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Archived Transcript for 7 November 2001: Pages
201 to250
201
1 MS GRAHAM: It would not be ten.
2 MR SHELDON: Well, there are how many per shift?
3 MS GRAHAM: At the weekends there is usually about six
4 people in that room altogether because in the morning
5 there is five in the morning and five in the afternoon.
6 So, say five people are waiting for handover and one is
7 giving handover, that is six people plus how many
8 students we have.
9 MR SHELDON: Amongst those six nurses present there was
10 a general discussion about the mechanism by which
11 Victoria had come by her burns?
12 MS GRAHAM: Yes.
13 MR SHELDON: And everybody thought that it sounded unlikely?
14 MS GRAHAM: At the time, yes.
15 MR SHELDON: Suspicious?
16 MS GRAHAM: Yes.
17 MR SHELDON: Was anything done, as far as you are aware, as
18 a result of this discussion and these suspicions at that
19 point?
20 MS GRAHAM: I cannot remember at that time, no.
21 MR SHELDON: Because we do not for example see anything on
22 the critical incident log recording the fact that all
23 the nurses regarded this as suspicious. You did not
24 think for example to record the suspicions of you and
25 your colleagues at that point?
202
1 MS GRAHAM: Nobody had been given their patient at that time
2 so nothing would have been written at that time. We
3 were still getting handover.
4 MR SHELDON: But as a result of that discussion, when you
5 went on the ward that morning, you knew that Victoria
6 had been admitted because of child protection concerns
7 and that there was a very suspicious account of how she
8 had come by her serious injuries; is that right?
9 MS GRAHAM: She was handed over in the handover, we got
10 whatever diagnosis she came in with and then we went on
11 from there.
12 MR SHELDON: So you were on the lookout from the beginning
13 on the 25th for evidence of physical abuse?
14 MS GRAHAM: We got the handover. We said what we had to say
15 in the handover. We did our walk around, then we got
16 our patients, so whatever was discussed in the ward
17 round that morning.
18 MR SHELDON: I am grateful for that summary of what you did.
19 What I was asking was whether you were on the lookout
20 from the time you assumed care of Victoria on 25th July
21 for evidence of physical abuse.
22 MS GRAHAM: Not at that time, no.
23 MR SHELDON: You were not?
24 MS GRAHAM: Not at that time, no.
25 MR SHELDON: So you knew the child has been admitted for
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1 suspected non-accidental injury, you knew there were
2 general suspicions about how she had come by serious
3 injuries to her head, you knew of the obligations on you
4 imposed by the Child Protection Guideline section to
5 which I have drawn your attention, but you were not on
6 the lookout for evidence of physical abuse?
7 MS GRAHAM: You are asking me about immediately. Once I am
8 on the ward then yes, I would be looking out for them
9 and note anything I saw.
10 MR SHELDON: Certainly that is what I asked. When you
11 assumed responsibility for Victoria on that ward that
12 morning you were on the lookout for evidence of physical
13 abuse?
14 MS GRAHAM: Yes, I understand that now. Yes.
15 MR SHELDON: In paragraph 14 of your statement you give
16 evidence of the suspicion of nurses or a discussion with
17 other nurses about the behaviour of Ms Kouao. Do you
18 recall that?
19 MS GRAHAM: Sorry, I am just reading this.
20 MR SHELDON: You only need to go about four lines down:
21 "Either at this or one of the later handovers when
22 I was on shift, I recall some discussion about the
23 person who we then thought to be Victoria mother (whom
24 I shall refer to in the remainder of this statement as
25 Ms Kouao)."
204
1 So do you remember a discussions take place?
2 MS GRAHAM: Yes.
3 MR SHELDON: Do you remember it being discussed that she had
4 apparently given inconsistent information to nurses at
5 various times?
6 MS GRAHAM: Yes.
7 MR SHELDON: And that in particular she had given
8 inconsistent information about her age and her
9 employment?
10 MS GRAHAM: Yes.
11 MR SHELDON: And that given that one can only have one age,
12 the implication was that at least on some of those
13 occasions she had been lying?
14 MS GRAHAM: Yes, the age was different all the time.
15 MR SHELDON: Did you think it might be significant in the
16 context of a child protection case that the mother was
17 thought to be untruthful?
18 MS GRAHAM: Yes.
19 MR SHELDON: Did you write that down anywhere?
20 MS GRAHAM: About her being untruthful?
21 MR SHELDON: About the suspicions of the nurses to which you
22 were party that the mother of a child who had strange
23 injuries seemed to be a liar?
24 MS GRAHAM: No, I did not write that down.
25 MR SHELDON: Did you think it might be significant in the
205
1 context of a child protection case?
2 MS GRAHAM: Yes.
3 MR SHELDON: I appreciate, Miss Graham, that you cannot be
4 expected to write down every single detail about every
5 single child every day. The reason I need to ask you
6 about this is because the first we hear of this
7 potentially significant observation is in your statement
8 to this Inquiry and I just want to be sure that you are
9 confident you remember this discussion taking place.
10 MS GRAHAM: I remember a discussion, yes.
11 MR SHELDON: So you are confident that on 25th July 1999
12 there was a discussion amongst the nurses in the nurses'
13 office that covered firstly the fact that Ms Kouao
14 seemed to be unreliable and, secondly, that all the
15 nurses were suspicious about the means by which Victoria
16 had come by her injuries?
17 MS GRAHAM: There was suspicion about the fact she had given
18 three different ages. The first one I noticed was when
19 she said she was 34 but she obviously had a child who
20 was 24, that meaning she had the child at 10.
21 THE CHAIRMAN: Mr Mason has caught my eye. Is there
22 something you want to --
23 MR MASON: Sir, it is a very minor point. It was put to
24 this witness that this was something that happened on
25 the 25th she is talking about, and actually the very
206
1 first line of this paragraph of her statement says,
2 "Either at this or one of the later handovers ..." so
3 she is not saying that it was something that happened on
4 the 25th.
5 THE CHAIRMAN: Thank you very much. Mr Sheldon, please.
6 MR SHELDON: Well, I need to put the question in two parts,
7 I think, to be accurate, sir.
8 Is it your evidence, Miss Graham, that there was
9 a discussion amongst the nurses about their suspicions
10 of how Victoria had come by the burns to her head on the
11 25th when you first assumed responsibility for her care?
12 MS GRAHAM: I cannot recall.
13 MR SHELDON: Because that is what you say in paragraph 13 of
14 your statement. I will read you the relevant bit:
15 "I recall that, when I came on shift on the morning
16 of Sunday 25th July 1999, the details of Victoria's
17 admission to Rainbow Ward the previous night were handed
18 over to us by one of the night staff (I do not remember
19 whom). I recall being informed at the handover that
20 Victoria had been admitted with a very itchy scalp which
21 was apparently due to scabies and that it was so itchy
22 she had poured a bowl of hot water over her head the
23 previous day. I, and I think other staff at the
24 handover, felt this sounded unlikely and there was some
25 discussion about how a child could do this."
207
1 Do I take it from your previous answer that you are
2 now not sure that conversation took place on the 25th?
3 MS GRAHAM: The conversation took place but I cannot
4 remember exactly what was said in there but the
5 conversation took place.
