|
Archived Transcript for 8 November 2001: Pages
101 to 150
101
1 MS GIBSON: Would you say that was done by Dr Forlee?
2 DR BANJOKO: Yes.
3 MS GIBSON: If we can explore that, looking at the child
4 protection forms that were completed by Dr Forlee which
5 appear in volume 37, page 53. Can you help with this:
6 firstly did you consider these forms when you went to
7 Rainbow Ward to see Victoria?
8 DR BANJOKO: Yes I did.
9 MS GIBSON: You read all of these particular forms in
10 evaluating her case?
11 DR BANJOKO: I looked through them, yes.
12 MS GIBSON: You looked through them but would you say that
13 you considered them thoroughly?
14 DR BANJOKO: I am sure I would have.
15 MS GIBSON: If you could have a look at the page 56 which is
16 the chart that Dr Forlee filled in, that is a chart of
17 Victoria's head.
18 DR BANJOKO: Yes.
19 MS GIBSON: But there is no body chart filled in so you were
20 aware when you saw those forms that no examination had
21 been conducted of Victoria's body or at least no
22 recordings had been made of that?
23 DR BANJOKO: Yes, I was, by the time I looked at the CP
24 forms, yes.
25 MS GIBSON: Did you learn from Dr Forlee that she had
102
1 carried out I think what could best be described as
2 a fairly cursory examination of Victoria while she
3 remained dressed?
4 DR BANJOKO: Not directly from Dr Forlee.
5 MS GIBSON: Where did you obtain that information?
6 DR BANJOKO: All the information I had about the examination
7 that was done was on looking at the CP forms.
8 MS GIBSON: Again although it does not specifically detail
9 how the examination was done, it would be apparent from
10 the absence of any charting of the body that a full
11 examination had not been conducted.
12 DR BANJOKO: Yes.
13 MS GIBSON: It is part of your obligation, is it not, as
14 registrar in the case, to countersign the form CP3?
15 DR BANJOKO: That form is usually signed by a registrar or
16 consultant and when the forms are being filled in it
17 says "I have discussed the above findings". The reason
18 it was signed by Dr Rossiter was because Dr Forlee
19 discussed first with Dr Rossiter the above findings.
20 MS GIBSON: It was signed by Dr Rossiter the following day.
21 DR BANJOKO: Yes, but she was the lead clinician and she was
22 the first person Dr Forlee reported to.
23 MS GIBSON: Again, it is your responsibility as registrar to
24 ensure that a full examination has been conducted. It
25 is apparent from these forms as you have already said
103
1 that Dr Forlee had only completed a partial examination
2 of Victoria.
3 DR BANJOKO: With regard to a full examination, we tend to
4 examine children -- when we examine children we have to
5 think of the child. We have to think and with regard to
6 this case I had to take in context the fact that this
7 child had suffered burns to the head, this child had
8 been in Casualty for a while, as far as I remember it
9 was a busy day at North Middlesex Hospital, I was also
10 covering the NICU and I was also covering labour ward
11 and postnatal wards. By the time I got round to the
12 wards it was quite late at night, I cannot remember the
13 time, and at that point in time I did not feel it was --
14 I did not feel it was morally right to subject Victoria
15 to a thorough physical examination when she would be
16 seen the next morning by Dr Rossiter, who would carry
17 out another examination.
18 MS GIBSON: Were you at all concerned that Dr Forlee had not
19 carried out a full examination? That is presumably what
20 is supposed to happen.
21 DR BANJOKO: Well, what is supposed to happen is that
22 a child should be examined by the person who feels the
23 most comfortable to examine them because in these cases
24 we do not want to subject these children to repeated
25 examinations. So I mean obviously from hearing
104
1 Dr Forlee's evidence she did not feel she had sufficient
2 experience to examine this child fully on her own.
3 MS GIBSON: You were aware when the bleep came through to
4 Dr Forlee -- I think you were working together on the
5 Special Care Baby Unit at the time --
6 DR BANJOKO: Yes, I was aware.
7 MS GIBSON: -- that this was a case of possible child abuse?
8 DR BANJOKO: Not necessarily, no. What I was aware of was
9 that this was a child with scabies who had presented to
10 Casualty with burns.
11 MS GIBSON: But is it not right that according to guidance,
12 burns in themselves are indicative of possible abuse and
13 have to be treated as a possible indicator?
14 DR BANJOKO: That is right. That in itself, yes, might give
15 you a suspicion of abuse but the way this child was
16 referred to us was a child with a medical problem and
17 Dr Forlee was going down to find out more about the
18 case.
19 MS GIBSON: But we know that Dr Forlee took with her child
20 protection forms.
21 DR BANJOKO: I do not know when she picked up the child
22 protection forms. Child protection forms as far as I am
23 aware are kept in Casualty. She definitely did not pick
24 up child protection forms when she was with me.
25 MS GIBSON: You would certainly be aware -- as you have
105
1 already said, it is a case of possible burns -- that it
2 is a case of scalding to a child that this is a case of
3 possible abuse.
4 DR BANJOKO: This is a case where you would need to rule out
5 child abuse. It is a case of possible abuse, but it is
6 not, I mean it is a case where you would have to think
7 of the possibility of child abuse, that is right.
8 MS GIBSON: And that possibility brings you in to the
9 guidelines that you have to follow when investigating
10 a case of possible abuse with all that that entails,
11 that you have to medically examine the child within
12 24 hours?
13 DR BANJOKO: Yes.
14 MS GIBSON: Conduct a comprehensive medical examination?
15 DR BANJOKO: That is right but 24 hours went on from when
16 Victoria was first seen in Casualty until 24 hours the
17 next day. What I am trying to say is that that night
18 I did not think it was morally in the best interests of
19 a girl who had already had some form of examination, had
20 suffered burns to her face, now got onto the ward in the
21 middle of the night, I did not think it was morally in
22 her best interests to examine her since it was something
23 that could be done properly in more controlled
24 situations with a consultant present the next morning.
25 MS GIBSON: What did you do to satisfy yourself that
106
1 Dr Forlee, who was the SHO working under your guidance,
2 was sufficiently qualified and sufficiently experienced
3 to deal with the case of possible abuse and to know what
4 to do?
5 DR BANJOKO: What I would have expected, because when
6 children get referred to Casualty, children are referred
7 for all sorts of things. They might be referred for
8 a fracture and in the long run it turns out to be a case
9 of NAI. What I would expect of an SHO is if they go to
10 Casualty and there is anything they are worried about,
11 there is anything, any suspicion of non-accidental
12 injury, I would expect them to get back to me.
13 MS GIBSON: Thank you. I am conscious of the time.
14 THE CHAIRMAN: I am grateful to you Ms Gibson. I did not
15 know how long you would be. I was hoping we might
16 finish with Dr Banjoko but it is clear we are not going
17 to.
18 MS GIBSON: No.
19 THE CHAIRMAN: Dr Banjoko, I had hoped we might be in a
20 position to release you but I am afraid we are not. If
21 this is a convenient time?
22 MS GIBSON: Yes, if it is convenient for you.
23 THE CHAIRMAN: Ladies and gentlemen, we will now break and I
24 think we will reassemble at 2 o'clock. Thank you very
25 much.
