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Archived Transcript for 8 November 2001: Pages
1 to 50
1
1 Thursday 8th November 2001
2 (10.00 am)
3 THE CHAIRMAN: Good morning ladies and gentlemen.
4 Mr Garnham.
5 MR GARNHAM: Sir, good morning. Before we resume with
6 Dr Forlee, can I indicate the matters that you are going
7 to be asked to consider this morning. Before Dr Forlee
8 resumes her evidence, Mr Mason has a point he wishes to
9 make. We will then proceed with Dr Forlee and can
10 I then indicate the witnesses who will be called
11 thereafter so that you know the order. We propose
12 taking the witnesses in the following order: Forlee,
13 Quinn, Taub, Banjoko, O'Boyce, Pereira, Davidson,
14 Jennings and Norman. Whether we get through that little
15 lot remains to be seen.
16 Sir, there is also a matter that will need your
17 consideration and decision after we have heard
18 Dr Forlee's evidence to conclusion. It seems to me, and
19 to the two counsel who have raised the matter with me,
20 it would be more prudent to deal with it after Dr Forlee
21 has finished her evidence. We will not raise it now.
22 I know Mr Mason has another point he wants to raise.
23 THE CHAIRMAN: Fine. Thank you very much. Mr Mason.
24 MR MASON: Thank you sir, I am afraid it is a bit more than
25 a one point matter. If I may start with a couple of
2
1 housekeeping matters, and three concerns arising out of
2 yesterday. Dr Banjoko who is giving evidence this
3 morning is a sort of late entry into the batting order
4 for us and she was only notified a week ago that she was
5 having to give oral evidence. Coupled with that she has
6 just come to the Inquiry straight from a 24 hour shift
7 on duty, so she is perhaps not as well prepared and as
8 mentally fresh as she would like to be. I hope you and
9 counsel will bear that in mind.
10 THE CHAIRMAN: On that point may I say I will gladly bear
11 that in mind.
12 MR MASON: Another housekeeping point. There was a lot of
13 discussion about who bathed who on what day. There is
14 a document called the Allocation Book, in the bundle as
15 a ward diary, volume 38/160. Only one day's entry seems
16 to have got in there. It was a daily book. I did have
17 a set of colour photocopies back in the office but
18 I could not find it last night. I am not sure where the
19 original book is at the moment. It certainly seems from
20 the documents people that what is in the bundle is what
21 they have got, so it may be a mistake at our end.
22 Also there is an off duty rota which is not an awful
23 lot of help. Just because you are not there officially
24 does not mean that you have not come back from bank
25 duty. So it proves when you were there, it does not
3
1 prove when you were not.
2 THE CHAIRMAN: Yes.
3 MR MASON: So we will try and get that sorted.
4 THE CHAIRMAN: I would be obliged.
5 MR MASON: Now if I may move on, I have three concerns about
6 yesterday. Certainly it is not a criticism of Counsel
7 to the Inquiry or his team or anything else. One
8 concern was that a number of NHS witnesses were asked
9 questions really outside their discipline. I do not
10 criticise anyone for that. I spent 13 years asking
11 questions of the wrong people as counsel. It is very
12 hard to know who does what, who knows what.
13 A suggestion I would like to make is if people have
14 any doubts about who should be asked questions --
15 Dr Forlee was asked what she would expect from triage
16 after an A&E person gave evidence and was not asked
17 about it. If people want to ask me who should cover
18 this issue I may not promise I know the answer but like
19 the AA advert, I know somebody who can. I can get the
20 right answer to them. That may help smooth things along
21 a bit.
22 Secondly, although I did not rise yesterday I was
23 very concerned about some of the criticisms of
24 Nurse Graham and what turned into criticisms of
25 Dr Forlee. Neither of them had any letter of criticism
4
1 so it came as rather a surprise to them. I am not
2 talking about criticism relating to note writing,
3 I think Counsel to the Inquiry suggesting to the NHS
4 witnesses they should write better notes is pushing at
5 an open door. The process of letters of criticism is
6 designed to protect witnesses from unexpected criticism.
7 I accept that something may arise because of what
8 a witness says during the course of their evidence, or
9 what somebody has just said or just produced may make it
10 necessary for the witness to address issues that were
11 not anticipated, but certainly in respect of Millicent
12 Graham's statement things were put to her about accuracy
13 and really integrity of her statement.
14 It all came from matters that were very familiar to
15 Counsel to the Inquiry and to all the interested parties
16 for weeks and if any other North Middlesex nurses are
17 going to be subject to criticism of this sort, they
18 would very much like to know in advance and so would I.
19 Thirdly, perhaps what may be the most important
20 point, I am concerned that Dr Rossiter may be asked
21 questions when she gives evidence on Monday as to
22 whether the amendment to CP3 form that she made on
23 1st August according to her contemporaneous note was not
24 in fact a note that she made that day. In
25 Lisa Arthurworrey's statement, volume 2, page 72,
5
1 paragraph 91, the version CP3 that she says she was
2 faxed from the hospital is what I may call the unamended
3 version without Dr Rossiter's additional comment.
4 Clearly if she was faxed an unamended version one two or
5 two days after Dr Rossiter purported to have written on
6 that document, then Dr Rossiter has some serious
7 explaining to do and perhaps not just in this forum.
8 However, your documents team are remarkably
9 efficient and when I rang up with this query they were
10 able to confirm the unamended one was what
11 Lisa Arthurworrey had attached to her statement but they
12 said, "Ah, but we do have the amended version which is
13 volume 6, page 286, which has got the fax header from
14 North Middlesex 3rd August and it has got Dr Rossiter's
15 amendments."
16 I was slightly concerned by a question from
17 Mr Garnham of Dr Forlee as well as she was asked whether
18 she saw Dr Rossiter write that note. I have spoken to
19 counsel, he says it was a question of curiosity because
20 he had not realised that the squiggle at the bottom of
21 that note is Dr Rossiter's signature. Certainly, sir,
22 if there is going to be any suggestion that Dr Rossiter
23 has in effect fraudulently made entries in the notes
24 then certainly the only fair thing is for her to know as
25 soon as possible because it is not the sort of thing it
6
1 is really fair to ambush anyone with.
2 THE CHAIRMAN: Mr Mason, I am happy to have you act as an
3 advocate for your clients. I will respond to each of
4 your points but if Mr Garnham is wanting to indicate
5 that he wants to say something I will listen to
6 Mr Garnham before I respond to each of your points, but
7 I have noted each of your points and I will respond.
8 MR GARNHAM: Thank you for that, sir. I think that the
9 Inquiry's document team have made some searches through
10 the allocation book and the off duty rota. We will
11 continue with those searches. If it turns out we do not
12 have them and they are still with the bodies that
13 produced them then obviously we would be grateful for
14 sight of them from Mr Mason and those who instruct him.
15 As to the question of questions being put to
16 witnesses outside their discipline, I take Mr Mason's
17 point and we will do our best to ensure that we direct
18 the right questions to the right witnesses but as he
19 acknowledges, that is not always easy and it is always
20 open to a witness to say "I do not know, this is outside
21 my discipline".