6 MR SHELDON: On the 25th?
7 MS GRAHAM: She came in that night, it was handed over to us
8 that morning. About the fact that she had poured water
9 on her head -- and this general discussion when on that
10 morning in the handover.
11 MR SHELDON: I see. Turning to the second discussion, if
12 indeed there was one, related at paragraph 14. This is
13 the discussion about suspicions relating to Kouao, and
14 whether she was truthful. Now, on what occasion did
15 that discussion take place?
16 MS GRAHAM: I honestly do not know. I cannot remember.
17 MR SHELDON: But you are sure it did take place?
18 MS GRAHAM: It did take place.
19 MR SHELDON: And you are sure it contained the matters that
20 you record in paragraph 14?
21 MS GRAHAM: Yes, I remember the age. I remember the
22 discussion about the age.
23 MR SHELDON: When you went and saw Victoria on 25th July,
24 the first thing you noticed was that she had wet the bed
25 and was pretending to be asleep. Is that right?
208
1 MS GRAHAM: I went in there and, as I said, her eyes were
2 blinking quite fast so I could see she was pretending to
3 be asleep.
4 MR SHELDON: Can we have a look at the notes in relation to
5 that event, volume 37, page 260. we have a note on that
6 page timed at 15.30, which is signed by Nurse Tsiagbe
7 who I think was sharing a responsibility for Victoria's
8 care with you, according to you, on that occasion; is
9 that right?
10 MS GRAHAM: Yes.
11 MR SHELDON: I will be corrected if I am wrong but I cannot
12 find any reference in that note to her wetting the bed.
13 Is that right?
14 MS GRAHAM: It is at the top.
15 MR SHELDON: I will read it from the top and you can say
16 where it is:
17 "Anna has been in bed until about 9.30 am. We have
18 woken her up and put her in the bath. Face has been
19 oozing all along. Pillowcase stained all over. She had
20 difficulty walking into the bathroom. Bruises all over
21 her body. Has felt much better after her bath.
22 Dr Rossiter has requested for swabs, which had been
23 done. Has also requested for admission and proper
24 photographs taken of her face. She had breakfast, lunch
25 with no difficulty."
209
1 Where is the reference to wetting bed?
2 MS GRAHAM: There is none.
3 MR SHELDON: There is not one, is there?
4 MS GRAHAM: No, I did not make that note.
5 MR SHELDON: Why did you not note the fact that she had wet
6 the bed?
7 MS GRAHAM: At the time Nurse Tsiagbe usually started at
8 8.30 in the morning when the others started at 7.30 and
9 whoever Nurse Tsiagbe was allocated to, someone else
10 looked after her until she came in and took over her
11 patients and at the time I did help her with the bath
12 and things and the bed was wet, but it is not noted
13 here.
14 MR SHELDON: So it is the position, is it, that almost two
15 years after the event, without the assistance of
16 any contemporaneous note, you have independently
17 recalled the fact that Victoria wet the bed on
18 25th July?
19 MS GRAHAM: When I was asked to make these notes
20 I remembered what had happened that morning and that is
21 what I have put these in my notes.
22 MR SHELDON: And you are confident in your recollection on
23 that point?
24 MS GRAHAM: Yes.
25 MR SHELDON: It is recorded there that it was decided to put
210
1 Victoria in the bath and she was taken to the bathroom
2 and we see in the notes she had trouble walking to the
3 bathroom. What trouble did she have?
4 MS GRAHAM: Her knees looked stiff and it looked as if she
5 was having trouble walking and straightening her knees.
6 MR SHELDON: Did that improve? Was she able to walk back
7 from the bathroom all right?
8 MS GRAHAM: We held her hand and led her there and on the
9 way back she seemed to be walking a bit better.
10 MR SHELDON: A bit better but not completely better. Did
11 you notice this difficulty with walking on any of the
12 subsequent occasions you came into contact with her?
13 MS GRAHAM: No.
14 MR SHELDON: You also note that her nails seemed infected
15 and that you thought some were going to fall off, is
16 that right?
17 MS GRAHAM: Yes, I did.
18 MR SHELDON: Do we find that in Nurse Tsiagbe's note on
19 page 260?
20 MS GRAHAM: No.
21 MR SHELDON: Why was that not noted?
22 MS GRAHAM: I did not note it down. I do not know whether
23 it was a presumption on my side but I did not note it
24 down at that time.
25 MR SHELDON: Again you are confident in your recollection?
211
1 MS GRAHAM: Yes.
2 MR SHELDON: You say in paragraph 21 of your statement that
3 during the time that you bathed Victoria you "noticed
4 a mark on her shoulder which looked to me as if
5 something had been heated and pressed into her skin".
6 MS GRAHAM: Yes.
7 MR SHELDON: Do you stand by that?
8 MS GRAHAM: Yes.
9 MR SHELDON: How do you feel able to tell that the mechanism
10 of the injury you saw was that something had been heated
11 and then pressed onto the skin?
12 MS GRAHAM: At the time I saw it I showed it to the doctor
13 as it was and it looked as if it was an old mark. You
14 can see the shape of it on her skin. It looked like
15 something had been pressed in there and it was actually
16 fading at the time but as you creamed her you could see
17 it more.
18 MR SHELDON: So it looked different, did it, to a mark that
19 one might get if you had bumped into something hot?
20 MS GRAHAM: Yes.
21 MR SHELDON: Are you saying that you thought that you were
22 suspicion that Victoria had been branded with something?
23 MS GRAHAM: The handover that we got, we started taking
24 notes because I gave her the bath and saw marks.
25 I pointed it out to the doctor as it was as I saw her
212
1 fingers and I pointed it out also.
2 MR SHELDON: Are you saying that you thought Victoria had
3 been branded with something?
4 MS GRAHAM: That is what it looked like and that is what
5 I said.
6 MR SHELDON: Do we see that in the notes?
7 MS GRAHAM: No, my note-keeping was really bad. I know
8 that.
9 MR SHELDON: In this respect that may even be an
10 understatement, might it not, because you have a child
11 about whom there are serious child protection concerns
12 and you have seen something of what you see as evidence
13 of her being branded as with a hot object, and that goes
14 down nowhere in the notes. That is remarkable, is it
15 not?
16 MS GRAHAM: Yes.
17 MR SHELDON: You must have been horrified to see this?
18 MS GRAHAM: Yes. Yes.
19 MR SHELDON: Are you sure you saw it?
20 MS GRAHAM: I saw them. I pointed them out. As I said, it
21 was a presumption on my part I left it to someone else;
22 I did not write it down myself.
23 MR SHELDON: At the time you made your statement, had you
24 been shown photographs that were taken of Victoria's
25 body whilst she was in in the North Middlesex Hospital?
213
1 MS GRAHAM: Do you mean at the court?
2 MR SHELDON: Prior to making the statement for use by this
3 Inquiry which you signed on 22nd June 2001, had you seen
4 photographs taken of Victoria's body whilst she was an
5 in-patient at the North Middlesex Hospital?
6 MS GRAHAM: Not on the ward, no.
7 MR SHELDON: Had you seen them anywhere?
8 MS GRAHAM: I saw them when I went to court.
9 MR SHELDON: So the answer is yes you had seen them?
10 MS GRAHAM: Yes.
11 MR SHELDON: And you saw marks in those photographs?
12 MS GRAHAM: That I recognised, yes.
13 MR SHELDON: Are you sure that that is your recollection of
14 what you say you saw on 25th July 1999?