107
1 (1.00 pm)
2 (The luncheon adjournment)
3 (2.00 pm)
4 THE CHAIRMAN: Miss Gibson.
5 MS GIBSON: Thank you sir. We are in the middle of
6 Dr Banjoko's evidence. I would ask her to come back to
7 the witness stand.
8 Thank you Dr Banjoko. Before we broke for lunch
9 I was asking you about delegation of responsibility to
10 an SHO in a case such as this and I wonder if you could
11 look at volume 39 of the bundle at page 240. I wonder
12 if someone could obtain volume 39, page 240. If you
13 would have a look at that document, it is right that
14 that deals with your responsibilities as a paediatric
15 registrar in a case of suspected child abuse. It is
16 from the Child Protection Guidelines from the hospital.
17 Are you familiar with that extract?
18 DR BANJOKO: Yes.
19 MS GIBSON: It is correct that that deals with your duties
20 in terms of delegation of cases. It is your job to
21 decide who should examine the child, is it not?
22 DR BANJOKO: Yes, it is.
23 MS GIBSON: For example, you then take a decision, as it
24 says below, to delegate to the SHO under supervision but
25 it is your job to countersign page CP3 of the child
108
1 protection forms?
2 DR BANJOKO: Yes, it is.
3 MS GIBSON: And you accept that you did not do that in this
4 case. Is that right, you did not do that in this case?
5 DR BANJOKO: That is right but the situation in this case is
6 very different from a normal child abuse -- it is very
7 different from the way a child -- how the suspicion of
8 child abuse will present to us.
9 MS GIBSON: Can you expand? I do not understand what makes
10 this case different.
11 DR BANJOKO: What makes this case different is that the SHO
12 had seen the child, had examined and had spoken to the
13 consultant before she informed me so I did not have the
14 opportunity to delegate who would do the examination.
15 That is what makes this case different.
16 MS GIBSON: But you were aware and I think we have
17 established when Dr Forlee was bleeped that this was
18 a case that involved a scalding injury and therefore
19 was, or came into the category under your guidelines of
20 a possible case of child abuse.
21 DR BANJOKO: Of a suspicion, yes.
22 MS GIBSON: Yes, and then these guidelines apply and it is
23 your job as registrar to decide who is best placed to
24 examine this child?
25 DR BANJOKO: Yes.
109
1 MS GIBSON: What did do you to satisfy yourself that
2 Dr Forlee had sufficient experience to carry out an
3 investigation of child abuse?
4 DR BANJOKO: As doctors as North Middlesex Hospital, we have
5 a training course which is attended by the registrars,
6 the consultants and the SHOs and we are all given
7 a level of training on how to deal with child abuse
8 cases and I would expect that if Dr Forlee stumbled upon
9 a case of child abuse she would know the initial things
10 to do and she will call for help.
11 MS GIBSON: So it would be normal if she came across a case
12 of child abuse to ask for help. Would you say she was
13 incorrect in this situation to proceed with an
14 examination or a cursory examination of the child?
15 Should she have then called you to look at the child?
16 DR BANJOKO: I think under those circumstances she did the
17 right thing because she did a cursory examination of the
18 child and the reason she did the examination, as she
19 said, was to see if there was anything that needed
20 immediate medical attention, which was dealt with.
21 MS GIBSON: Can I ask you then again on this page one of the
22 other obligations placed on you as paediatric registrar
23 is to discuss the case with the consultant paediatrician
24 who may prefer to examine the child. Do you regard that
25 as an obligatory requirement?
110
1 DR BANJOKO: In this particular case, the case had been
2 discussed already with the consultant paediatrician
3 before it got formally discussed with me. So I am
4 really in a difficult situation here to make judgments
5 based on this document.
6 MS GIBSON: And what was your understanding of what
7 Dr Forlee relayed to you about what Dr Rossiter had said
8 to her?
9 DR BANJOKO: My understanding was that this was a case where
10 there was suspicion of child abuse. We were going to
11 admit this child and we were going to investigate
12 further as to the causes of whatever injuries she might
13 have and we were also going to treat any medical
14 conditions that needed to be treated, is my
15 understanding of the conversation that Dr Forlee had
16 with Dr Rossiter.
17 MS GIBSON: Can you recall, please, as precisely as you are
18 able to, what Dr Forlee told you when she spoke to you,
19 I think by phone?
20 DR BANJOKO: I cannot. I cannot recall her exact words but
21 that was my understanding of the conversation.
22 MS GIBSON: So the gist that you recall is that the child
23 was to be admitted?
24 DR BANJOKO: The child was to be admitted because there was
25 suspicion of abuse, because we felt this child was at
111
1 some sort of risk and she was to be admitted because of
2 that, and also to investigate further what was going on
3 and then also to offer whatever medical treatment we
4 needed to.
5 MS GIBSON: How did you satisfy yourself about what
6 Dr Rossiter knew about the case, and what had happened
7 in the case at that point?
8 DR BANJOKO: Okay. By the time I saw Victoria it was really
9 quite late in the night and, as I said, I was also --
10 I was not just covering the children on the
11 Rainbow Ward, I was covering lots of different places in
12 the hospital and North Middlesex is an extremely busy
13 hospital by any standards. I knew Dr Rossiter was
14 informed. I knew she was aware. I knew a management
15 plan had been agreed. And the next morning, before
16 I went off duty, I handed over to -- I mean, as we would
17 normally do, we would sit down and hand over to the
18 registrars who were coming on and to the SHOs, and
19 I handed over all the children on the wards to them,
20 saying with her we have had Dr Rossiter's involvement
21 and we knew Dr Rossiter was coming the next morning.
22 MS GIBSON: Do you know who you handed the case over to?
23 DR BANJOKO: I cannot remember but we carry an on-call bleep
24 so we always do a physical handover because you have to
25 give the bleep to somebody, so you cannot just finish
112
1 your duty and go off. We sit down and talk about all
2 the cases. It is a formal, sit down handover.
3 MS GIBSON: Did you know whether Dr Forlee had indicated to
4 Dr Rossiter what the nature of her examination of the
5 child had been?
6 DR BANJOKO: I do not know.
7 MS GIBSON: If we could have a look at the child protection
8 forms, which appear at volume 37, page 53, please. We
9 have already established that you looked through those
10 forms that evening when you went up to Rainbow Ward.
11 Looking at page 53, there is information at the bottom
12 of that form about some question of separation of mother
13 from daughter by social workers. What did you do to
14 investigate that aspect of the case?
15 DR BANJOKO: Nothing that late at night.
16 MS GIBSON: Whose responsibility would it have been to
17 pursue that matter?
18 DR BANJOKO: As far as I was aware social services had been
19 contacted. A message had been left for them. We were
20 waiting for them to get back to us, as far as I was
21 aware. And when they got back to us then we would have
22 taken it further with them.
23 MS GIBSON: What about the knowledge that Victoria was not
24 in school and did not have a GP? Whose responsibility
25 do you say it would have been to pursue those matters?
113
1 DR BANJOKO: I think it will be the responsibility of the
2 whole team. I cannot name a person because I do not
3 know -- in my knowledge I do not know who is the named
4 person to ensure that a child has a GP, but I believe it
5 is a responsibility of the whole team, to make sure that
6 a child has a GP and a health visitor.