22 As to the criticisms as Mr Mason describes them of
23 Nurse Graham and Dr Forlee yesterday, this is an
24 Inquiry. We do learn as we go along. That is the point
25 of it. We are aided in that growing understanding by
7
1 answers from witnesses and by questions put to us by
2 interested parties and it is inevitable I am afraid that
3 we will understand more as the matter progresses and
4 that that may lead to us putting questions that we had
5 not been able to anticipate when notices of criticism
6 were drawn up.
7 I take Mr Mason's point nonetheless and if witnesses
8 are finding themselves surprised by lines of questioning
9 that are put and that were not anticipated in the notice
10 of criticism, it is of course open to Mr Mason to write
11 to us indicating that and my submission to you would be
12 in those circumstances that by one means or another
13 those witnesses should be given the opportunity to give
14 a considered reply to anything that had not been set out
15 in the notice of criticism. It may well be that could
16 be done in writing or orally and we can address that
17 when the occasion arises.
18 THE CHAIRMAN: Thank you for that. Mr Mason, I think it
19 fair to tell you in some detail how I react to your
20 three points, irrespective of what Mr Garnham has just
21 said. Not that I disregard what Mr Garnham has just
22 said but I would like to share with you my views on the
23 subject.
24 First of all, I have no concerns about questions
25 being put to the wrong person. This is an Inquiry which
8
1 is largely dealing with professional people and they are
2 well able in my view to say, "That is outside my area of
3 knowledge" and I will respect that. I do not think that
4 it is my responsibility, nor do I think it is the
5 responsibility of Counsel to the Inquiry to consult
6 anyone about which question should be put to which
7 person. I would gladly have your comments on that, as
8 any other advocate, but I do not think that I want
9 Counsel to the Inquiry or his team to be inhibited in
10 any way.
11 MR MASON: I think that is a very fair point. I do not want
12 to inhibit them. I am trying to suggest a mechanism by
13 which the process may be made --
14 THE CHAIRMAN: I appreciate your help but I would rather err
15 on the side of making sure that as many questions are
16 put even if they are put to someone who has every right
17 to say, "That is outside my knowledge and my
18 experience".
19 Secondly, as far as criticisms are concerned,
20 I think that I said in my opening comments to this
21 Inquiry, and I will just check it, that as far as
22 possible we would in advance let witnesses know of any
23 possible criticisms. That is as far as is possible. It
24 seems to me that in an investigation there are always
25 going to be issues that arise, otherwise we would not
9
1 have an investigation. I think there are other
2 mechanisms for dealing with this which I am happy to
3 have employed. I am anxious to be fair but I am not
4 willing to -- and I am sure it is not your intention to
5 in any way limit the Inquiry.
6 MR MASON: No, sir, I have no objection to any of the
7 questions, just perhaps the notice that the witness has.
8 THE CHAIRMAN: I have not heard any questions -- I mean I do
9 not know about the evidence to be brought by Dr Rossiter
10 so I will reserve my comment about Dr Rossiter or indeed
11 any other witness whose name has been mentioned that has
12 not come before the Inquiry, but for the record it is my
13 view that the witnesses that have already come before
14 the Inquiry have been treated in a reasonable way and
15 that if there are further criticisms to be made which
16 have not been drawn to their attention or any criticisms
17 that have not been drawn to their attention I am happy
18 to make sure that happens in a proper way, but I really
19 do think that I want this Inquiry to be exhaustive, it
20 certainly wants to be fair, but I want it to be in a way
21 which commands the confidence of everyone that all
22 issues have been properly and thoroughly examined.
23 I appreciate the points you have made but I hope I have
24 made plain my position.
25 MR MASON: Thank you, that is very helpful. I was certainly
10
1 not wishing to suggest otherwise.
2 THE CHAIRMAN: Thank you very much indeed.
3 MR GARNHAM: Sir, can I ask Dr Forlee to resume her seat at
4 the witness table. She is on oath, she does not need to
5 be sworn again.
6 DR SIMONE FORLEE (continued)
7 MR GARNHAM: Dr Forlee, I think a copy of your witness
8 statement has been put back in front of you and you will
9 recall that you are still on oath. It looks as if you
10 have some further notes in front of you. Could you tell
11 us what those are?
12 DR FORLEE: I was just wondering, arising from yesterday
13 I felt that there were issues that were becoming
14 blurred. I felt I was allowing myself to be led into
15 answering questions in such a way as to blur issues.
16 I was wondering whether I would have the opportunity to
17 clarify some of the issues that arose from yesterday.
18 MR GARNHAM: Absolutely. I am entirely happy you should do
19 that. Please do so.
20 DR FORLEE: The first issue I wanted to address was that of
21 the role of the SHO on-call. Essentially this is an
22 emergency after hours service that is provided. The
23 usual situation would be that as an SHO you begin your
24 hours of duty at about 8.30 am, work the normal day in
25 terms of covering your area of responsibility until 5 or
11
1 5.30. At that stage if you were on-call you would be
2 handed over to by the rest of the paediatric team and
3 then would resume duties which I do not think I need go
4 into but suffice to say the hours would be 8.30 am,
5 conceivably on a normal on-call call you would expect to
6 get a prolonged period of rest probably at about
7 midnight. Not uncommonly the first chance you would get
8 for prolonged period of rest might be later, 2, maybe 4
9 am in the morning. So rather uncommonly it was
10 sometimes the case that you would work continuously from
11 8.30 am to 8.30 the following morning without a break or
12 without a substantial period of rest.
13 As an on-call call service by definition that would
14 be an unpredictable environment. You did not know when
15 the next call would be coming or what you would be
16 facing that night. So realistically in such a setting
17 you would have to pace yourself. By that I mean when
18 you saw a particular child you would gather sufficient
19 information to make what you thought would be an
20 accurate assessment of that child and then institute
21 a plan of management and manage the child to a level of
22 safety which you deemed to be one of adequate safety and
23 then you would really have to leave that case and move
24 on to the next. Because as I say things were
25 unpredictable and you really did not know what was going
12
1 to happen next and what you would be facing.
2 Translating that to a case of a child with child
3 protection issues, and particularly in the case of
4 Victoria, I think in this particular instance gaining
5 the amount of information that was gained in this
6 particular instance was sufficient to make the
7 assessment of a child at risk and the priority was
8 really to institute the plan of management to ensure the
9 safety of that child and then to move on to ensure that
10 the investigation could proceed. Furthermore, I feel
11 that further questioning of an adult accompanying such
12 a child or the parent could lead to them becoming quite
13 defensive about the situation. You could lose their
14 cooperation and that certainly would not help in the
15 early stages of a child protection case.
16 Secondly, I would like to address the role of the
17 SHO as part of paediatric team. Essentially an SHO is
18 the most junior member of the paediatric team. The next
19 step up on the hierarchy is the middle grades which are
20 the specialist registrars and one step above them would
21 be the consultants. In an on-call capacity SHOs would
22 be exposed to assessing children themselves and making
23 management decisions and treating to a level which we
24 deem to be of adequate safety. However, once a child
25 was admitted to the ward further management decisions
13
1 would really be left to the consultants because they
2 would lead the team.