15 MS GRAHAM: Yes.
16 MR SHELDON: It has not been coloured by what you saw in
17 those photographs in the trial?
18 MS GRAHAM: No.
19 MR SHELDON: Can you offer any explanation why this
20 potentially enormously significant finding is not
21 recorded anywhere in the notes?
22 MS GRAHAM: As I said, it is probably just an oversight on
23 my part and my note-keeping was absolutely disgusting at
24 the time.
25 MR SHELDON: You saw this as a result of bathing Victoria on
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1 25th July 1999; is that right?
2 MS GRAHAM: Yes.
3 MR SHELDON: Could you be shown volume 46, please, page 94.
4 This is a statement that you gave to the Crown
5 Prosecution Service in preparation for the trial of
6 Kouao and Manning. Fifth line down:
7 "I, Millicent Graham, looked after Anna Kouao as her
8 allocated nurse during July 1999 and August 1999. On
9 the morning of 31st July 1999 I gave Anna her bath,
10 washing her head which was still very weepy from the
11 burns ..."
12 And so it goes on. There is no mention there of you
13 giving her a bath on 25th July 1999. Why is that?
14 MS GRAHAM: Because as I said I put that down -- that is
15 Nurse Tsiagbe's patient. I was looking after her till
16 Nurse Tsiagbe came. She was the one who wrote the
17 evaluation that day. I was helping her.
18 MR SHELDON: I understand why she may have written the note.
19 Why did you not mention the event in the statement to
20 the Crown Prosecution Service?
21 MS GRAHAM: I do not know.
22 MR SHELDON: Is it because it did not happen?
23 MS GRAHAM: It did happen.
24 MR SHELDON: Could you have a look please at volume 49,
25 page 139. This is a transcript of the evidence you gave
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1 during the course of the criminal trial and at letter E
2 on that page you were asked a question by Mr Gledhill:
3 "Question: Was 31st July the first time you had the
4 care of this little girl?
5 "Answer: Yes, sir."
6 So perhaps I should ask you again. Are you sure
7 that you had care of Victoria on 25th July 1999?
8 MS GRAHAM: As I said her main nurse was Nurse Tsiagbe,
9 I was helping her. I was allocated to her the first
10 time on the 31st.
11 MR SHELDON: So how do you explain your answer to
12 Mr Gledhill's question during the course of the trial?
13 MS GRAHAM: He asked me if this was the first time I had her
14 to look after.
15 MR SHELDON: No, he said is this the first time you had the
16 care of this little girl, and you said yes.
17 MS GRAHAM: "Was this the first time you were looking after
18 her?"
19 MR SHELDON: Well, he asked you both, yes. And you say
20 "yes" in both cases. You do not say, and one might
21 think that surprising, that "No, I had cared for her on
22 25th July 1999 where I discussed suspicions about her
23 injuries and her mother and noticed what I thought were
24 brand marks on her body". Why is that?
25 MS GRAHAM: Sorry sir, say that again.
216
1 MR SHELDON: What you do not say in response to Mr Gledhill
2 on either occasion on which he asks you about this point
3 is, "No, the 31st was not the first time I looked after
4 this little girl. I looked after her on 25th July when
5 I discussed suspicions about her care and noticed
6 branding marks on her body". Why is that?
7 MS GRAHAM: I do not know.
8 MR SHELDON: Let us turn to Ms Kouao's visit to the ward on
9 25th July 1999 that you also recall. You give an
10 account at paragraph 25 of your statement of an occasion
11 in which Ms Kouao visited Victoria, Victoria sat on her
12 lap, stroked Ms Kouao's face saying something along the
13 lines "my mummy is a nice mummy." Do you recall that
14 event?
15 MS GRAHAM: Yes, I do.
16 MR SHELDON: It is right, is it not, that that is not in any
17 of the notes?
18 MS GRAHAM: No, I did not write it down.
19 MR SHELDON: So can I take it again that you remember it two
20 years after the event because it is something that
21 seemed significant to you at the time?
22 MS GRAHAM: We were asked to do these statements. We were
23 asked to write down as much as we could remember about
24 Victoria's care while she was in hospital.
25 MR SHELDON: Did it seem to you that this was something of
217
1 a show being put on for your benefit by Victoria?
2 MS GRAHAM: That is what it seemed like at the time.
3 MR SHELDON: So inappropriate behaviour and a strange
4 interaction between mother and daughter?
5 MS GRAHAM: Yes.
6 MR SHELDON: That is exactly the sort of thing that you are
7 supposed to put in a critical incident log, is it not?
8 MS GRAHAM: Yes.
9 MR SHELDON: Any explanation for its absence?
10 MS GRAHAM: No.
11 MR SHELDON: You also note in paragraph 27 of your statement
12 a general impression you got that Victoria's behaviour
13 changed on the ward when Ms Kouao came to visit her. Is
14 that right?
15 MS GRAHAM: Yes.
16 MR SHELDON: She seemed a lot quieter when Ms Kouao was
17 there than she did when she was on her own, when she was
18 lively and much more full of fun, is that right?
19 MS GRAHAM: Yes.
20 MR SHELDON: Is that something that you thought might be
21 significant in the context of child protection?
22 MS GRAHAM: Yes.
23 MR SHELDON: Did either of those two things, either the
24 strange behaviour of Victoria on the 25th or the general
25 change in her demeanour when Ms Kouao came to visit, did
218
1 either of those things cause you concern given that you
2 knew there was suspicion this child was being abused?
3 MS GRAHAM: The strange behaviour had been noted by quite
4 a few nurses and had been noted down, so for me to be
5 writing it down would be repeating what other nurses had
6 put.
7 MR SHELDON: My question was did it cause you concern?
8 MS GRAHAM: I discussed it with other people.
9 MR SHELDON: Did it cause you concern?
10 MS GRAHAM: Yes.
11 MR SHELDON: You will probably recall this being put to you
12 somewhat aggressively during the course of the criminal
13 trial and I will not take you through the transcript of
14 that again. But I must ask you to confirm that you are
15 sure that you had those concerns at the time and that
16 you had not subsequently come to feel them with
17 hindsight.
18 MS GRAHAM: No, I had them at the time.
19 MR SHELDON: And so I have to ask again why you did not
20 record them.
21 MS GRAHAM: And I have to say again, I do not know.
22 MR SHELDON: On this occasion you say in paragraph 28 that
23 Kouao stayed for about an hour and you stayed in the
24 cubicle for five minutes.
25 "I think Ms Kouao and the man probably stayed with
219
1 Victoria for about an hour but I did not see them go."
2 Is that right, that is your recollection?
3 MS GRAHAM: I did not see them go, so I am not sure how long
4 they did stay.
5 MR SHELDON: So the hour is a complete guess?
6 MS GRAHAM: It is a guess, yes.
7 MR SHELDON: You also say that a man was there at that time
8 as well. Are you clear in your recollection about that?
9 MS GRAHAM: There was a man there, yes.
10 MR SHELDON: Could you have a look at volume 49 again,
11 please, page 155. This is another extract from your
12 cross-examination during the course of the criminal
13 trial. Letter E:
14 "Question: Did you ever see a man visit?
15 "Answer: No, just her and her mum."