7 MS GIBSON: There is a difficulty, is there not, when
8 responsibility is left to a team because nobody knows --
9 if no-one has the job allocated to them then no one
10 personally bears the responsibility.
11 DR BANJOKO: I know -- I understand what you are saying but
12 as far as I am aware there is no named person who has to
13 make sure a child has a GP. I mean, this -- it has been
14 flagged up in the form that the child does not go to
15 school, has not got a GP, and those are issues that will
16 be addressed and hopefully set right at a later date.
17 MS GIBSON: Would you regard it as the responsibility of the
18 consultant in charge of the case to make sure all of
19 those aspects were pursued?
20 DR BANJOKO: What I can say is that the consultant is the
21 lead physician and as hard as it is -- and I know it is
22 hard because they have lots of pressures on their time
23 and everything -- overall the person who is the lead
24 person is the in-charge person who makes sure everything
25 works the way it should and they do delegate because one
114
1 person cannot physically do everything themselves. So
2 I would expect that the lead person, overall, will make
3 sure that everything that should happen has happened.
4 MS GIBSON: What about the information on page 54 about the
5 earlier admission to Central Middlesex Hospital? That
6 is an important piece of information, when you are
7 looking at a case of child abuse, that there has been an
8 earlier admission, to pursue that with Central Middlesex
9 and find out what that was all about, because it may
10 have shed quite a bit of light on what had happened to
11 Victoria.
12 DR BANJOKO: Well, I would expect that to be done but as you
13 are aware, doctors do an on-call system and the
14 possibility of you ringing Central Middlesex in the
15 middle of the night on a Saturday night and finding
16 somebody who knows about Victoria will be quite unlikely
17 and, as I said, with Victoria proceedings had already
18 been put into place from the minute she got into the
19 hospital, was admitted on to the wards, and we would
20 expect for those proceedings to be followed through as
21 time went on. But as far as I was aware it was not
22 immediate priority to get notes from Central Middlesex
23 the first night she presented to North Middlesex.
24 MS GIBSON: Would it have been possible for you to make
25 a telephone call to Central Middlesex and say, "We have
115
1 a child admitted with suspected non-accidental injuries
2 who we understand had been admitted to your hospital
3 a couple of weeks previously, can you let me know from
4 the records what that was about"?
5 DR BANJOKO: Yes, it would have been possible, but the
6 immediate need, I think, when Victoria presented the
7 first time to North Middlesex Hospital was to make sure
8 she was safe and also to treat whatever medical
9 conditions she had and we could get more information at
10 a later stage.
11 MS GIBSON: As well as those aspects, one of the
12 responsibilities is to ensure that the suspected abuse
13 was investigated, is it not?
14 DR BANJOKO: Sorry, could you repeat that again?
15 MS GIBSON: As well as treating her and protecting her in
16 the short term, another very important obligation, when
17 you were presented with a case of suspected abuse, is to
18 evaluate that case and to investigate it.
19 DR BANJOKO: It is to evaluate it and then to investigate it
20 in conjunction with people who are experts at
21 investigating this type of a case.
22 MS GIBSON: You are a registrar, presumably you have
23 experience of dealing with cases of child abuse and
24 investigating those cases.
25 DR BANJOKO: Yes.
116
1 MS GIBSON: Can you describe what your experience is?
2 DR BANJOKO: As a senior house officer and also as
3 a registrar, I mean I have been involved in management
4 of cases where there was suspicion of some sort of
5 abuse. It could either be with children who presented
6 to Casualty and the history was not consistent with the
7 child's injury, and in such cases we might have to admit
8 them to the wards and do further investigations and get
9 more detailed history as we go along, and then I have
10 also been involved in cases where the children are
11 already on the wards and the investigation is being
12 carried out.
13 MS GIBSON: Can you help with how often you would find
14 yourself filling in the CP forms? In particular, how
15 often would you find yourself conducting the initial
16 examination and preparing body charts of a child with
17 suspected physical abuse?
18 DR BANJOKO: I would say on the average maybe once or twice
19 in a year. No more frequent than that.
20 MS GIBSON: And do you feel happy and confident to deal with
21 these type of cases or would you tend to defer them to
22 the consultant?
23 DR BANJOKO: Obviously one learns more as one goes along and
24 I would say that at this stage, yes, I would feel happy
25 and competent to deal with the case. And if a child
117
1 presented to me and I was the first person on the line
2 of duty, the child needed examination, I would examine
3 the child because I feel more competent to do it in
4 a more thorough manner. But obviously in Victoria's
5 case we had a child who had had a very difficult day,
6 had burns, had had some form of examination in Casualty
7 who I saw very late in the night, was already sitting in
8 bed, and I did not think it was right, at that stage, to
9 start undressing her and examining her all over again
10 when she was going to be seen the next morning on the
11 ward round.
12 MS GIBSON: When you saw Victoria, was she in bed or was she
13 still dressed in her daytime clothes?
14 DR BANJOKO: I cannot remember, to be honest with you.
15 I saw her in -- I saw her on the wards and she was
16 sitting in bed. I cannot remember exactly what she was
17 wearing.
18 MS GIBSON: Do you remember whether when you saw her she was
19 still covered in white lotion?
20 DR BANJOKO: Yes, I think. Sorry ...
21 MS GIBSON: If you really cannot remember, please say.
22 DR BANJOKO: I cannot remember, I cannot remember whether
23 she was still covered in white lotion.
24 MS GIBSON: You would have been aware from the child
25 protection forms that no thorough examination had been
118
1 conducted of Victoria's body?
2 DR BANJOKO: At that stage, yes, I was aware.
3 MS GIBSON: You say that you did not think it was
4 appropriate to conduct that examination because of the
5 lateness of the hour and the fact that she had already
6 been seen by Dr Forlee. Now we know Dr Forlee's
7 examination had been fairly cursory. There was nothing
8 preventing you from examining her on the ward, was
9 there?
10 DR BANJOKO: From my point of view, yes there was. We had
11 a child who had been subjected to -- we had a child who
12 had burns, who obviously would be in some degree of
13 discomfort from the burns she had, who had been sitting
14 in Casualty, her carer had been interrogated with the
15 child present, the child had already been examined,
16 there had been a transition period before this child got
17 on to the wards, got settled on to the wards, and at
18 that stage I did not think it was right for me to
19 unsettle this child all over again and start examining
20 her all over again.
21 MS GIBSON: If you were dealing with a case -- I am just
22 going to put a hypothetical case to you -- a case of
23 another condition, not child abuse but an organic
24 problem and your SHO had seen Victoria, examined her,
25 not been able to evaluate the problem, would you have
119
1 thought it appropriate to examine the child again?
2 DR BANJOKO: If the SHO had seen the child and as you said
3 has not been able to evaluate the child properly, and
4 the child was getting further at risk from whatever
5 medical condition it was, the child was deteriorating,
6 then definitely I would re-examine the child.
7 MS GIBSON: But there is a difficulty, when you treat child
8 abuse in a separate category from any other type of
9 illness that a child might suffer, that the problem --
10 in this case it is not a disease but the problem of
11 abuse is not properly investigated. Because there is an
12 urgency in the need to investigate a child promptly when
13 they present in hospital.