3 On a practical level these decisions would be made
4 on a ward round, usually led by the consultant or
5 sometimes by the specialist registrar. At such a ward
6 round decisions would be made about what plans of action
7 or jobs needed to be carried out that day and those
8 would generally be delegated to the SHOs. In practical
9 terms, at North Middlesex essentially all those jobs
10 would take you the entire day and sometimes more, so
11 jobs would have to be carried over because you did not
12 have time to complete them on a specified day.
13 I think it would be fair to say as well that in
14 reality it would be very unusual for an SHO to be able
15 to instigate and carry out additional tasks that were
16 not decided upon in the morning in addition to the rest
17 of the sort of workload. Certainly in terms of child
18 protection cases they would very much be consultant led
19 because even though the junior members of staff may have
20 had quite extensive experience in managing very unwell
21 children, medically unwell children, child protection
22 issues were not an area of great expertise for junior
23 staff and certainly not for me. I felt, as I said
24 before, Victoria's case was the only one where
25 I personally admitted a child with child protection
14
1 issues from A&E.
2 The third issue I want to discuss is that of
3 responsibility. Yesterday two specific issues about
4 following up a child not having a GP and attending
5 school were raised. If I recall correctly, I think
6 I stated that perhaps the paediatric team was
7 responsible for following up a child who did not have
8 a GP. I may have to retract that answer because in fact
9 I am not entirely sure of that. I would have to take
10 advice and guidance from someone more senior than myself
11 with more experience in child protection issues.
12 Certainly in this particular case my responsibility
13 would be to document those concerns and hand them over,
14 which I felt I did.
15 In terms of further decisions, it was my
16 understanding that our priorities were to document or to
17 look after the medical needs of a child where there were
18 child protection issues and then to address physical
19 evidence for non-accidental injury and those were --
20 those priorities were borne out in the two ward rounds
21 that I did attend on the morning after Victoria was
22 admitted and on the day subsequent to that.
23 As I understand it, the role of medical team or
24 paediatric team in child protection cases are threefold.
25 Firstly, and probably first and foremost would be to
15
1 attend to the medical needs of the child and then
2 subsequently to gather information on physical evidence
3 for non-accidental injury. Secondly, to ensure the
4 safety of the child, and thirdly to in the first -- at
5 the point of first contact to initiate the process
6 whereby an investigation could proceed and largely that
7 would involve the Child Protection Team and then
8 subsequently to assist and cooperate with that
9 investigation.
10 I truly believe that on the night of 25th July 1999
11 when Victoria was seen in A&E that those -- that the
12 duties incumbent upon me and the paediatric team and of
13 those main categories were satisfactorily carried out.
14 Thank you for hearing me out.
15 MR GARNHAM: Thank you Dr Forlee, we are entirely happy to
16 give you the chance to say that in the circumstances
17 that have arisen. Can I ask you though as I go through
18 the rest of the questions I have if you would take the
19 time in answering it to make sure that we have the full
20 picture. I do not want you to feel rushed so that you
21 have to add later to your answers. If you do not
22 understand a question, please say so. If you want
23 longer to express your view, indicate that as well.
24 DR FORLEE: I will try my best.
25 MR GARNHAM: Picking up one point you made in what you have
16
1 just said, what hours were you working on the 24th?
2 I think it was 24th July, not the 25th that Victoria was
3 admitted.
4 DR FORLEE: She was admitted on the night of the 24th.
5 I would have started at 8.30 that morning and continued
6 until after the ward round on the 25th which may have
7 been 10 o'clock or 11 o'clock, depending on --
8 MR GARNHAM: That is about 26 hours.
9 DR FORLEE: Roughly and that would be usual.
10 MR GARNHAM: At the time you saw Victoria you had been on
11 duty for ...?
12 DR FORLEE: About 12 hours or just under.
13 MR GARNHAM: 10 hours or so, yes?
14 DR FORLEE: From about 8.30 am, so roughly 11 hours.
15 MR GARNHAM: 10 and a half hours I think.
16 DR FORLEE: That is right.
17 MR GARNHAM: We ended our questioning yesterday afternoon
18 with you explaining the circumstances in which you had
19 examined Victoria. Sorry, we ended our questioning
20 yesterday afternoon by your telling us what your
21 decisions were in relation to the language in which she
22 should be examined.
23 You told us I think that you were intending to get
24 a direct history from Victoria via an interpreter later.
25 DR FORLEE: That would be the plan for the team, yes.
17
1 MR GARNHAM: You decided to admit Victoria fairly early on
2 I think, in your conversation with her that day.
3 DR FORLEE: Yes. There were sufficient concerns early on
4 that this child was at risk.
5 MR GARNHAM: In particular before you had examined her.
6 That is not meant to be critical but you made that
7 decision fairly early on, did you not?
8 DR FORLEE: I had already examined her to the extent of
9 assessing the severity of her burns.
10 MR GARNHAM: And in the light of that alone you were fairly
11 sure you were going to need to admit her?
12 DR FORLEE: And on the basis of the history that had been
13 provided to me.
14 MR GARNHAM: From what I understand of your evidence
15 yesterday you had two motivations in wishing to admit
16 her, firstly to ensure the burns were properly treated
17 and secondly to keep her safe.
18 DR FORLEE: That is right.
19 MR GARNHAM: If there had been no concerns about keeping her
20 safe, would it have been necessary on the grounds of the
21 burns alone to admit her?
22 DR FORLEE: On that basis I took advice from Dr Rossiter and
23 she thought there were sufficient grounds on both
24 accounts to warrant admission.
25 MR GARNHAM: Can I ask about your own views? If there had
18
1 been a child with those burns but without the concerns
2 of child abuse, if you had been satisfied there was an
3 explanation for the burns that was entirely consistent
4 with their being accidental, would it have been
5 necessary on clinical grounds to admit Victoria?
6 DR FORLEE: I think it would really depend on the setting,
7 the environment the child was in. If there was very
8 good community support for that child in terms of
9 parents that you could rely upon or you thought would
10 have the skills to look after such a child in the home,
11 good community support in terms of nursing and GP
12 services, it may have been possible that such a child
13 could go to a home environment but obviously you would
14 have to assess that environment quite carefully before
15 making such a decision.
16 MR GARNHAM: You say, paragraph 29 of your statement, that
17 one of the advantages of admission would be that there
18 would be time for a more detailed discussion with
19 Victoria in the absence of the woman understood to be
20 her mother.
21 DR FORLEE: That is right.
22 MR GARNHAM: Was that also one of the motivating factors in
23 the decision to admit her?
24 DR FORLEE: Yes, essentially an admission would -- all those
25 opportunities would be provided, yes.
19
1 MR GARNHAM: Did you have that discussion with Victoria?
2 DR FORLEE: No, I did not.
3 MR GARNHAM: Did anyone else to your knowledge?
4 DR FORLEE: In terms of doing it that particular night we
5 would have to get a French interpreter. That would have
6 been fairly difficult on a Saturday night so I did not
7 do it on that particular evening.
8 MR GARNHAM: Do you know whether it was done in the period
9 between that Saturday evening and the ward round on the
10 Monday in which you were involved?
11 DR FORLEE: I cannot recollect specifically. I do not think
12 so. I think we were trying to secure someone to come
13 and help us interpret but we did not manage to do that
14 as far as I can recall.