16 Why is it that you seem to recall a man visiting
17 when you make your statement to the Inquiry but do not
18 when you gave your evidence to the Criminal Court?
19 MS GRAHAM: This is for the Criminal Court. You have to
20 write in it what you have written in your notes. You
21 cannot go making things up. It is fact.
22 MR SHELDON: You can go making things up here, can you?
23 MS GRAHAM: No, you cannot make things up here.
24 MR SHELDON: What is the significant difference?
25 MS GRAHAM: This is what you remember and how you remember
220
1 Victoria on the ward.
2 MR SHELDON: I am afraid I am going to have to ask you to
3 explain that answer.
4 MS GRAHAM: I was asked to write the criminal -- for the
5 police I was asked to write down what had happened and
6 what I had written in the notes so I can only write what
7 I had written in the notes when it comes to going to
8 court.
9 MR SHELDON: Do you remember a man going to visit Victoria
10 on 25th July?
11 MS GRAHAM: I had not written it in the notes so how could
12 I put it in there?
13 MR SHELDON: That is not the question I asked with respect
14 Miss Graham. Do you remember a man coming to visit
15 Victoria on 25th July?
16 MS GRAHAM: I remember a man being there once, yes.
17 MR SHELDON: Did you remember the man coming to visit when
18 you gave evidence to the trial of Kouao and Manning?
19 MS GRAHAM: No.
20 MR SHELDON: So when has this recollection of a man visiting
21 arisen?
22 MS GRAHAM: The Inquiry came along and I had to write down
23 what I could recall that happened with her care.
24 MR SHELDON: So you remembered something two years later
25 that you had not remembered one year after the event?
221
1 MS GRAHAM: When you have to write things in detail
2 sometimes things do come up.
3 MR SHELDON: I see. So your answer, in other words, to the
4 point I put to you was that you told the truth as far as
5 you knew it at the trial, but that your recollection has
6 changed since?
7 MS GRAHAM: Not my recollection, more details.
8 MR SHELDON: Because that is slightly different to the first
9 answer you gave me which was you have to be absolutely
10 sure about what you say to the criminal trial but that
11 slightly different considerations may apply here.
12 MS GRAHAM: Maybe I am saying it wrong but that is what
13 I mean about the court and the Inquiry and all that.
14 MR SHELDON: Let us move to the 31st July. We see you were
15 allocated Victoria's care on 31st July for what you say
16 was the second time. We can see a note from you,
17 volume 37, page 268. Could you turn to that, please.
18 We can see a note which seems to be countersigned by you
19 albeit made by a student nurse about halfway down the
20 page dated 31st July 1999. Is that right?
21 MS GRAHAM: Yes.
22 MR SHELDON: We can see that Victoria will appear to have
23 been measured and weighed.
24 MS GRAHAM: Yes.
25 MR SHELDON: Did you do that at the request of a doctor?
222
1 MS GRAHAM: Yes.
2 MR SHELDON: Were the results entered on a standard growth
3 chart?
4 MS GRAHAM: We will let the doctors know what it is and they
5 will do the entrance onto the chart.
6 MR SHELDON: That is the doctor's responsibility, is it?
7 MS GRAHAM: Yes.
8 MR SHELDON: And they can take their results from your
9 recording in the history as we see it here?
10 MS GRAHAM: Yes.
11 MR SHELDON: We can also see there that Piriton was
12 prescribed and that the scalp was washed with saline.
13 That is in those two respects at least exactly what you
14 say in your statement to the Inquiry you did on
15 25th July. That may be coincidence that you did the
16 same thing on two occasions, but I will put it to you
17 again: you are sure that you bathed Victoria on
18 25th July?
19 MS GRAHAM: Yes, I did.
20 MR SHELDON: Washed her hair with saline and prescribed
21 Piriton?
22 MS GRAHAM: Yes.
23 MR SHELDON: On 5th August 1999 you were given
24 responsibility for Victoria's care again. Is that
25 right?
223
1 MS GRAHAM: Yes.
2 MR SHELDON: You say in your statement at the bottom of
3 page 8, paragraph 37:
4 "At this handover, I would have been informed that
5 the social worker, Lisa Arthurworrey, was due to do
6 a home visit to Victoria's house that day."
7 I am just concerned to understand why you put it
8 that way. Why do you say you would have been informed?
9 Were you or were you not?
10 MS GRAHAM: I put it that way because I was not sure when it
11 was given to me, if it was in the handover or on the
12 ward.
13 MR SHELDON: I see, but you are clear that you were told on
14 5th August that that was the position?
15 MS GRAHAM: Yes.
16 MR SHELDON: But you just cannot remember exactly when you
17 were told?
18 MS GRAHAM: When it was given.
19 MR SHELDON: Could you have a look at volume 37 at page 271,
20 please. There are two entries on that page at the top
21 before we get to the 5th August when you took over.
22 First on the 3rd:
23 "Mum visited Anna this morning for half an hour."
24 On the 4th:
25 "Anna took a long time to settle last night."
224
1 The point I make is a simple one, that there is no
2 mention there of any plan or any indication from
3 a doctor or anybody else that Lisa Arthurworrey was to
4 do a home visit to Victoria's house on 5th August. That
5 is right, is it not?
6 MS GRAHAM: It is not there, no.
7 MR SHELDON: Could we then have a look in that case at
8 page 275. This is the critical incident log. At the
9 bottom, date 3rd August 1999, one entry at 11.20, second
10 entry at 14.30:
11 "Lisa Arthurworrey will be making a police visit at
12 Anna's tomorrow morning", i.e. the 4th August 1999.
13 So, not only is there no reference to the fact that
14 a home visit was going to take place on 5th August 1999,
15 there is an explicit reference that says it was supposed
16 to have taken place on 4th August 1999. So, can you
17 help us as to where that indication was from?
18 MS GRAHAM: It may not have been written down in the notes
19 but that was what was handed over to me, that they were
20 going to make a visit at that time.
21 MR SHELDON: So you are sure that is what you were told by
22 a nurse but you cannot say where the nurse got that
23 information from?
24 MS GRAHAM: It was either handed over to me at the handover
25 or somewhere on the ward.
225
1 MR SHELDON: You spoke to Lisa Arthurworrey later that day,
2 did you?
3 MS GRAHAM: Yes.
4 MR SHELDON: We can see that you have recorded that
5 conversation I think in two places in the notes.
6 Firstly, volume 37, page 108. Is the last entry on that
7 page in your writing?
8 MS GRAHAM: Yes.
9 MR SHELDON: It says, does it not:
10 "Lisa Arthurworrey phoned today. She will be coming
11 to see Anna tomorrow at 14.30. If all is well then Anna
12 will be discharged home on 6th August to mum."
13 Then there is a phone number there. Do you know
14 whose phone number that is?
15 MS GRAHAM: I believe that is the social worker's.
16 MR SHELDON: You should probably look at page 271 for
17 completeness because you make another note of this
18 conversation. Or if not of the conversation, then its
19 result. The entry by 2000 hours "comfortable" -- what
20 does that say?
21 MS GRAHAM: "Comfortable evening".
22 MR SHELDON: "Comfortable evening. To be seen by social
23 worker Lisa A 6th August at 2.30. Eating lots. No
24 visit from mum or phone calls."
25 Going back to the first of those entries where it
226
1 says, "If all is well then Anna will be discharged home
2 on 6th August".