14 DR BANJOKO: I think in these type of cases what you have to
15 consider is the emotional state of the child you are
16 dealing with. A child is not just an object that you --
17 you know, anybody who knows anything about children will
18 know even if they come in with a life threatening
19 condition, you examine them first, you inspect them
20 first, and most of your diagnosis is based on your
21 inspection and when they are a bit more stable then you
22 might be able to do a detailed examination.
23 So a child really is not an object that -- you know,
24 I have a child who is settled after having had
25 a traumatic day and the lesions, whatever lesions she
120
1 has, they are not going to change by the next morning,
2 and I personally did not think it was morally right,
3 after what she had gone through in the day, for me to
4 say I was going to give her a thorough examination at
5 that time of the night. Because we keep coming back to
6 this question and really this is the only answer that
7 I have.
8 MS GIBSON: Looking back at the child protection forms, you
9 can see that Dr Forlee on page 55 ticked the box that
10 she wished to await further information before
11 committing herself to any diagnosis. Firstly, did you
12 agree with that evaluation of the case?
13 DR BANJOKO: At that point in time, yes.
14 MS GIBSON: Were you aware of the consequences of that, the
15 commitment to that particular box on the form, the fact
16 that that box was ticked, insofar as what that would
17 convey to social services?
18 DR BANJOKO: Could you enlighten me?
19 MS GIBSON: Well I am asking you if you know how social
20 services would respond to receipt of a form saying,
21 "I am not willing to commit myself"?
22 DR BANJOKO: What that would mean, as far as I am aware, is
23 that we still need to get a lot more information.
24 Social services need to obviously investigate or
25 interrogate, investigate the people in charge. We need
121
1 to ask more questions and then after that we can make
2 our minds up exactly on what we think. I mean, that is
3 my understanding of that statement because it is very
4 different from the previous ones which say "I consider
5 it not to be non-accidental." That says it is
6 non-accidental but this statement is saying, "I need
7 further information. We need to investigate this
8 further before I can commit myself".
9 MS GIBSON: Can you help us, and maybe you do not know the
10 answer to this, but do you know what that would lead
11 social services to do or not to do if they got a form
12 saying "unwilling to commit"?
13 DR BANJOKO: I have not got a clue what they would do,
14 sorry.
15 MS GIBSON: Can you have a look at the charts that were
16 prepared by Dr Reynders, page 60 onwards. Looking at
17 those charts, can you help with what you would view as
18 the significance of the bilateral marks on the top of
19 the arms, where it says "swelling and tender on both
20 sides"?
21 DR BANJOKO: I never saw them so this is just talking
22 from -- I really cannot comment on --
23 MS GIBSON: I am just asking you as a paediatric registrar,
24 what would that convey to you in a case of suspected
25 child abuse?
122
1 DR BANJOKO: It is very difficult to say because all you
2 have here is just some marks. So all it says to me is
3 that when Dr Reynders did the examination of Victoria,
4 there were marks on her body and some swelling, as he
5 has noted on there. It does not say anything else.
6 MS GIBSON: But is there any significance in the fact that
7 in a case of abuse you have marks parallel on either
8 side of the child's body? Would that be indicative of
9 someone perhaps gripping or shaking the child?
10 DR BANJOKO: I cannot comment on that because I am not --
11 I am not an expert as to how the nature of injuries are
12 caused, so I cannot commit myself.
13 MS GIBSON: So you would say that is beyond your experience
14 and training to say whether that may be indicative of
15 abuse?
16 DR BANJOKO: I would say it is beyond the scope of my
17 experience to say it is caused by abuse.
18 MS GIBSON: Could you offer any other medical explanation
19 for those marks?
20 DR BANJOKO: It is extremely difficult to say because
21 I cannot see the marks.
22 MS GIBSON: Could you just have a look at the same volume,
23 page 210 onwards. This is a series of photographs of
24 Victoria that I am looking for at page 210.
25 DR BANJOKO: Yes.
123
1 MS GIBSON: If you can go through those photographs until
2 you reach photographs of Victoria's back. Do you have
3 a picture of Victoria's back there with a mark on the
4 back?
5 DR BANJOKO: Yes.
6 MS GIBSON: There is a mark there. Can you assist with what
7 your clinical judgment would be if you saw that mark on
8 a child presenting -- or that you were examining?
9 DR BANJOKO: I mean I really would not know what caused the
10 injury. If I saw this, just looking at it would not
11 give me a clue as to the cause of the injury.
12 MS GIBSON: Would you think, looking at that mark -- and it
13 appears on looking at it that it has the appearance of
14 a horseshoe shape -- would it be your evaluation that
15 that was accidental or non-accidental injury?
16 DR BANJOKO: I would have to have -- I would have to ask for
17 the history as to how this mark occurred and then with
18 a history then I might be able to form an opinion as to
19 whether it was accidental or non-accidental.
20 MS GIBSON: The problem is that in this situation no history
21 was asked for from Kouao, not on the evening when you
22 saw Victoria, no examination was conducted. If you had
23 seen that mark and had a history which did not
24 sufficiently explain the mark, what would your
25 evaluation be?
124
1 DR BANJOKO: If I had seen this, I mean it would have just
2 further heightened my suspicion of non-accidental injury
3 in this case.
4 MS GIBSON: You saw Kouao and Victoria on Rainbow Ward that
5 evening. Can you help with what you recall of your
6 conversations with firstly Kouao that evening?
7 DR BANJOKO: What I recall is that I had said to her we were
8 admitting Victoria because we needed to clarify -- we
9 needed to clarify some issues as to the nature of the
10 injury and then also because we were offering her some
11 medical treatment for the injuries she had.
12 MS GIBSON: Is that all you recall?
13 DR BANJOKO: That is all I recall. I did not further
14 question her as to the nature of the injuries because
15 I felt she had already been questioned, we had
16 documented what she had said and I felt that further
17 questioning of Kouao should be done in a more controlled
18 setting where there was a consultant there and when
19 there were other members of the Child Protection Team.
20 MS GIBSON: And you saw Victoria that evening. Again, what
21 assessment did you make of Victoria?
22 DR BANJOKO: My assessment of Victoria that night was that
23 she was a child who had scalds to her face, who we had
24 decided to admit into hospital to further investigate
25 the cause of the scalds.
125
1 MS GIBSON: You did not make any entry on the notes that
2 evening. Do you accept that that was a defect in your
3 practice?
4 DR BANJOKO: Yes, I accept that was a grievous mistake on my
5 part and all I can say is that I am more careful with
6 note keeping and people do learn from mistakes as they
7 go along.
8 MS GIBSON: Do you agree that you should have made a note to
9 ensure that Victoria's case was evaluated by Dr Rossiter
10 the following morning?
11 DR BANJOKO: I do not think so because Dr Rossiter was
12 already informed about Victoria and she knew and she was
13 coming in the next morning to assess Victoria.
14 MS GIBSON: How did you satisfy yourself that Dr Rossiter
15 knew that she would have to conduct an examination of
16 Victoria, because it may be from what we have learned
17 before that she thought that that had already been done
18 by Dr Forlee.
19 DR BANJOKO: If it had been done then it would have been
20 documented in the CP notes or it would have been
21 documented elsewhere and it was not.