15 MR GARNHAM: What efforts were made to your knowledge to
16 obtain an interpreter?
17 DR FORLEE: As I recall, in the first instance people
18 thought, or the resident team felt that the easiest
19 option would be to get a member of -- one of the nursing
20 staff who spoke French to come and help us with
21 interpretation and so it was trying to get her involved
22 and to come down.
23 MR GARNHAM: With a view to her providing an interpretation
24 of a formal history taking?
25 DR FORLEE: Yes.
20
1 MR GARNHAM: Was that done to your knowledge?
2 DR FORLEE: Not at the time that I was involved, I do not
3 think that happened.
4 MR GARNHAM: You understand my concern, and this is not
5 a criticism of you personally, but you had in mind that
6 one of the advantages of admission would be that that
7 would give an opportunity for a full history to be taken
8 from Victoria via an interpreter?
9 DR FORLEE: That is right.
10 MR GARNHAM: And I am anxious to understand whether that in
11 fact occurred and I think you are telling us, are you
12 not, that to your knowledge, as far as you know it did
13 not?
14 DR FORLEE: I think by the Monday morning it had not but
15 I am not sure what happened subsequently.
16 MR GARNHAM: Very well. You decided nonetheless that you
17 would conduct some level of examination of Victoria.
18 DR FORLEE: That is right.
19 MR GARNHAM: Why have even that level of examination, given
20 that you had decided to admit her already?
21 DR FORLEE: Firstly just to ensure there were no other
22 injuries that specifically needed treatment in the
23 immediate setting and secondly just to gain an overall
24 view of her condition.
25 MR GARNHAM: So the reason for the relatively cursory
21
1 examination of the rest of her body that you carried out
2 was to ensure there was no obvious serious injuries that
3 needed immediate attention and to get an overall
4 picture?
5 DR FORLEE: That is right.
6 MR GARNHAM: You say in the Inquiry statement that you had
7 in mind that it would be better to do the examination
8 after admission.
9 DR FORLEE: Yes.
10 MR GARNHAM: That was your thinking, was it?
11 DR FORLEE: Yes.
12 MR GARNHAM: Can I ask you to look at your CPS statement
13 which is in volume 46, page 79. Can you go on to the
14 last page of that, page 81. You note there that she was
15 covered with a whitish lotion and you say opposite the
16 first punch hole:
17 "For this reason and because the artificial light in
18 the A&E Department is not the best setting in which to
19 do this type of examination I did not make detailed
20 drawings of the rest of Anna's body at this stage."
21 It sounds as if from that that your concern was the
22 adequacy of the lighting and the fact that she was
23 covered in a whitish material, that was the reason for
24 not doing the examination then and there.
25 DR FORLEE: I think overall there were lots of factors in
22
1 why I felt that an examination at that point was not
2 appropriate.
3 MR GARNHAM: We find some of them in your Inquiry statement
4 and some in your CPS statement. Is that right?
5 DR FORLEE: Can you review what was actually in the Inquiry
6 statement?
7 MR GARNHAM: Yes. Paragraph 29 you have explained that
8 because of what you say in paragraph 28 relating to the
9 need to obtain more information from her in the ward,
10 you did not feel it necessary in the A&E department to
11 attempt a detailed discussion with Victoria. Then
12 paragraph 30 you say:
13 "For similar reasons I did not propose to carry out
14 an extensive examination of Victoria's body there and
15 then as I thought it would be better to carry out a full
16 examination once she was admitted."
17 What I think you are saying is that that was for
18 a number of reasons including the fact that the lighting
19 would be better on admission.
20 DR FORLEE: That is right, I do not think the two statements
21 are contradictory to each other.
22 MR GARNHAM: I do not suggest they are. I suggest that they
23 are complete only if you take the two together. Would
24 that be fair?
25 DR FORLEE: Yes, that is probably true to say.
23
1 MR GARNHAM: Can I ask you a little about the examination.
2 Could you have volume 37 please. At page 56 in that
3 volume we have the sketch of Victoria's head and face
4 that you completed, is that right?
5 DR FORLEE: That is correct.
6 MR GARNHAM: You did not do any other body mapping at that
7 stage?
8 DR FORLEE: No, I did not.
9 MR GARNHAM: For the reasons you said you thought it better
10 to do it on the ward?
11 DR FORLEE: That is right.
12 MR GARNHAM: You then lifted her dress to carry out some
13 level of examination of her body?
14 DR FORLEE: That is right.
15 MR GARNHAM: You noticed three things. First of all she was
16 covered in a whitish lotion.
17 DR FORLEE: Yes.
18 MR GARNHAM: You thought that was calamine lotion, did you?
19 DR FORLEE: That is the first thing that passed through my
20 mind but in retrospect it could have been Derbac which
21 Kouao said she had been applying.
22 MR GARNHAM: Kouao said that she had been applying Derbac to
23 Victoria on a daily basis.
24 DR FORLEE: That is right.
25 MR GARNHAM: Do you know anything about the use of Derbac
24
1 for the treatment of scabies?
2 DR FORLEE: That would be incorrect usage of Derbac.
3 MR GARNHAM: Because it is a single application cream?
4 DR FORLEE: It is a single application.
5 MR GARNHAM: What did you conclude from what she had said
6 about its multiple application, that she had
7 misunderstood or --
8 DR FORLEE: Well, she may have, yes, she may have
9 misunderstood instructions given to her previously.
10 MR GARNHAM: Did you know what repeated applications of
11 Derbac, what their reaction is with the skin?
12 DR FORLEE: I did not at the time but I have since
13 discovered.
14 MR GARNHAM: And?
15 DR FORLEE: I now know that it can cause an allergic type
16 reaction, can cause persistent itching.
17 MR GARNHAM: Thank you. The second thing you have
18 discovered on lifting Victoria's dress was that she was
19 wearing no underwear.
20 DR FORLEE: That is right.
21 MR GARNHAM: You thought that was odd?
22 DR FORLEE: I did.
23 MR GARNHAM: Because it is not often a child of that age
24 comes into hospital without underwear?
25 DR FORLEE: Yes, and the fact that Kouao did appear so
25
1 immaculately presented. You would usually, if the
2 mother took such care about her own appearance you would
3 expect her to do the same with her child.
4 MR GARNHAM: Third, you noticed small darkish marks on
5 Victoria's body.
6 DR FORLEE: That is right.
7 MR GARNHAM: Can you describe them a little more please,
8 size, shape?
9 DR FORLEE: That would be very difficult. Her skin was
10 particularly dark. There was a substance on top of the
11 skin as well. All I could say was they were quite dark,
12 irregular marks.
13 MR GARNHAM: Did you form any view as to how it was likely
14 they had been caused?
15 DR FORLEE: Under the circumstances it was plausible that
16 because she had had a history of scabies those could
17 have been scars from the infestation. With her
18 persistent scratching she could have herself caused
19 scarring. So those were possibilities.
20 MR GARNHAM: You examined her hands, arms and legs I think
21 briefly.
22 DR FORLEE: During the cursory examination that was -- those
23 areas were looked at as well.