3 MS GRAHAM: Right.
4 MR SHELDON: It is not clear from that note whose decision
5 it was if all was well Victoria would be discharged
6 home. Who did you understand had made that decision?
7 MS GRAHAM: The doctors on the round that morning.
8 MR SHELDON: So it was your view, having spoken to
9 Lisa Arthurworrey, that the doctor doing the ward round
10 on the morning of 5th August had said Victoria is all
11 right for discharge on the 6th if all was well?
12 MS GRAHAM: It was said that she was ready for discharge,
13 and they were supposed to make a home visit and if they
14 said everything was okay, then she could go home.
15 MR SHELDON: So the "all is well" refers to the conducting
16 the home visit?
17 MS GRAHAM: The home visit and all that.
18 MR SHELDON: Given that the critical incident log on the
19 page that we have already looked at seemed to indicate
20 that the home visit should already have been done -- by
21 that I mean it should have been done on 4th August --
22 did you ask Lisa Arthurworrey what was going on as far
23 as the home visit was concerned?
24 MS GRAHAM: They were supposed to come and visit her the day
25 before but they phoned and said that they are not coming
227
1 until the day after.
2 MR SHELDON: Could you have a look at page 271 of volume 37,
3 please. I may be wrong and I will be corrected if I am,
4 but I cannot see anything in those clinical notes
5 relating to a doctor saying that Victoria could go home
6 on 6/8 if all was well as a result of a home visit. If
7 there is such a reference in the notes, I am sure it
8 will be pointed out and you can comment on it in
9 re-examination, but your clear understanding was, was
10 it, that the doctors were happy with the plan?
11 MS GRAHAM: Yes.
12 MR SHELDON: That Victoria could be discharged with if the
13 social workers were happy with the result of their home
14 visit?
15 MS GRAHAM: Yes.
16 MR SHELDON: Did you receive that information from a doctor
17 face to face?
18 MS GRAHAM: No.
19 MR SHELDON: Did you receive it from Lisa Arthurworrey?
20 MS GRAHAM: No.
21 MR SHELDON: Where did you get that impression from?
22 MS GRAHAM: The nurse in charge who handed over to me.
23 MR SHELDON: I see. Who was that?
24 MS GRAHAM: I believe it was Isabel Quinn at the time.
25 MR SHELDON: Lastly 6th August 1999, paragraph 41 of your
228
1 statement. I take it that the first line of
2 paragraph 41 should read 6th August 1999 rather than
3 6th July?
4 MS GRAHAM: Yes.
5 MR SHELDON: Again, you use the words halfway down that
6 paragraph:
7 "I think I would have been informed at the handover
8 that morning that, if everything was fine after the
9 police and social services home visit, Victoria could go
10 home."
11 Why do you think you will have been informed? Can
12 you not remember whether you were or you were not?
13 MS GRAHAM: I cannot remember if I was.
14 MR SHELDON: That seems, if I may say so, a strange answer
15 given that you go on to say in your statement that you
16 spoke to Ms Kouao on the phone after you had received
17 notification from Lisa Arthurworrey that all was well
18 with the home visit and you said she could come and pick
19 Victoria up.
20 MS GRAHAM: No, I am putting here I do not know if I was
21 given it at the handover or again on the ward. That is
22 what I am putting there.
23 MR SHELDON: So we should interpret "I think I would have
24 been informed at the handover that morning that, if
25 everything was fine after the police and social services
229
1 home visit, Victoria could go home" as saying, "I was
2 informed that if everything was fine after the police
3 and social services home visit Victoria could go home,
4 I just cannot remember if that was at the handover or on
5 the ward"?
6 MS GRAHAM: That is what I am saying.
7 MR SHELDON: But you were absolutely clear in your mind that
8 was the plan and the plan had been approved by the
9 doctors?
10 MS GRAHAM: We do not discharge the children.
11 MR SHELDON: Lisa Arthurworrey came on the ward with
12 a policewoman, is that right?
13 MS GRAHAM: Yes.
14 MR SHELDON: Had you read when you made your note at
15 volume 37, page 108 the notes immediately above it?
16 MS GRAHAM: I cannot remember that, if I had.
17 MR SHELDON: Is it your normal practice to read the notes
18 immediately previous when you are making notes on this
19 history sheet or do you sometimes not?
20 MS GRAHAM: Most of the time we do, yes.
21 MR SHELDON: Do you recall, for example, being aware of the
22 information contained in the note at the top of that
23 page that:
24 "On the advice of medical staff, Lisa and the police
25 were told protective clothing should be worn in Anna's
230
1 home because Anna was admitted to ward with scabies
2 which is highly infectious. A message was left by Lisa
3 on Anna's mum's mobile phone and arrangements have been
4 made for a meeting to take place on 5th August 1999,
5 11 am."
6 Do you recall being aware of that?
7 MS GRAHAM: No.
8 MR SHELDON: Because that seems to suggest, does it not,
9 that no home visit had taken place?
10 MS GRAHAM: No.
11 MR SHELDON: Well it seems to suggest that on the advice
12 that scabies was highly infectious a message had been
13 left by Lisa on Anna's mother's mobile phone and
14 arrangements had been made for a meeting to take place
15 on 5th August 1999 at 11 am. Now it may be that that
16 meeting was to take place at the home, but if you were
17 in any doubt about that, that doubt would have been
18 dispelled by the next note down which is Anna's home
19 phoning saying she did not make the meeting.
20 MS GRAHAM: When Lisa and the policewoman came to see Anna
21 that day and say that they said they had been in for
22 a visit, they said they had been in and visited the home
23 and everything was fine. She had no worries, she could
24 go home and that is what they told me.
25 MR SHELDON: You are absolutely confident, are you, in your
231
1 recollection?
2 MS GRAHAM: Yes.
3 MR SHELDON: Well let me ask the question first. You are
4 absolutely confident in your recollection that
5 Lisa Arthurworrey told you that she had visited
6 Victoria's home and found everything fine?
7 MS GRAHAM: Yes.
8 MS HOYAL: I am sorry to interrupt but my note indicated
9 that she said it was Lisa Arthurworrey and the WPC
10 police officer and then Mr Sheldon just led the witness
11 that in fact it was Lisa Arthurworrey. We have not
12 established it was.
13 MR SHELDON: Quite right, thank you very much. I am
14 grateful to my learned friend.
15 Who told you that the visit had taken place?
16 MS GRAHAM: She introduced herself as Lisa Arthurworrey.
17 MR SHELDON: Who told you that the visit had taken place?
18 MS GRAHAM: I see what you mean. The social worker.
19 MR SHELDON: Did the social worker introduce herself?
20 MS GRAHAM: Yes, as Lisa Arthurworrey.
21 MR SHELDON: You describe in your statement that one of the
22 things that was said, or the way in which it was put --
23 and this is paragraph 47 -- was that you were told that
24 they had been to Ms Kouao's house and checked it out and
25 everything was fine. Are you confident that they said
232
1 they had been to Ms Kouao's house?
2 MS GRAHAM: Yes, they said they had made the home visit and
3 that everything was fine.
4 MR SHELDON: I am not sure if that precisely answers the
5 question. Are you confident that they said they had
6 been to Ms Kouao's house?
7 MS GRAHAM: No, they did not say Ms Kouao's house, they said
8 they had been to the mum's house and everything was
9 fine.