22 MS GIBSON: Thank you. Finally, a question on a separate
23 point. It is just something I wonder if you could help
24 with. Were you contacted by anyone from the police at
25 this time, and I am not asking about what happened
126
1 following Victoria's murder, but during this sequence of
2 events in July 1999 do you recall any telephone calls
3 from any police officer concerning Victoria's case?
4 DR BANJOKO: No. I mean, I never heard about Victoria any
5 more up until all this happened.
6 MS GIBSON: Thank you Dr Banjoko. If you wait there.
7 THE CHAIRMAN: Thank you Miss Gibson. Mr Mason, please.
8 MR MASON: Thank you sir. Just three very brief matters
9 Dr Banjoko. First of all, you were put a number of
10 questions about finding out further information such as
11 Victoria's school position. You said that something --
12 the need to be investigated by the whole team. In that
13 context were you talking about an NHS team or
14 a multi-agency team of NHS, social services, police and
15 anyone else who is appropriate?
16 DR BANJOKO: I think it would have to be a multi-agency
17 team. It has to be a multi-agency approach.
18 MR MASON: In relation to CP3 -- the reference is 37/55,
19 I do not think I need to take you to it -- where it said
20 "Need more information", the ticked box, "Need more
21 information", you said that meant we needed to
22 investigate. Again, do you think that is an NHS
23 investigation or a multi-agency investigation?
24 DR BANJOKO: Multi-agency because if it was just NHS then
25 social services would never have been informed about
127
1 this child, so it is definitely multi-agency.
2 MR MASON: Thank you. Last question. You were asked in
3 a couple of different contexts how you would satisfy
4 yourself that Dr Rossiter had all the information that
5 she needed. Would you have expected Dr Rossiter to be
6 able to work out for herself what information she
7 needed?
8 DR BANJOKO: Yes.
9 MR MASON: So Dr Rossiter did not need your help to know
10 what she wanted?
11 DR BANJOKO: No.
12 MR MASON: Thank you very much.
13 THE CHAIRMAN: Thank you Mr Mason. Dr Banjoko, a couple of
14 points, please. Just so I am clear, did you speak to
15 Dr Forlee about Victoria when she was either on her way
16 from Accident and Emergency or actually when she arrived
17 on the ward, or was it simply the notes that you had?
18 DR BANJOKO: Dr Forlee rang me and told me after she had
19 spoken to Dr Rossiter, told me of her findings and that
20 she had already discussed Victoria with Dr Rossiter and
21 they had agreed a management plan.
22 THE CHAIRMAN: I thought that was the case. Did you take
23 that as being a formal handover of medical
24 responsibility from Dr Forlee to you?
25 DR BANJOKO: No. I just have to think about this.
128
1 THE CHAIRMAN: Please do. (Pause).
2 DR BANJOKO: I took it as a formal handover of Dr Forlee's
3 responsibility to me and Dr Rossiter.
4 THE CHAIRMAN: Right. So that when Victoria was on the ward
5 that evening, she was your medical responsibility, or
6 you were her named doctor?
7 DR BANJOKO: From the minute she got admitted to hospital,
8 yes, but the normal proceedings will still be that if
9 anything happened to Victoria in the middle of the
10 night, the first person who will get called will be
11 Dr Forlee because we will both be responsible for her.
12 Because the senior house officers, they are the first on
13 the line. They are the first on the line and the nurses
14 would bleep them first and if they felt there was
15 something they could not handle then they would get in
16 touch with me. But in a broad sense, in the hospital
17 I am the most senior paediatrician on site, so I am
18 ultimately responsible for all the children when I am
19 on-call.
20 THE CHAIRMAN: All right. Let me be clear: what you are
21 telling me is that irrespective of who might be the
22 first point of call, the ultimate responsibility for
23 Victoria was yours when you were on duty?
24 DR BANJOKO: Well, the ultimate person in charge when in the
25 hospital was me, yes.
129
1 THE CHAIRMAN: Just this issue of examination and I am sorry
2 to raise it again but I just want to be clear about
3 that. When a child comes on the ward in these
4 circumstances, having had for what would seem to be good
5 reason only a cursory examination in A&E, would it not
6 be normal practice for someone on the ward to actually,
7 in effect, see what they are dealing with? I mean,
8 until they actually examine the child they do not know
9 what other injuries this child may have had because
10 I think you said earlier on that you understood that the
11 examination by Dr Forlee was only a very cursory
12 examination, for reasons that I understand.
13 DR BANJOKO: The thing to say is that when you are dealing
14 with situations where there are allegations of child
15 abuse, it is a very delicate situation to deal with, and
16 when you are faced with a situation you have to make
17 a decision that you think is in the best interest of the
18 child at that time. It has definitely been drummed into
19 us that we need to get the most amount of information
20 from minimum examination of children and it is my
21 understanding that in cases of child abuse, physical
22 abuse, the consultant on-call would want to see the
23 injuries themselves, they would want to make a note of
24 the injury.
25 As I said f I had been first on line and I had been
130
1 the first person to see Victoria, to examine her,
2 I might have done a more detailed examination because
3 I would have felt more comfortable with doing it but
4 I did not think that at that time of the night I needed
5 to subject her to a thorough examination when she would
6 have one the next day.
7 THE CHAIRMAN: Reference has been made to white powder on
8 Victoria's body. Would it not have been helpful at
9 least to know what that white powder was? The next day
10 it would have gone.
11 DR BANJOKO: Yes but -- it would have been difficult to know
12 what the white powder was just by looking at it.
13 THE CHAIRMAN: Well, maybe but that is only something you
14 can determine if you do actually look at it. What
15 I mean is -- I used the white powder only as an example
16 or an illustration. In child abuse, is it not important
17 to build up as much intelligence as possible, factual
18 information as possible, as quickly as possible?
19 DR BANJOKO: It is important to build it up, but how quickly
20 you have to do that --
21 THE CHAIRMAN: Well sufficiently quickly before the evidence
22 might disappear.
23 DR BANJOKO: From what Dr Forlee had written or from what
24 she had said about marks on the body, they did not seem
25 like things that would disappear the next morning.
131
1 THE CHAIRMAN: Right then. The next morning, so I am clear,
2 were you on the ward round?
3 DR BANJOKO: No I was not. What we do is the next morning
4 on Special Care Unit we sit down, the doctors come in
5 and sit down with us and we talk through all the cases
6 with them and then I would go off, the SHOs
7 definitely -- as far as I can remember definitely during
8 the week the SHOs would stay until the end of the ward
9 round, but during the weekend they would stay for the
10 cases where they thought it was difficult or there were
11 some aspects of their managements that needed to be
12 sorted out.
13 THE CHAIRMAN: So although you were there not, you were
14 clear that you handed over responsibility to somebody
15 else?
16 DR BANJOKO: Yes, because I handed over responsibility to
17 the on-coming registrar.
18 THE CHAIRMAN: And that is the person that you cannot
19 remember?
20 DR BANJOKO: I cannot remember who that person was. I would
21 have to look on the on-call rota.
22 THE CHAIRMAN: You gave your bleep but you --
23 DR BANJOKO: And I spoke about all the children. We always,
24 always do that; sit down and talk about every single
25 child.