24 MR GARNHAM: And your findings there?
25 DR FORLEE: As you mentioned before there were these dark
26
1 marks on her limbs and she also appeared to be quite
2 masculine in terms of having quite well-defined muscles
3 which I found unusual for a child of her age.
4 MR GARNHAM: And she was lean?
5 DR FORLEE: Yes.
6 MR GARNHAM: Did you form any view about what you saw on her
7 hands, arms and legs beyond what you have told us, that
8 scabies was a possible diagnosis?
9 DR FORLEE: Not at the time.
10 MR GARNHAM: Can you describe the state of her hands please,
11 do you remember?
12 DR FORLEE: Again, that was quite a cursory examination but
13 what I do remember is her scratching quite incessantly.
14 MR GARNHAM: Did you notice anything about her little finger
15 on the left hand?
16 DR FORLEE: Not at the time.
17 MR GARNHAM: You did not notice the nail being loose or
18 coming away?
19 DR FORLEE: Not at that stage, no.
20 MR GARNHAM: Was your examination sufficiently thorough so
21 that you could be confident you would have noticed it
22 had it been there, a nail coming away?
23 DR FORLEE: I think I probably would have noticed that at
24 that stage.
25 MR GARNHAM: And had you noticed that, would you have
27
1 recorded it?
2 DR FORLEE: Yes, I would have.
3 MR GARNHAM: Can we conclude from that that you do not think
4 the nail was coming away at the time you examined her on
5 the 24th?
6 DR FORLEE: As far as I am concerned, yes.
7 MR GARNHAM: How did Victoria and Kouao behave while you
8 conducted that examination? How did they interact?
9 DR FORLEE: As I said before, Victoria was quite passive and
10 in retrospect did not really seek comfort from Kouao,
11 nor did Kouao offer her any comfort. They did not seem
12 to be particular -- there did not seem to be
13 a particular warmth between the two.
14 MR GARNHAM: Did that also add to your suspicions about
15 Victoria's injuries?
16 DR FORLEE: Yes, that was another factor.
17 MR GARNHAM: By the time you had admitted Victoria to the
18 ward you had made what you fairly accept is a cursory
19 examination because you were at the time conducting an
20 on-call SHO examination and you knew she was going to go
21 into the ward and you thought a more thorough
22 examination on the ward would take place. You were next
23 involved with Victoria the following Monday, which was
24 the 26th.
25 DR FORLEE: Yes, and I briefly saw her on the ward round on
28
1 handover the following morning with Dr Rossiter.
2 MR GARNHAM: On the Sunday?
3 DR FORLEE: Yes.
4 MR GARNHAM: I do not think you mention that in your
5 statement, do you?
6 DR FORLEE: Yes, at the beginning -- no, it is not mentioned
7 in my statement. Initially I did not have the
8 opportunity to mention any additions to my statement but
9 on reading it I have realised that that was an omission.
10 I was actually present on the ward round on the 25th, on
11 the morning handover ward round.
12 MR GARNHAM: So having admitted her on the 24th you were
13 then present on the morning of Sunday the 25th at the
14 ward round and again on the 26th?
15 DR FORLEE: That is right.
16 MR GARNHAM: By the time of the 26th then, you were seeing
17 her for the second time?
18 DR FORLEE: Yes.
19 MR GARNHAM: Had the full examination which you expected to
20 take place on the ward taken place by then?
21 DR FORLEE: On the Sunday morning the nurses had at this
22 stage given Victoria a bath and had raised the alert in
23 terms of the fact that they had seen quite suspicious
24 looking marks. Dr Rossiter then requested the person
25 coming on-call that day to do a diagram of the other
29
1 marks on the body.
2 MR GARNHAM: So your understanding is that on Sunday the
3 25th Victoria had been bathed and the nurses had seen
4 the suspicious marks on her body?
5 DR FORLEE: (Nods).
6 MR GARNHAM: And that on that same day, the 25th,
7 Dr Rossiter had instructed maps to be drawn up?
8 DR FORLEE: As far as I can recall, yes.
9 MR GARNHAM: Because it appears from what we have seen so
10 far that the body maps were only completed by
11 Dr Reynders on the 26th, which was the Monday, but are
12 you confident that this information was gathered on the
13 25th?
14 DR FORLEE: I recall the ward round in the morning and that
15 is what I remember of the ward round. I cannot say why
16 the date on the map was the 26th, I cannot comment on
17 that.
18 MR GARNHAM: Do you have a positive recollection now of
19 a ward round on the morning of the 25th in which it was
20 noted mentally at least that Victoria had suffered these
21 further injuries noticed when the child was bathed?
22 DR FORLEE: Yes.
23 MR GARNHAM: And is it your recollection that on that day an
24 instruction was issued that those marks should be
25 recorded?
30
1 DR FORLEE: Yes.
2 MR GARNHAM: Would you agree that given the circumstances in
3 which you had examined and then admitted Victoria it was
4 important that an examination should be completed,
5 a full examination should be completed promptly on her
6 arriving on the ward?
7 DR FORLEE: That evening?
8 MR GARNHAM: Before we come to specifics would you agree
9 that it should be done promptly?
10 DR FORLEE: Yes.
11 MR GARNHAM: Because otherwise there is a risk, is there
12 not, firstly that if injuries are found that have not
13 been noted by you in your relatively cursory
14 examination, that somebody might say, "Well, those
15 injuries were not there when I brought this child into
16 hospital"?
17 DR FORLEE: That is true.
18 MR GARNHAM: Secondly, because the aim is to get a complete
19 picture of the state of this child when she is admitted.
20 Now back to the question of what prompt would mean. She
21 is admitted at 7 or 8 o'clock on a Saturday evening?
22 DR FORLEE: I think by the time she got to the ward it was
23 probably later.
24 MR GARNHAM: Can you tell us what time?
25 DR FORLEE: I cannot remember specifically. Telephone calls
31
1 were made I would have thought between 8.30 or so, 8 to
2 8.30 to Dr Rossiter, to the on-call social worker and
3 I did see a note stating that message was left at 20.30
4 to the social worker, so I can only estimate that is the
5 sort of time I was making telephone calls.
6 MR GARNHAM: So admission by?
7 DR FORLEE: An admission probably by 9.30/10.
8 MR GARNHAM: Given that you had only been able to carry out
9 a partial examination in A&E would you expect a full
10 examination to be conducted that evening?
11 DR FORLEE: No, not necessarily.
12 MR GARNHAM: But you certainly would expect it the following
13 morning?
14 DR FORLEE: Yes.
15 MR GARNHAM: Is there a danger with a partial examination of
16 the sort you conducted that those coming afterwards will
17 assume that a complete examination has been conducted or
18 would it always be assumed following an admission via an
19 SHO's examination in A&E that a full examination is
20 still required?
21 DR FORLEE: I think that was fairly clear from the following
22 morning ward round that the full examination was still
23 outstanding and that was planned.
24 MR GARNHAM: How was that clear?
25 DR FORLEE: Via discussions and the plan --
32
1 MR GARNHAM: Discussions in which you took part?
2 DR FORLEE: Yes.
3 MR GARNHAM: So you would have made it clear during the
4 discussions on the morning of the 25th that you had only
5 done a partial examination and that a full examination
6 was required?