10 MR SHELDON: They used the word "house" and they used the
11 word "mum's"?
12 MS GRAHAM: Yes.
13 MR SHELDON: Can you remember what else they said?
14 MS GRAHAM: When we went into the cubicle, myself, the
15 policewoman, Victoria and Lisa, we all sat down.
16 I think they said a few words to Victoria and then the
17 next question to Victoria was, "Do you want to go home?"
18 MR SHELDON: You make no mention of the fact that Lisa
19 Arthurworrey said that she had been to Ms Kouao's house
20 and everything was fine in your CPS statement, do you?
21 MS GRAHAM: No, I did not.
22 MR SHELDON: Do you know why that is?
23 MS GRAHAM: I do not know.
24 MR SHELDON: Sorry, you do not know?
25 MS GRAHAM: No.
233
1 MR SHELDON: Could you be shown volume 49, please, page 139.
2 We should probably start on page 138 to put it into
3 context. This is another part of your cross-examination
4 at the trial and the penultimate question on page 138
5 reads:
6 "Question: Dr Rossiter, who is the consultant
7 paediatrician ultimately in charge of the case, was very
8 worried about Anna, was she not?"
9 "Answer: Yes.
10 "Question: She recorded in the notes that she
11 though Anna has been emotionally abused and she was
12 exhibiting frightening behaviour in front of her mother.
13 You would be aware of that?
14 "Answer: Yes.
15 "Question: Did the social worker give any sort of
16 explanation as to what she thought she was doing?
17 "Answer: No.
18 "Question: Did she explain why she was returning
19 Anna to the mother?
20 "Answer: No, but everything was checked, everything
21 was checked out."
22 You make no mention there of Lisa Arthurworrey
23 saying, "I have been to the house and everything is
24 fine". Why is that?
25 MS GRAHAM: I do not think I was given time to explain
234
1 anything there.
2 MR SHELDON: Sorry, I do not understand, what do you mean
3 you were not given time? You were asked a direct
4 question, "Did she explain why she was returning Anna to
5 the mother?" "No".
6 MS GRAHAM: No, she did not explain to me.
7 MR SHELDON: But you are now saying she did explain, she did
8 explain she went to the house and everything was
9 satisfactory. So did she explain it or did she not?
10 MS GRAHAM: The explanation she gave me on the ward was that
11 she had been to the house and everything was fine. She
12 could not find anything wrong, she could go home.
13 MR SHELDON: So how do you explain your answer in the trial?
14 MS GRAHAM: Maybe it is because I was not asked to expand on
15 it. I do not know.
16 MR SHELDON: How good do you think your recollection of this
17 conversation with Lisa Arthurworrey and the WPC was?
18 MS GRAHAM: It is good.
19 MR SHELDON: Could you turn back to page 138, top of the
20 page:
21 "Question: Was that done after a visit by the
22 social worker called Lisa Arthurworrey and a police
23 constable, and you could not remember the police
24 constable's name, could you?
25 "Answer: No.
235
1 "Question: Was she a black lady?
2 "Answer: No.
3 "Question: No?
4 "Answer: I cannot remember."
5 Given that you cannot remember whether the WPC was
6 black or not might suggest that you do not have a very
7 good recollection of that meeting, might it not?
8 MS GRAHAM: I did have a recollection. I did introduce
9 myself. They introduced themselves. But this is quite
10 a while.
11 MR SHELDON: Are you able to remember whether the WPC was
12 black or not now?
13 MS GRAHAM: I have actually seen her, so ...
14 MR SHELDON: We know, Miss Graham, that -- or at least we
15 have evidence to the effect from other people that no
16 home visit was ever undertaken to Victoria's home --
17 MS GRAHAM: That has come out in this case.
18 MR SHELDON: I have to put it to you therefore in fairness
19 to those witnesses that may suggest otherwise that you
20 are mistaken in your recollection of being told that?
21 MS GRAHAM: I am not mistaken at all.
22 MR SHELDON: And that the reason that it does not find its
23 way into your CPS statement or indeed your evidence to
24 the Crown Court is because it did not happen?
25 MS GRAHAM: It is my note keeping, that is all I can put it
236
1 down to. What took place took place.
2 MR SHELDON: Who took the final decision that Victoria could
3 be discharged?
4 MS GRAHAM: It came from the doctors that if everything is
5 okay she could go home, so that was it.
6 MR SHELDON: Which doctor?
7 MS GRAHAM: It was at the handover of the afternoon. I have
8 no idea.
9 MR SHELDON: So you do not know who took the final decision?
10 MS GRAHAM: No. It was at handover of the round and he
11 spoke to me.
12 MR SHELDON: You spoke to Ms Kouao and said she could come
13 and pick up her daughter?
14 MS GRAHAM: Before I spoke to her I spoke to the nurse in
15 charge.
16 MR SHELDON: You spoke to Ms Kouao on the phone and said she
17 could come and pick up her daughter?
18 MS GRAHAM: Yes.
19 MR SHELDON: On whose authority were you acting?
20 MS GRAHAM: It was said she that could go home.
21 MR SHELDON: On whose authority were you acting?
22 MS GRAHAM: The doctor that did the round that morning.
23 MR SHELDON: Who was that?
24 MS GRAHAM: I do not know.
25 MR SHELDON: You have given a fairly consistent picture
237
1 throughout your evidence of being extremely concerned
2 about Victoria, suspicious of how she came by her
3 injuries and suspicious of her mother. Is that fair?
4 MS GRAHAM: Yes.
5 MR SHELDON: You thought she was being abused?
6 MS GRAHAM: I think everyone did at the time, yes.
7 MR SHELDON: Despite that, you have authorised her mother to
8 come and pick her up without even knowing who has given
9 authority for that to happen.
10 MS GRAHAM: I did not authorise her mother, it is just what
11 was said. From what I understood is the doctors were
12 happy, she was ready to go home. It is up to the social
13 worker and the police now. If the home had checked out
14 fine, they said they checked it out and she can go home,
15 so --
16 MR SHELDON: You say you did not authorise her. Would you
17 look at paragraph 50 of your statement, please. There
18 you describe the phone conversation you had with
19 Ms Kouao, four lines up from the bottom:
20 "I then took the telephone and explained that
21 Victoria could go home and that she could come and
22 collect her at any time."
23 So you did authorise her?
24 MS GRAHAM: No, I did not authorise she could go home.
25 I cannot say, "You keep this child." I was told to send
238
1 this child home, and she went home.
2 MR SHELDON: Who told you to send the child home?
3 MS GRAHAM: In the morning they do the round. It comes from
4 there. I was handed over, when the police and the
5 social worker sees the home, if they are happy then the
6 child can go home. They come and see Victoria, then
7 they say she can go, they are happy with everything.
8 When I asked them about her staying until Monday at
9 least, they say they have no reason to keep her, that
10 she can go home.
11 MR SHELDON: Who told you to phone up Ms Kouao and say, "You
12 can come and collect Victoria"?
13 MS GRAHAM: After I have had the discussion there was
14 nothing else that could be done, the child could go
15 home, so I phoned what I thought was her mum at the time
16 to come and pick her up.