132
1 THE CHAIRMAN: And just a final question. If you cannot
2 remember, just tell me. Can you remember what you said
3 about Victoria?
4 DR BANJOKO: I cannot remember my exact words.
5 THE CHAIRMAN: The gist, can you remember anything about
6 what you said?
7 DR BANJOKO: All I can say is that it would have been in the
8 lines of, "This is a child who we think is at risk and
9 we need to investigate further whilst she is on the
10 ward."
11 THE CHAIRMAN: Thank you very much indeed. Miss Gibson?
12 MS GIBSON: Sir I have one more question in what is
13 described as re-re-examination but it is a question
14 suggested by another party.
15 THE CHAIRMAN: Fine.
16 MS GIBSON: You were asked by Mr Mason about the
17 multi-agency investigation would follow referral and
18 I wonder if you could have a look at volume 39,
19 page 279. Firstly, are you aware of this extract from
20 the Child Protection Guidelines concerning referral to
21 the Social Work Department from NMH?
22 DR BANJOKO: Well I am sure it was part of the documents
23 when I was there.
24 MS GIBSON: And it is clear from that that, looking down, in
25 order to address the questions the social workers need
133
1 to look at primarily is the child suffering or likely to
2 suffer significant harm, the social worker needs as much
3 information as possible, and that includes at (2)
4 specifying whether this is a child protection case,
5 a child in need case or both. So that aspect of the
6 investigation is the responsibility of the hospital
7 staff to tell the social workers what they are dealing
8 with before they can become engaged.
9 DR BANJOKO: According to this document, then yes.
10 MS GIBSON: According to this document but can you help with
11 whether that is something you were familiar with or that
12 you understood at the time?
13 DR BANJOKO: What I understood at the time was that if we
14 had any suspicions of abuse in a child we will inform
15 social services, the on duty social worker, and let them
16 know we have this child, these are our concerns and we
17 are investigating further. Obviously we would expect
18 them to do whatever investigations they needed to do.
19 That is my understanding.
20 MS GIBSON: But in order to begin those investigations they
21 need to understand what your diagnosis is, what they are
22 looking at. Are they looking at a child in need case or
23 a child protection case. Do you follow that?
24 DR BANJOKO: I understand what you are saying but usually
25 when we refer a child to social services, even if it is
134
1 in a category of -- if it is in that category where you
2 are saying "I need to get more investigation", social
3 services usually would still engage and they would carry
4 out their own investigations alongside us carrying out
5 our own investigations, is what I am aware of.
6 MS GIBSON: Thank you Dr Banjoko. I have no more questions
7 and I am sure you can go now and get some well deserved
8 rest.
9 THE CHAIRMAN: Thank you very much indeed. I do not know
10 when you are next on duty but I hope that you manage to
11 get some sleep before then.
12 DR BANJOKO: Thank you.
13 MS GIBSON: Thank you sir. Mr Sheldon will take the next
14 witness.
15 THE CHAIRMAN: Mr Sheldon.
16 MR SHELDON: Thank you sir. With your permission I will
17 call Isobel Quinn, please.
18 MRS ISOBEL QUINN (sworn)
19 MR SHELDON: Good afternoon Mrs Quinn, please take a seat.
20 Would you confirm your full name, please.
21 MRS QUINN: My name is Isobel Quinn.
22 MR SHELDON: And Mrs Quinn I believe it is right you
23 prepared a statement for the use of this Inquiry.
24 MRS QUINN: I have, yes.
25 MR SHELDON: A copy of that is being put in front of you.
135
1 Sir, volume 6 of the green files starting at
2 page 211.501. Mrs Quinn also made a statement to the
3 Crown Prosecution Service in bundle 46, page 172.501,
4 and the transcript of her evidence to the Central
5 Criminal Court is in bundle 49 starting at page 257.
6 Mrs Quinn, have a look at that statement and turn to the
7 last page of it. Is that your signature?
8 MRS QUINN: It is, yes.
9 MR SHELDON: Are you content that the facts and matters in
10 that statement are true?
11 MRS QUINN: I am.
12 MR SHELDON: You qualified as a registered general nurse in
13 1985 I think, is that right?
14 MRS QUINN: That is correct.
15 MR SHELDON: And as a registered sick children's nurse in
16 1990?
17 MRS QUINN: Yes.
18 MR SHELDON: You mention in paragraph 2 of your statement
19 that you have a qualification you designate as ENB 970
20 (Child Protection) --
21 MRS QUINN: Yes.
22 MR SHELDON: -- which you refer to in paragraph 5 as
23 "ENB 1970". Firstly, which is it and secondly what does
24 it mean?
25 MRS QUINN: It is ENB 970 and it is a course run on child
136
1 protection.
2 MR SHELDON: How long does it last?
3 MRS QUINN: That I cannot recall. It is done as a day
4 release over a few months. It was run by Middlesex
5 University.
6 MR SHELDON: So several days in total of actual training?
7 MRS QUINN: Yes.
8 MR SHELDON: You worked on Rainbow Ward at North Middlesex
9 Hospital between May 1997 and December 1999; is that
10 right?
11 MRS QUINN: I did.
12 MR SHELDON: As a senior staff nurse?
13 MRS QUINN: Yes.
14 MR SHELDON: As far as knowledge and training in child
15 protection matters are concerned, in addition to the ENB
16 course that you have already referred to, you also
17 received some training in child protection during your
18 registered sick children's nurse course; is that right?
19 MRS QUINN: Yes.
20 MR SHELDON: I believe that at some stage you have also
21 trained other nurses in child protection matters?
22 MRS QUINN: I have, yes.
23 MR SHELDON: Was that at UCH or NMH?
24 MRS QUINN: It was at UCH.
25 MR SHELDON: I take it from your background and training in
137
1 child protection you are well aware of the importance of
2 recording matters observed on the ward that may be
3 relevant to child protection?
4 MRS QUINN: I am, yes.
5 MR SHELDON: Were you familiar with the child protection
6 procedures that were in operation in North Middlesex
7 Hospital in mid-1999?
8 MRS QUINN: Yes.
9 MR SHELDON: I wonder if a copy of volume 39 could be put in
10 front of you and turned up to page 241. Perhaps you
11 should have an opportunity to identify the document
12 first of all, Mrs Quinn. That would involve you turning
13 to page 221 in that volume. It is a document headed
14 "Child Protection Guidelines, North Middlesex Hospital
15 NHS Trust". Is that a document you have seen before?
16 MRS QUINN: It is, yes.
17 MR SHELDON: In that case could I ask you to go back to
18 page 241. You will see there a page headed "Children's
19 Wards". About two-thirds of the way down the page is
20 a paragraph number 2 and it states there:
21 "Information relevant to child protection including
22 accidents on the ward, parental visiting, decisions of
23 planning/strategy meeting or case conference should be
24 recorded on form CP6."
25 Was that a requirement of the procedures with which
138
1 you were familiar?
2 MRS QUINN: Sorry, could you point it out to me again
3 please?
4 MR SHELDON: Two-thirds down the page at paragraph 2.
5 MRS QUINN: Yes.
6 MR SHELDON: I will not read it again, I will let you glance
7 through it, but the question I asked was whether or not
8 that was a requirement with which you were familiar.