7 DR FORLEE: Yes.
8 MR GARNHAM: And that would have been apparent to
9 Dr Rossiter, would it?
10 DR FORLEE: She specifically requested body maps to be done,
11 so yes.
12 MR GARNHAM: After you had examined Victoria, you then
13 checked the CP register, I think?
14 DR FORLEE: Yes.
15 MR GARNHAM: And you say you contacted the consultant
16 paediatrician Dr Rossiter?
17 DR FORLEE: That is right.
18 MR GARNHAM: Are you confident that Dr Rossiter was present
19 or was on-call that day?
20 DR FORLEE: I am very confident of that.
21 MR GARNHAM: Was she an on duty consultant on the 24th July
22 then?
23 DR FORLEE: I am pretty confident she was because I clearly
24 recollect thinking, "Great, she is the person on-call
25 and I feel very comfortable calling her directly at home
33
1 because she is on-call and she is the named consultant
2 for child protection issues".
3 MR GARNHAM: Being on-call would have meant that Dr Rossiter
4 was not in the hospital but at home?
5 DR FORLEE: That is right.
6 MR GARNHAM: But available?
7 DR FORLEE: Yes.
8 MR GARNHAM: Can I ask you to look at the paediatric rota
9 for that day, volume 37, page 49. This is the on-call
10 paediatric rota for evenings, weekends and bank
11 holidays, and if you look to Saturday 24th and
12 Sunday 25th, do you see those two dates?
13 DR FORLEE: Yes.
14 MR GARNHAM: The consultant on-call for those two days is
15 noted to be Dr Meates.
16 DR FORLEE: Yes.
17 MR GARNHAM: Dr Rossiter first appears thereafter on Monday
18 the 26th.
19 DR FORLEE: Yes.
20 MR GARNHAM: Do you say nonetheless that it was Rossiter who
21 was on-call?
22 DR FORLEE: Yes.
23 MR GARNHAM: How do you discover that it is Rossiter on-call
24 if the rota says it is Meates?
25 DR FORLEE: I mean some of the times they may have done an
34
1 informal swap and I just remember very clearly that
2 Dr Rossiter was the on-call person because I clearly
3 remember thinking I can feel quite confident in just
4 phoning her at home because I am not disturbing her when
5 she should not be disturbed, as she was the named
6 consultant for child protection cases. She certainly
7 attended the ward round on Sunday which probably would
8 imply that she was covering.
9 MR GARNHAM: Ms Gibson has just pointed out to me the
10 handwritten correction which I initially had not read.
11 It may be that this helps us. Would you look again at
12 page 49. By Sunday the 25th it looks as if Dr Meates --
13 there is a cross through the M of Meates and then there
14 are some initials which may be MAR. Is that
15 Dr Rossiter's initials?
16 DR FORLEE: Yes.
17 MR GARNHAM: That is Sunday the 25th. I think you are
18 telling us that it was Saturday the 24th when Rossiter
19 was on-call consultant.
20 DR FORLEE: I accept this is the printed rota. I just
21 recall very clearly feeling confident that I could call
22 her and not feeling that I was contacting her out of
23 hours that she should not be covering, and I cannot
24 remember exactly where I got that information from but
25 I do feel confident that she was the right person to
35
1 contact.
2 MR GARNHAM: Dr Rossiter in her statement to this Inquiry
3 says that she was the on-call consultant for Sunday the
4 25th. That is volume 6 of the witness bundles, page 233
5 for your note sir. But as I read her statement, I will
6 be corrected if I am wrong, there is nothing in her
7 statement to suggest that she was the on-call consultant
8 on Saturday the 24th.
9 DR FORLEE: I cannot comment specifically about this printed
10 rota and whether amendments were made and not entered on
11 the rota but I did feel very confident that she was the
12 person to contact on the Saturday. As far as I knew she
13 was the on-call consultant. I called her directly at
14 home, discussed the case with her and she attended the
15 following morning on the ward round.
16 MR GARNHAM: May it have been not until the 25th that you
17 had your discussion with Dr Rossiter?
18 DR FORLEE: No, I am absolutely positive about phoning her
19 first after seeing Victoria. She was the very first
20 person I contacted on that evening and that I recollect
21 absolutely clearly. I can remember some of her words
22 directly.
23 MR GARNHAM: I was going to ask you what passed between you.
24 Perhaps you could tell us.
25 DR FORLEE: I talked to her about the circumstances in which
36
1 Victoria was presented to me. I told her about the
2 injuries that she had presented with. She said to me
3 that there were two issues here, one -- and her very
4 words were, "We need to get to know this child a little
5 better", and secondly she was concerned that these burns
6 may become infected and thus we needed to attend to
7 those. She thus felt it correct that we did admit
8 Victoria on that evening.
9 MR GARNHAM: She certainly signs the CP3 form on the 25th,
10 not the 24th, but you would say that is not inconsistent
11 with your --
12 DR FORLEE: No, because she would have only come in in the
13 morning -- exactly.
14 MR GARNHAM: Is it possible that the conversation you had
15 with Victoria on the evening of the 24th was with the
16 Senior Registrar, Dr Banjoko, rather than Dr Rossiter,
17 the consultant?
18 DR FORLEE: No, I remember this incredibly clearly.
19 I remember this case more clearly than I do any other
20 case probably that I have seen in my experience and
21 I remember the phone calls very clearly in my mind.
22 I called Dr Rossiter first. I then called the on-call,
23 the duty social worker on-call. She was not available.
24 I left a message and she bleeped me back later on that
25 night, and after leaving a message for the duty social
37
1 worker I called Dr Banjoko and told her I had already
2 discussed the case with Dr Rossiter and that this was
3 the plan and I remember that very clearly, it is crystal
4 clear in my mind.
5 MR GARNHAM: You tell us you tried to contact the duty
6 social worker.
7 DR FORLEE: That is right.
8 MR GARNHAM: Initially without success.
9 DR FORLEE: It is not uncommon that they are out visiting
10 other cases.
11 MR GARNHAM: You left a message?
12 DR FORLEE: Yes.
13 MR GARNHAM: She rang back at 11 or 12 --
14 DR FORLEE: I cannot remember the exact time but it was
15 quite late that evening.
16 MR GARNHAM: Was that social worker Luciana Frederick?
17 DR FORLEE: Yes.
18 MR GARNHAM: Is she somebody you knew?
19 DR FORLEE: The name was familiar to me but I had never met
20 her before.
21 MR GARNHAM: What discussion took place between you?
22 DR FORLEE: I cannot remember the exact details of the
23 discussion but I would have told her that I had seen
24 a child about whom I had concerns, that we had admitted
25 her. I vaguely recall her telling me that we would have
38
1 to contact the hospital social workers as well,
2 considering she was now admitted, and we did have
3 a discussion about whether she needed to see the child
4 immediately that night and my understanding of the
5 situation was that if a child was admitted and we deem
6 her to be relatively safe then that did not need to
7 happen that night, and Luciana Frederick confirmed that
8 view with me and said proceedings could take place later
9 on during normal office hours.