17 MR SHELDON: Why did you want her to stay until Monday?
18 MS GRAHAM: I am a part-time nurse and I go and I work there
19 three days a week. What happened is I thought there was
20 a lot of ups and downs with this child, with Victoria,
21 sorry. For them to come in and just say -- because
22 I was not sure whether they had met Victoria before --
23 to come and just say she could go home I was saying why
24 can she not stay? What is the rush? Why can she not
25 stay until Monday when Dr Rossiter sees her on the round
239
1 again and see how she goes over the weekend.
2 MR SHELDON: You wanted Dr Rossiter to see her before she
3 went home?
4 MS GRAHAM: She is the one who deals with child protection.
5 MR SHELDON: Do I take it from that that you thought
6 Dr Rossiter had not approved the discharge?
7 MS GRAHAM: No, you cannot take it like that.
8 MR SHELDON: Well, if you wanted her to stay in until
9 Dr~Rossiter had had the opportunity of seeing her the
10 following Monday, why can I not take it like that?
11 MS GRAHAM: One weekend, that is all I thought.
12 MR SHELDON: Did you think Dr Rossiter had approved the
13 discharge on 6th August 1999?
14 MS GRAHAM: I do not know which doctor it was.
15 MR SHELDON: I cannot put it any more simply Miss Graham.
16 Did you think Dr Rossiter had approved the discharge on
17 6th August 1999?
18 MS GRAHAM: As I say, I do not know.
19 MR SHELDON: Well, the answer must be no, must it not?
20 MS GRAHAM: I do not know.
21 MR SHELDON: Because even if you thought for a minute that
22 she had, you would not be asking for Victoria to be
23 staying in for another two or three days so Dr Rossiter
24 could see her again, would you?
25 MS GRAHAM: I just asked the question anyway to see if she
240
1 could stay a bit longer.
2 MR SHELDON: Two short points. You say in your statement at
3 paragraph 47 that you cannot remember whether it was
4 Lisa Arthurworrey or the police officer who told you
5 that everything was fine and Victoria could go home.
6 You have been quite clear in your evidence today that it
7 was Lisa Arthurworrey and not the policewoman. Which is
8 the accurate reflection of your recollection?
9 MS GRAHAM: It was Lisa who introduced herself to me. She
10 did most of the talking.
11 MR SHELDON: Why were you not sure about that point when you
12 made your statement?
13 MS GRAHAM: It is been quite a long time. I was not quite
14 sure at the time. That is why I put that.
15 MR SHELDON: Lastly, was Victoria at any time while you were
16 looking after her being nursed in isolation in a double
17 cubicle?
18 MS GRAHAM: Yes.
19 MR SHELDON: What was the reason for that?
20 MS GRAHAM: Because of her burns and a suspected case of
21 scabies.
22 THE CHAIRMAN: Mr Mason, I propose we take a break now. It
23 has been rather a long --
24 MR GARNHAM: Sir, I wonder if I could raise a point. It is
25 now a quarter to 4. You are now going to take a short
241
1 break so we are going to have only an hour or so in the
2 day when we come back. This witness is nearly finished.
3 Our next witness is Dr Simone Forlee. I anticipate
4 I will be more than an hour with her, let alone the
5 questions that Mr Mason may have, and I know that
6 Mr Mason is concerned that Dr Forlee needs to be in work
7 the following day. Mr Mason has been extremely helpful
8 in helping ensure that the witnesses we need are here.
9 Nonetheless sir it would be unfortunate to lose the time
10 this afternoon and we do need to hear from Dr Forlee and
11 I thought I therefore ought to raise that point now so
12 that Mr Mason can think about it and address you and we
13 can make a decision as how best to proceed.
14 THE CHAIRMAN: Mr Mason I am very happy to hear from you
15 now. What I wonder is whether or not it might be more
16 profitable if you and Mr Garnham had a word whilst we
17 retire.
18 MR MASON: Sir, yes. I will be very short with Miss Graham.
19 She may well prefer to have her sort of interrogation
20 come to an end without hanging over a break and I think
21 that might perhaps be a little kinder in the
22 circumstances. Mr Garnham says he will be just over an
23 hour with Dr Forlee. I do --
24 MR GARNHAM: No sir, I said I shall be at least an hour.
25 I shall be more than an hour.
242
1 MR MASON: That is what I meant to say. I have been very
2 short with my re-examinations, I hope to date, I would
3 not intend to be any longer than my average with
4 Dr Forlee. I am very keen, if possible, we get her done
5 today. I know it is finishing late after an early
6 start. I know she has important commitments in a busy
7 unit tomorrow and it would be quite difficult to hang
8 her over.
9 MR GARNHAM: If we follow that course you will have to be
10 thinking about sitting until gone 6. Sir, perhaps I can
11 explain. Mr Mason raises a query. Of all the witnesses
12 we have had so far, by far the greatest number of
13 suggested lines of questioning that counsel to the
14 Inquiry have received is in respect of Dr Forlee. They
15 are not just my questions, they are from a range of
16 other represented parties here.
17 THE CHAIRMAN: Mr Mason, I take the points. I think that
18 I would much rather have a short break now. I would be
19 obliged if you and Mr Garnham could have a word whilst
20 we have this short break and then in the light of what
21 you say when I return I will decide what is reasonable.
22 So we will now break until 4 o'clock, by that clock.
23 Thank you very much.
24 (3.50 pm)
25 A short break)
243
1 (4.00 pm)
2 MR GARNHAM: Sir there is no easy solution to the problem we
3 have. My submission to you, sir, is that the most
4 sensible way to proceed with regard to Dr Forlee would
5 be to hear her straight away after this witness has
6 finished. I wonder, sir if I could ask you to sit say
7 to 5.15 this evening. That is called pushing it as far
8 as I dare. Then we hope to get through as much as
9 Dr Forlee as we can, finish her tomorrow morning, then
10 she can get back to her work.
11 THE CHAIRMAN: Mr Garnham, I hope that everyone feels I try
12 very hard to accommodate these things and I have
13 detected sometimes a sigh when I have only allocated 35
14 or 45 minutes for lunch, and I do think that as an
15 Inquiry we are sitting fairly unusually long hours. But
16 because I believe everybody else also has been equally
17 accommodating and reasonable, I will accept that
18 situation of 5.15 but I would like to stop at 5.15.
19 MR GARNHAM: One consequence of that I have been asked to
20 raise is that Mr and Mrs Climbie will not be here for
21 the latter part of the session -- I think they may have
22 gone already, because of childcare commitments. They
23 asked me to raise that with you, indicating that it is
24 because we are sitting late that they are not here, not
25 through any lack of courtesy or interest in the
244
1 proceedings.
2 THE CHAIRMAN: I fully understand that. Ms Boye, if you
3 could convey to Mr and Mrs Climbie that I fully
4 understand their childcare responsibilities. In the
5 circumstances that we are in that is certainly something
6 we would wish to support them in doing.
7 I think we got to Mr Mason.
8 MR MASON: Thank you, sir. And thank you for agreeing to
9 Mr Garnham's proposal which I think creates an equality
10 of dissatisfaction but I hope that is --
11 THE CHAIRMAN: Oh dear. If I conveyed that then I am sorry.
12 MR MASON: No, between doctors going to clinics and the
13 lawyers and everything else ...
14 Thank you Miss Graham and thank you for your
15 patience during the break, I know it cannot be easy.