9 MRS QUINN: Yes.
10 MR SHELDON: As I understand it, in mid-1999 in North
11 Middlesex Hospital and on the Rainbow Ward in particular
12 it was the practice in some instances to record child
13 protection information on a critical incident log,
14 rather than on a form CP6. Is that right?
15 MRS QUINN: It was, yes.
16 MR SHELDON: As far as that is concerned, they were
17 interchangeable, were they?
18 MRS QUINN: I do not -- interchangeable?
19 MR SHELDON: By that I mean could you write a particular
20 piece of information on a form CP6 and on a critical
21 information log or were there some bits of information
22 that went in one place as opposed to the other?
23 MRS QUINN: My understanding would be they would be
24 interchangeable.
25 MR SHELDON: Thank you. You might also, might you not, as
139
1 a nurse on a children's ward who had suspicions of child
2 protection matters or of non-accidental injury, you
3 might want to tell somebody about it as well as
4 recording it, might you not?
5 MRS QUINN: Yes.
6 MR SHELDON: And that somebody might be a senior nurse on
7 the shift or a member of the medical staff?
8 MRS QUINN: Yes.
9 MR SHELDON: Does the fact that you tell somebody about your
10 concerns remove the obligation on you to record them as
11 well?
12 MRS QUINN: Not necessarily, no.
13 MR SHELDON: When would it remove the obligation on you?
14 MRS QUINN: I think if there is something you are concerned
15 about that is a suspicion rather than a fact then
16 generally you would discuss it as opposed to writing it
17 down.
18 MR SHELDON: I see. So your understanding of the child
19 protection procedures and requirements was you only had
20 to write down facts, suspicions you did not write down?
21 MRS QUINN: Me personally, no.
22 MR SHELDON: But the suspicions of nurses, some of whom
23 might be extremely experienced in looking after children
24 generally and in identifying child protection concerns
25 in particular, might be of an extraordinary value, might
140
1 they not, in deciding how a child had been treated?
2 MRS QUINN: Of course.
3 MR SHELDON: So would those suspicions not merit being
4 recorded so somebody could take advantage of them later
5 when they are considering the case?
6 MRS QUINN: Yes.
7 MR SHELDON: For example, it would be very difficult for
8 a nurse to know, as a fact, that a child was being
9 abused by virtue of the way in which that child
10 interacted with its parents or carer, however she might
11 have extremely strong suspicions, and if she was
12 experienced and knowledgeable of child protection those
13 suspicions might be very significant; she should record
14 those, should she not?
15 MRS QUINN: Yes.
16 MR SHELDON: So it is not the case, is it, that you should
17 only record facts; suspicions may be equally valuable
18 and should be recorded?
19 MRS QUINN: Yes.
20 MR SHELDON: Turning to your role on the ward. It was part
21 of your job as I understand it to supervise and mentor
22 junior and student nurses?
23 MRS QUINN: Yes.
24 MR SHELDON: You also indicate in your statement that
25 another aspect of your responsibility was the
141
1 maintenance of effective communication, as you put it,
2 between all disciplines.
3 MRS QUINN: Yes.
4 MR SHELDON: What do you mean by "all disciplines" there?
5 MRS QUINN: All members of the multi-disciplinary team.
6 MR SHELDON: And the multi-disciplinary team was made up of
7 whom?
8 MRS QUINN: It is made up of many people; it is made up of
9 medics, nurses, teachers, play leaders, social workers
10 can come into that team.
11 MR SHELDON: Child protection officers?
12 MRS QUINN: Child protection officers.
13 MR SHELDON: So you were responsible, do I understand it, in
14 mid-1999 on the Rainbow Ward for ensuring mechanisms
15 were in place for effective communication between all
16 those people?
17 MRS QUINN: Yes.
18 MR SHELDON: How did you go about ensuring that those
19 mechanisms were in place?
20 MRS QUINN: As you say, generally by note-keeping and we
21 have procedures and protocols and standards and
22 guidelines to follow.
23 MR SHELDON: I see. Are they the guidelines we have
24 referred to already?
25 MRS QUINN: They would be, yes.
142
1 MR SHELDON: Did you draw up any guidelines of your own for
2 use by nurses, by anybody else, as to how she should
3 communicate concerns among the multi-disciplinary team?
4 MRS QUINN: No.
5 MR SHELDON: I believe from your statement that you saw
6 Victoria on three occasions and we will deal with each
7 of them in turn. The first, as I understand it, was
8 that it was on the night shift of 26th July, is that
9 right, going into the morning of the 27th?
10 MRS QUINN: Yes.
11 MR SHELDON: Are you sure about the dates?
12 MRS QUINN: I am very sure about the dates.
13 MR SHELDON: How can you be sure about the dates?
14 MRS QUINN: I am sure about the dates from the off duty and
15 communication book.
16 MR SHELDON: I see. Let me just show you two extracts of
17 the notes if I may. They are both in volume 37 and the
18 first is at page 275. This is a document called the
19 "Communication/Critical Incident Log Sheet". The first
20 entry on it seems to be written by a Nurse Pereira.
21 Does that seem to be right?
22 MRS QUINN: Yes.
23 MR SHELDON: During the course of that entry she describes
24 an incident where what she believed to be Victoria's
25 mother and a gentleman visited and she saw what she
143
1 regarded to be a master/servant relationship. I do not
2 need to take you in detail to it now but this is an
3 incident that you recall and record in your statement;
4 is that right?
5 MRS QUINN: Yes.
6 MR SHELDON: You will see that she has dated that 25th July
7 1999.
8 MRS QUINN: Yes.
9 MR SHELDON: Turn now, please, to the same volume page 73.
10 That would appear to be the first page of a two-page fax
11 that you wrote to Lisa Arthurworrey on 3rd August 1999.
12 Is that right?
13 MRS QUINN: Yes.
14 MR SHELDON: Again, the first entry on it is that at
15 9 o'clock on 25th July 1999 Staff Nurse Pereira observed
16 mother and Anna together, and again the same remark
17 about master and servant attitude. It would appear
18 therefore that at least on two occasions in the notes
19 you have that incident as occurring on the 25th July,
20 whereas in your statement it is the 26th. I am just
21 wondering if you could help me with that?
22 MRS QUINN: I was on night duty on the 26th and
23 Staff Nurse Pereira called me over to witness the
24 behaviour.
25 MR SHELDON: I see. I am afraid that does not help me very
144
1 much. I am trying to understand why firstly
2 Staff Nurse Pereira --
3 MRS QUINN: Could she not have witnessed it both nights?
4 Could it not have happened on both the 25th and 26th?
5 MR SHELDON: Perhaps Mr Mason has something he wants to say.
6 (Pause).
7 MR MASON: Sir, maybe I can help because I actually have the
8 off duty and perhaps if it could be shown. (Handed).
9 MR SHELDON: Sir, I am afraid I do not know what Mr Mason
10 wants to say so I am in a bit of difficulty --
11 THE CHAIRMAN: I take it this is going to be helpful.
12 MR MASON: Well, I hope so, sir. First of all, can you
13 please explain what that document is?