10 MR GARNHAM: We have a record of the conversation between
11 you and Ms Frederick in the social services files and
12 I want to ask you whether you agree with what is
13 recorded there. Would you have a look please at
14 volume 7, page 000.510. Whilst that is being found can
15 I ask you the order of the phone calls you made? We
16 know the people you say you spoke to are Rossiter,
17 Frederick and Banjoko. What is the order?
18 DR FORLEE: I am absolutely certain I spoke to Dr Rossiter
19 first.
20 MR GARNHAM: And then?
21 DR FORLEE: I think almost certainly I spoke to, not to
22 Luciana Frederick but made the phone call to the duty
23 social worker second, and third of all, once all that
24 had been done I contacted Dr Banjoko.
25 MR GARNHAM: And then presumably you had the actual
39
1 conversation with Frederick after that?
2 DR FORLEE: Yes.
3 MR GARNHAM: Would you look at page 510. This is not your
4 note, this is the note of Ms Frederick, but I want to
5 ask you whether you agree with it. Date in the top
6 left-hand corner 24th July, time 20.30, referred by
7 Dr Forlee.
8 DR FORLEE: I think this would not have been
9 Luciana Frederick's entry.
10 MR GARNHAM: This may have been the note of your --
11 DR FORLEE: Message left.
12 MR GARNHAM: Would that fit if it was in terms of time?
13 DR FORLEE: Yes, I think that would have been correct.
14 MR GARNHAM: Then the situation at referral in the box:
15 "1. Child admitted to hospital. Concern about
16 injury caused by hot water poured onto face causing
17 facial burns.
18 "2. It appeared to be an accident, however mother
19 may need support."
20 Now, as to the first of those points would that be
21 an accurate reflection of the message you left?
22 DR FORLEE: Yes, I think that would have been a reasonable
23 representation.
24 MR GARNHAM: Would it have been a reasonable representation
25 of what you subsequently told Frederick when you spoke
40
1 to her?
2 DR FORLEE: Yes, I think -- I mean I would have mentioned
3 the injury she presented with and the fact that we
4 needed to gain further information about this child in
5 the circumstances.
6 MR GARNHAM: What about point 2, "It appeared to be an
7 accident, however mother may need support"?
8 DR FORLEE: No, I really cannot recollect handing over that
9 information.
10 MR GARNHAM: That would have been plainly contrary to what
11 you have told us was your view?
12 DR FORLEE: Yes.
13 MR GARNHAM: "3. Advice given, doctor agreed to discuss
14 case with hospital social worker the following day."
15 First of all, was that in your message left for the
16 absent social worker?
17 DR FORLEE: No, that would not have been in the message left
18 because obviously I was seeking advice from them.
19 MR GARNHAM: So would it have been part of the conversation
20 that you actually had with Frederick when you spoke to
21 her?
22 DR FORLEE: We certainly would have discussed the hospital
23 social worker. I am not sure that the following day was
24 correct because she did say during working hours and
25 Sunday was not a working hour or not normal working
41
1 hours. But yes, the gist of that would have been
2 correct.
3 MR GARNHAM: But if this record is right, and you may well
4 say it is not and I am interested to have your views,
5 but if this record is right then this is what happened
6 at half past 8 that evening, not at nearly midnight?
7 DR FORLEE: No, my recollection is very clear about the
8 night. The discussion I had with LF was much later.
9 I did not get in touch with her initially, I remember
10 that clearly. The message was left and she bleeped me
11 back. The exact time I cannot remember but it was --
12 MR GARNHAM: Between 11 and 12.
13 DR FORLEE: A lot later in the evening.
14 MR GARNHAM: Then point number 4, "NFA", which I suspect
15 does not mean no fixed abode but no further action.
16 Assuming it means no further action, would you have said
17 that no further action beyond what is recorded above was
18 necessary?
19 DR FORLEE: No.
20 MR GARNHAM: It may well be that is what Ms Frederick wrote
21 as a note to herself. I do not know, we will ask her,
22 but you did not tell her that no further action other
23 than what is recorded above was necessary.
24 DR FORLEE: I was seeking advice from her. Our
25 responsibility is to inform the duty social worker and
42
1 they then advise us of what action they would take.
2 I would presume that some form of social work
3 involvement would be expected and would happen.
4 MR GARNHAM: At the bottom of that page there are some
5 letters and codes which we will have to ask Ms Frederick
6 about but it may be that if you look at the boxes
7 towards the right-hand side that F1, that is 2000 hours
8 and F2 at 2100 hours, would that be consistent with the
9 timings of your two calls?
10 DR FORLEE: Unfortunately I do not remember the specific
11 times of my calls. I think the 8.30 would probably be
12 a reasonable time because I saw Victoria some time
13 between 7 and 8, assessed her, then had the discussion
14 with Dr Rossiter and then would have made the phone
15 call. So I am not sure what the times at the bottom
16 mean. My recollection is that I then was busy with
17 other matters and was bleeped back fairly later on in
18 the evening and I cannot recall the time unfortunately.
19 MR GARNHAM: Thank you. Can you look again at volume 37
20 please. This is page 57 and this is CP5, the fifth
21 child protection form. There is mention there under the
22 heading of "The following being informed" social worker
23 LF, Luciana Frederick, and you remember we looked at
24 this yesterday?
25 DR FORLEE: Yes.
43
1 MR GARNHAM: Is there any other note beside that of the
2 conversation you had with Frederick?
3 DR FORLEE: When I filled out the child protection forms
4 I wrote "message left". Victoria was then admitted to
5 the ward with the CP form so I did not have them to
6 hand. As events occur on-call I was then I think busy
7 in Casualty later on that evening when I got bleeped so
8 I did not have the forms to hand and thus recorded
9 nothing on the CP forms.
10 MR GARNHAM: So the answer to my question is that is the
11 only record of the conversation with Frederick?
12 DR FORLEE: The record of the message left, yes.
13 MR GARNHAM: You also spoke to Dr Banjoko?
14 DR FORLEE: Yes.
15 MR GARNHAM: You have told us something about that
16 conversation. Was anything else that you recall said
17 between you? What did you need from her, you having
18 spoken to Rossiter you say?
19 DR FORLEE: The normal procedure was that you informed the
20 registrar because you were the junior member of the
21 team.
22 MR GARNHAM: Was it just a matter of you informing her,
23 there was no other --
24 DR FORLEE: And if she felt that there were further issues
25 that needed to be dealt with then that would be at her
44
1 discretion.
2 MR GARNHAM: Were there?
3 DR FORLEE: I cannot recall specifically. I think she may
4 have reviewed the situation herself.
5 MR GARNHAM: So beside your telling Dr Banjoko what had
6 happened and what you planned to do there was nothing
7 else that passed between you?
8 DR FORLEE: I am not sure what you are --
9 MR GARNHAM: It is an open question. I am asking whether
10 you recall anything else that passed between you and
11 Dr Banjoko other than you informing her what had
12 happened and what you were going to do.
13 DR FORLEE: And informing her about the actions I had
14 already taken, no, that was it.
15 MR GARNHAM: You then went back to Victoria and Kouao and
16 you told them that Victoria was going to be admitted.
