
2 MS GRAHAM: Yes.
3 MR SHELDON: It says they should go on the form CP6 there.
4 We have also heard evidence that there was
5 a critical incident log in operation and so you could
6 choose, could you, whether you recorded that information
7 on the critical incident log or the CP6 form?
8 MS GRAHAM: At the time it was going on a critical incident.
9 MR SHELDON: I see. So you were entirely clear in mid-1999
10 that if you saw anything relevant to child protection in
11 respect of any child on the ward you should record it
12 and tell either a senior nurse or a member of the
13 medical staff?
14 MS GRAHAM: Medical staff or the nurse in charge and just
15 record what you have seen.
16 MR SHELDON: Was your understanding of your obligations that
17 even if you told somebody -- so even if you told another
18 nurse -- you should still record it?
19 MS GRAHAM: You should still record.
20 MR SHELDON: Let us go to the occasion you first encountered
21 Victoria on 25th July 1999. Presumably you received
22 a handover before you assumed responsibility for her
23 care.
24 MS GRAHAM: Yes.
25 MR SHELDON: That took place, did it, in the nurses' office
199
1 in the first place in the manner you have described?
2 MS GRAHAM: In the office, yes.
3 MR SHELDON: You say in your statement -- and it is
4 paragraph 13 -- that you were told during the course of
5 that handover that Victoria had been admitted with
6 a very itchy scalp. That is your recollection of what
7 you were told, is it?
8 MS GRAHAM: Yes.
9 MR SHELDON: That, on the face of it, seems a curious way of
10 categorising the extensive burns to the head and face of
11 which we have seen photographs during the course of this
12 Inquiry. I have been asked to read the whole sentence
13 which is that:
14 "... [she] had been admitted with a very itchy scalp
15 which was apparently due to scabies and that it was so
16 itchy she had poured a bowl of water over her head the
17 previous day. I, and I think other staff at the
18 handover, felt this sounded unlikely and there was some
19 discussion about how a child could do this."
20 You were told, were you, she had extensive burns to
21 her head?
22 MS GRAHAM: This was why she was admitted with this; this is
23 why she was handed over to us this morning.
24 MR SHELDON: You recall a discussion about whether or not it
25 seemed likely that she would have poured a bowl of water
200
1 over her head so as to cause those burns. Is that
2 right?
3 MS GRAHAM: The general discussion among the nurses that
4 were there about -- well as soon as hot water touches
5 anybody you do stop or pull away.
6 MR SHELDON: You record that one of the nurses expressed the
7 view that as soon as one drop of scalding water touched
8 you, you would desist from continuing to pour it over
9 your head.
10 MS GRAHAM: Yes.
11 MR SHELDON: Did anybody raise the possibility that when one
12 is pouring a bowl of water over one's head one might
13 pour it all in one go rather than a drip at a time?
14 MS GRAHAM: I cannot remember that conversation.
15 MR SHELDON: You say everyone was suspicious about this.
16 Who was "everyone" in that context?
17 MS GRAHAM: All the nurses that were there that morning
18 having handover.
19 MR SHELDON: Just so I am clear, who is present at handover?
20 This is presumably all the nurses who are coming on
21 shift in the morning?
22 MS GRAHAM: The morning shift that are waiting for handover
23 and the night staff giving handover. Those are the ones
24 in the room at the time.
25 MR SHELDON: So ten nurses or so?
|