14 MRS QUINN: This document?
15 MR MASON: Yes, in the plastic envelope.
16 MRS QUINN: This is a record of the off duty, starting
17 July 12th until August 8th -- it does not have 1990 but
18 I assume it to be the period we are talking about.
19 MR MASON: What is an off duty form?
20 MRS QUINN: An off duty is the duty rota for the nurses on
21 the ward.
22 MR MASON: So it is really an on duty?
23 MRS QUINN: It is an on duty.
24 MR MASON: But it is called an off duty for some reason.
25 MRS QUINN: Because we look for our off duty not our on
145
1 duty.
2 MR MASON: If you were on duty according to that form, does
3 it mean you are definitely on duty, barring perhaps
4 some --
5 MRS QUINN: Barring omission, yes it would, and it is very
6 clear here that I changed my nights anyway to do the
7 Monday night.
8 MR MASON: Monday 26th?
9 MRS QUINN: Yes.
10 MR MASON: From that document you are on duty on the night
11 of Monday 26th?
12 MRS QUINN: Yes.
13 MR MASON: If you are according to that document off duty,
14 does that mean that you cannot have been on duty on the
15 ward or is the ward allocation book a more reliable
16 guide?
17 MRS QUINN: I would say the ward allocation book.
18 THE CHAIRMAN: Sorry, I think I must allow Mr Sheldon to
19 carry on --
20 MR MASON: I had reached the --
21 THE CHAIRMAN: I think I am quite happy for the witness to
22 have a document in front of her like that but I think
23 Mr Sheldon should be allowed to ask the questions.
24 MR MASON: I should say counsel does have the allocation
25 book now.
146
1 THE CHAIRMAN: Mr Sheldon, feel free to begin wherever you
2 wish to begin.
3 MR SHELDON: I am grateful sir and of course grateful to
4 Mr Mason for his help, but I am not sure Miss Quinn if
5 the on-call sheet is going to assist in relation to the
6 question that I am attempting to ask you, which is this:
7 I do not seek for the moment to challenge whether you
8 were on duty on 26th July or not. If you say you were,
9 you were. What I am attempting to understand is why an
10 incident that you describe, and indeed for that matter
11 Nurse Pereira describes, as having taken place on
12 26th July 1999 in your respective Inquiry statements is
13 noted in two places in the contemporaneous notes as
14 having taken place on 25th July. Now, the reason I need
15 to understand that is not to be critical of you but to
16 understand whether there were two incidents or one.
17 MRS QUINN: I cannot answer that. I can only answer for the
18 26th and I witnessed that. You would need to ask
19 Staff Nurse Pereira whether she witnessed it twice.
20 MR SHELDON: I see, but you only witnessed it once?
21 MRS QUINN: I witnessed it once on the 26th.
22 MR SHELDON: Is that an incident you thought worthy of
23 recording in the critical incident log?
24 MRS QUINN: No it was not, because when I looked I thought
25 it had already been recorded.
147
1 MR SHELDON: So by the time you looked at the critical
2 incident note on 26th July you saw Nurse Pereira's note
3 of 25th July already there, did you?
4 MRS QUINN: Yes.
5 MR SHELDON: So that would suggest there were two incidents,
6 would it not?
7 MRS QUINN: It would suggest that, yes, perhaps. I cannot
8 say.
9 MR SHELDON: On 26th July when you came on the night shift
10 presumably a routine handover took place in the nurses'
11 office?
12 MRS QUINN: Yes.
13 MR SHELDON: Is it the case during the course of such
14 a handover that if there are child protection concerns
15 relating to any of the children on the ward, they will
16 be brought to the attention of the nurses coming on to
17 the shift?
18 MRS QUINN: Yes.
19 MR SHELDON: Is it right that during the course of that
20 handover, if there were relevant entries on it,
21 attention would be brought to the critical incident log?
22 MRS QUINN: Yes.
23 MR SHELDON: Do you remember reference being made to the
24 critical incident log when you came on duty, on shift
25 during the course of the handover on 26th July?
148
1 MRS QUINN: I do not recall that, no.
2 MR SHELDON: Can you recall whether you were told when you
3 came on shift during the course of that handover whether
4 there were concerns about Victoria of a child protection
5 nature?
6 MRS QUINN: Yes, I recall there were concerns re the burn
7 that (a) was it a burn self-inflicted or had it been
8 inflicted by somebody else, and (b) if it had been
9 self-inflicted, why was an 8-year old child left in
10 possession of a boiling kettle?
11 MR SHELDON: So during that handover it was indicated that
12 either this child had been deliberately scalded or she
13 had been the victim of some fairly sloppy care?
14 MRS QUINN: Yes.
15 MR SHELDON: So you would have been on the lookout as you
16 went on to the ward that day, and presumably would have
17 instructed your nurses to do the same, to be on the
18 lookout for evidence of abuse or things that might be
19 relevant to child protection?
20 MRS QUINN: Yes.
21 MR SHELDON: Can we turn to precisely what was said during
22 the course of that handover in relation to the scalding
23 and the hot water. I will need you to look at
24 paragraph 10 of your statement in order to do that.
25 You say in your statement:
149
1 "It was at this report [by which you mean the
2 handover] that I learned that Victoria had received
3 burns to her scalp. Ms Kouao (whom we understood to be
4 Victoria's mother) had stated at the time of admission
5 that Victoria had poured a kettle of boiling water over
6 her head to stop the itching ..."
7 Are you confident that whoever was conducting the
8 handover said those words, "poured a kettle of boiling
9 water over her head"?
10 MRS QUINN: As confident as I can be two years on and this
11 was actually written a year afterwards because this was
12 taken from my police statement.
13 MR SHELDON: I see. The reason I ask is it may be that
14 there has been a case of Chinese whispers about this and
15 I will explain what I mean. We heard yesterday from
16 Nurse Graham that she was told that Victoria had poured
17 a bowl of water over her head. You, however, are as
18 confident as you can be that the word "kettle" was used;
19 is that right?
20 MRS QUINN: Yes.
21 MR SHELDON: You are also as confident as you can be that
22 the word "boiling" was used in respect of the water.
23 MRS QUINN: As confident as I can be.
24 MR SHELDON: Can you remember the name of the nurse who told
25 you that?
150
1 MRS QUINN: No, as it says in my statement, I no longer
2 remember the name of the nurse who gave the report.
3 MR SHELDON: The reason that may be surprising is that as
4 far as I can tell -- and I am sure I will be corrected
5 by Mr Mason if I am wrong about this -- there is no
6 reference to the word "kettle" or even "boiling water"
7 in any of the contemporaneous notes.
8 Could I ask to you turn to page 54 of bundle 37,
9 first of all. We see there one of the child protection
10 forms written by Dr Forlee when Victoria was first
11 admitted. Do you recall ever having seen that form
12 before, first of all?
13 MRS QUINN: I cannot recall now seeing it, no. I am sure
14 I must have done.
15 MR SHELDON: We can see a sentence starting three lines down
16 that page in the handwritten section:
17 "Mum heard a scream and went to bathroom to find
18 Anna had scalded her face. Apparently she poured hot
19 water over her head to try and stop the itching."
20 I will not weary you or anybody else with the other
21 references in the notes to something similar. Sir, for
22 your note pages 244, 251 and 256 of the bundle all say
23 something similar.
24 No reference to a kettle and no reference to boiling
25 water. That is why I am asking you if you are sure that
|