17 DR FORLEE: Yes.
18 MR GARNHAM: Did you tell them, did you tell Kouao that one
19 of your reasons for admitting Victoria was your concerns
20 that she might be the subject -- she might have been the
21 subject of abuse, of non-accidental injury?
22 DR FORLEE: I cannot remember specifically. As is usual
23 when I fill out child protection forms I usually do say
24 that I am duty bound to fill out these forms because we,
25 our prime responsibility is looking after children and
45
1 ensuring their safety, so that is something I usually
2 say to parents accompanying children whenever I do fill
3 out the forms. I cannot remember the specific
4 discussion with her in this instance.
5 MR GARNHAM: You tell us in paragraph 45 that although you
6 cannot remember the exact conversation you would not
7 have laboured the point about child abuse concerns with
8 Kouao.
9 DR FORLEE: As I said before, I was very inexperienced in
10 child protection issues at the time I saw Victoria. It
11 was my opinion that if I did labour the point I may not
12 get her cooperation. Now, whether that was right or
13 wrong is subject to opinion.
14 MR GARNHAM: Were you seeking to get Victoria -- as regards
15 your conversation with Kouao, did you feel you were
16 presenting to Kouao the full reasons for the admission
17 or was the need for treatment of the burns something of
18 a pretext?
19 DR FORLEE: As I said before I do not think I laboured the
20 issue of child protection issues, just because with my
21 lack of experience I just felt that that was not a wise
22 way to try and get cooperation from an accompanying
23 adult.
24 MR GARNHAM: Did you challenge Kouao about any parts of her
25 story?
46
1 DR FORLEE: No.
2 MR GARNHAM: Did you challenge her about the cause of the
3 injuries, and your doubts about that?
4 DR FORLEE: No, again possibly through lack of -- well, with
5 my inexperience I just felt that challenging her again
6 would --
7 MR GARNHAM: Lose her cooperation?
8 DR FORLEE: Yes, would result in the loss of her
9 cooperation.
10 MR GARNHAM: Does the same answer apply in respect of the
11 delay in getting Victoria to hospital after the reported
12 occurrence?
13 DR FORLEE: My initial discussion with Kouao was just to
14 establish her version of events for my opinion as to
15 whether I thought that was credible or not and then
16 instigate proceedings where we could investigate things
17 further.
18 MR GARNHAM: I think we have the reasons why you did not
19 challenge Kouao already but I want to make sure that
20 I understand whether you challenged her about anything.
21 Did you challenge her about the difference in dress?
22 DR FORLEE: No.
23 MR GARNHAM: About the fact that Victoria was wearing no
24 underwear?
25 DR FORLEE: No.
47
1 MR GARNHAM: About the unkemptness of Victoria as opposed to
2 the elegance of Kouao?
3 DR FORLEE: No, I did not.
4 MR GARNHAM: Victoria and Kouao were both then taken across
5 to Rainbow Ward.
6 DR FORLEE: Yes.
7 MR GARNHAM: And Victoria was admitted. Who escorted them
8 across to the ward?
9 DR FORLEE: It would usually be a member of the nursing
10 staff from the Accident and Emergency department.
11 MR GARNHAM: But not you?
12 DR FORLEE: Sometimes I would accompany the patient but it
13 really would depend on what else I had to do after
14 seeing them so I cannot remember for certain whether
15 I accompanied them or not.
16 MR GARNHAM: Do you remember whether you visited Victoria or
17 saw Victoria at all on the ward that evening?
18 DR FORLEE: I cannot remember for certain.
19 MR GARNHAM: You certainly did not do any examination of her
20 that evening --
21 DR FORLEE: No.
22 MR GARNHAM: -- on the ward. Had that not been your
23 intention, that you would do an examination once she got
24 there?
25 DR FORLEE: Part of the issue is that I did not feel I was
48
1 experienced enough to do an examination unsupervised
2 because that was something I had not done before. The
3 other issue is that I am not certain what the rest of
4 the evening involved and it may have been that I was
5 busy elsewhere and just did not have the actual time to
6 go back and visit Victoria on the ward. I cannot
7 remember the details.
8 MR GARNHAM: Volume 37, page 57, do you have that in front
9 of you?
10 DR FORLEE: Yes.
11 MR GARNHAM: That is the action checklist for CP5. The top
12 box is "Actions Needed" and "Actions Achieved" and then
13 it is indicated that the Child Protection Register had
14 been checked. "Not on it. Child admitted? Yes. If
15 so, emergency protection order?" That is not answered.
16 "Siblings at risk in household? Check". Did you
17 consider those two points?
18 DR FORLEE: Yes.
19 MR GARNHAM: So why do we not have a yes no answer?
20 DR FORLEE: Unfortunately an omission.
21 MR GARNHAM: Do we take it from the absence of an entry
22 there that the answer was no to emergency protection
23 order?
24 DR FORLEE: Yes.
25 MR GARNHAM: What about siblings at risk in household?
49
1 DR FORLEE: I would answer that as no. My enquiries were
2 based on details given to me by Kouao that there were
3 four older children but they were in France and I deemed
4 that to represent siblings not at risk.
5 MR GARNHAM: You tell us you were on duty all night and you
6 were still on duty the following morning.
7 DR FORLEE: Yes.
8 MR GARNHAM: And you took part in the ward round on the
9 25th July. And the fact that we do not find any mention
10 of that in your statement is an omission that did not
11 occur to you at the time you signed it?
12 DR FORLEE: Unfortunately not.
13 MR GARNHAM: We do have your description of a ward round led
14 by Dr Richardson on the 26th.
15 DR FORLEE: Yes.
16 MR GARNHAM: The notes for which you wrote up?
17 DR FORLEE: Yes.
18 MR GARNHAM: We have those notes at 37/261. Is that right?
19 The second entry on that history sheet.
20 DR FORLEE: The third.
21 MR GARNHAM: I am sorry, the third entry, "Ward round with
22 Dr Richardson". Can I ask you about the two entries
23 before that? The first one looks as if it is signed by
24 a staff nurse.
25 DR FORLEE: Yes.
50
1 MR GARNHAM: And the second one is another signature I
2 cannot read.
3 DR FORLEE: I think that is Lucy Hines.
4 MR GARNHAM: I can now see it. So you made neither of
5 those?
6 DR FORLEE: No.
7 MR GARNHAM: You were present, you tell us, on the ward
8 round on the 25th. Was any note made of that?
9 DR FORLEE: I am not entirely sure. It would usually be the
10 responsibility of the SHO coming on to document the ward
11 round.
12 MR GARNHAM: If you look at the previous page of the notes
13 we have the events of the 25th. Is there anything to
14 suggest you are present there?
15 DR FORLEE: No, I do not think so.
16 MR GARNHAM: You have had a chance I think to look at all
17 the hospital notes for Victoria. Is there any mention
18 anywhere of your attending on a ward round on the 25th?
19 DR FORLEE: It may have been that no notes were made,
20 I cannot comment specifically, but normal procedure
21 would be that you would attend the following morning's
22 ward rounds and I can recollect that very clearly as
23 I can recollect most of the details of this case.
24 MR GARNHAM: Can we look at your notes of the ward rounds on
25 the 26th which is on 261:
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