16 You very bravely described your note writing then as
17 "disgusting" at one point. Has your note writing
18 practice changed as a result of what you have learned
19 through Victoria's case?
20 MS GRAHAM: It has improved quite a lot. Everyone's note
21 taking has improved quite a lot.
22 MR MASON: It is not just you who has improved, it is the
23 whole ...
24 MS GRAHAM: The whole department, yes.
25 MR MASON: You were asked about the bath that you and
245
1 Nurse Tsiagbe -- have I pronounced it correctly?
2 MS GRAHAM: Yes.
3 MR MASON: -- gave on 25th August. If you look at volume 6,
4 page 267, her description of the bath is rather long, so
5 if I may take you to paragraph 13. I will just read out
6 the last couple of sentences:
7 "During her bath Staff Nurse Graham and I cleaned
8 Victoria gently and used gauze to clean the wounds to
9 her head, and earlier before then she had referred to
10 marks that had been found."
11 So she at least seems to agree with you it took
12 place on the 25th.
13 MS GRAHAM: Yes.
14 MR MASON: And you believe her recollection is accurate, do
15 you?
16 MS GRAHAM: Yes.
17 MR MASON: You were also asked about whether doctors were
18 happy to see Victoria discharged and whether or not
19 there was a home visit planned. I do not want to take
20 you up hill and down dale again, but black volume 37,
21 page 272, it says "WR" -- ward round -- "senior house
22 officer". We in fact now know that that senior house
23 officer was Dr David Reynders, and sir for your note it
24 is witness volume 6, page 211.606, paragraph 19, where
25 he writes:
246
1 "The final entries I made in the notes is the ward
2 round that I conducted on 6th August."
3 Do you remember Dr Reynders at all?
4 MS GRAHAM: Yes.
5 MR MASON: He was South African, I think. He certainly
6 wrote: "planned for home visit today with police".
7 MS GRAHAM: Right.
8 MR MASON: Is that, in your view, a home visit by social
9 services or were you expecting someone from the ward to
10 go with the police to conduct a home visit?
11 MS GRAHAM: No. It says the police here but I believe it to
12 be the police and the social worker.
13 MR MASON: Then he writes "query discharge after that if it
14 is safe" and who did you think was to make the decision
15 whether or not it was safe for Victoria to go home?
16 MS GRAHAM: After that the police and the social worker.
17 MR MASON: If you had been in any doubt as to whether or not
18 the social worker and the police -- whether they had
19 visited or not, what would you have done?
20 MS GRAHAM: Then I would have contacted the doctor again and
21 conversed with them to see what is happening, let them
22 know they have not been in for the visit and then let
23 them go from there.
24 MR MASON: Which doctor do you think you would have
25 contacted?
247
1 MS GRAHAM: The paediatrician that was on call at the time.
2 MR MASON: You discussed the discharge arrangement. If in
3 a similar situation today, would you send a child about
4 whom there are child protection concerns or possible
5 concerns home without the express approval of a doctor?
6 MS GRAHAM: No. Things have changed on the ward with
7 children going home, especially at weekends. The doctor
8 has to see them first before they can go anywhere.
9 MR MASON: And in a child protection case now, who has the
10 authority to give the final decision that yes, that
11 child can go home now?
12 MS GRAHAM: The child protection doctor, Dr Rossiter.
13 MR MASON: Or any other consultant will do? The paediatric
14 consultant?
15 MS GRAHAM: Dr Rossiter or anyone else if she is not there.
16 MR MASON: Do you think that is an improvement on the
17 existing system?
18 MS GRAHAM: Yes.
19 MR MASON: Thank you Miss Graham, thank you sir.
20 THE CHAIRMAN: Thank you Mr Mason.
21 Miss Graham, a couple of questions, please. First
22 of all, at the time that Victoria was on the ward was it
23 the practice for nurses to discharge patients?
24 MS GRAHAM: Without the approval of the doctor, no, sorry,
25 no.
248
1 THE CHAIRMAN: Just to be clear, a nurse on their own
2 decision could not discharge a patient?
3 MS GRAHAM: No.
4 THE CHAIRMAN: And how, generally, was the decision to
5 discharge communicated from the doctor to the nurse?
6 Not now but when Victoria was on the ward?
7 MS GRAHAM: They have the ward round and the doctor will see
8 the child and they will say that the child can go home
9 later, or if they are waiting for a result the child can
10 go home if everything is fine. If we have any other
11 worries to that child going home, we contact the doctor
12 again. If the child is fine and everything okay then we
13 can discharge the child.
14 THE CHAIRMAN: Would that decision be recorded anywhere and
15 whose responsibilities would it be to record it?
16 MS GRAHAM: You mean the follow up?
17 THE CHAIRMAN: No. The decision you have said on the ward
18 round the doctor says --
19 MS GRAHAM: It would be in the morning ward round or
20 whichever ward round they do they will record it in the
21 notes that the child can go.
22 THE CHAIRMAN: Who would record it?
23 MS GRAHAM: The paediatrician, SHO, registrar --
24 THE CHAIRMAN: It would not be the nurses' reponsibility to
25 record it?
249
1 MS GRAHAM: No, the doctor's.
2 THE CHAIRMAN: Was it the practice that discharge could take
3 place without the nurse actually seeing that recorded?
4 MS GRAHAM: No.
5 THE CHAIRMAN: So when you phoned whoever you did phone --
6 I am not making any assumptions by that -- had you
7 already seen it recorded that Victoria should now be
8 discharged?
9 MS GRAHAM: As long as the home visit went okay then she
10 could have gone home. That is what I saw.
11 THE CHAIRMAN: The second thing I want to ask you is at any
12 time either whilst Victoria was on the ward or
13 immediately after Victoria left the ward did a police
14 officer visit the ward to ask you about what you had
15 observed or any concerns that you had about Victoria?
16 MS GRAHAM: Not me personally, no.
17 THE CHAIRMAN: Do you know whether a police officer spoke to
18 any of the nurses?
19 MS GRAHAM: I do not know.
20 THE CHAIRMAN: At any time did a social worker visit the
21 ward and interview you?
22 MS GRAHAM: Just that time when they came to see Victoria on
23 the last day, they both came to the ward. That is it.
24 THE CHAIRMAN: But not to interview you about your concerns
25 or observations?
250
1 MS GRAHAM: No.
2 THE CHAIRMAN: During the course of your evidence it has
3 become clear that there are some variations -- let me
4 put it that way. I will try and put that in a neutral
5 way. There are some differences between your CPS
6 statement and your statement to this Inquiry. Just so
7 that I am clear, could you explain why those differences
8 exist?
9 MS GRAHAM: When I was asked to write my statement after
10 Victoria died I was asked to write what I had written in
11 the notes and I could not -- what I had written in the
12 notes, that is what I had to write in the statement
13 because that might end up in court at the time.
14 THE CHAIRMAN: Just go back again and say that again,
15 please. Yes, have a drink of water and just tell me
16 exactly what you are saying.
17 MS GRAHAM: The statement for the court, I was asked to
18 write the statement for the court of what -- as I said,
19 my note keeping was not wonderful so I had to write what
20 was in the notes as my statement for the court, if
21 I went there. When the Inquiry was coming about I had
22 to write what I had observed on the ward in Victoria's
23 care while she was there between the times I looked
24 after her and things like that. That is why my note
25 keeping might seem a lot better here than it did with
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