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Archived Transcript for 9 November 2001: Pages
1 to 50
1
1 Friday, 9th November 2001
2 (9.30 am)
3 THE CHAIRMAN: Good morning, ladies and gentlemen. Before
4 we start may I take the opportunity to correct something
5 I said yesterday which is that thinking I was being
6 super-efficient I said next Friday we would start at
7 9.30 and finish at 1 o'clock. In fact Friday is one of
8 the days where we start at 9 o'clock and finish at
9 1 o'clock. Thank you very much.
10 MR GARNHAM: Thank you, sir. Two matters before we begin
11 the evidence this morning, sir. First of all, I said
12 I would indicate the order of evidence this morning.
13 Our plan is to take the witnesses in the following
14 order: Pereira, Davidson, Ryan, Jennings, Norman,
15 Richardson and Alexander.
16 Sir, the second thing is Mr Mason has just raised
17 with me very helpfully that the two registrars from NMH
18 will be sitting in the public gallery and we have
19 checked the record and your direction yesterday was that
20 nurses from NMH not hear the evidence of others, and it
21 seems to us therefore that Mr Mason is right.
22 THE CHAIRMAN: Thank you.
23 MR GARNHAM: Can I then ask Mr Sheldon to take the first
24 witness.
25 THE CHAIRMAN: Thank you Mr Garnham. Mr Sheldon, thank you.
2
1 MR SHELDON: Thank you sir. Grace Pereira, please.
2 MRS GRACE PEREIRA (sworn)
3 MR SHELDON: Good morning Mrs Pereira.
4 MS PEREIRA: Good morning.
5 MR SHELDON: Could you confirm your full name.
6 MS PEREIRA: Grace Pereira.
7 MR SHELDON: And your current professional address.
8 MS PEREIRA: North Middlesex Hospital, Rainbow Ward.
9 MR SHELDON: I understand that you qualified as a nurse in
10 Kenya, is that right?
11 MS PEREIRA: Yes.
12 MR SHELDON: You nursed in Kenya for around about 27 years
13 before coming to the United Kingdom?
14 MS PEREIRA: Yes, something like that.
15 MR SHELDON: Between 1986 and 1990 you were the principal
16 tutor of the School of Nursing I take it in Nairobe, is
17 that right?
18 MS PEREIRA: No, outside Nairobe, Niare(?).
19 MR SHELDON: You were the Deputy Chief Nursing Officer at a
20 large hospital in Kenya between 1990 and 1997. You
21 arrived at the North Middlesex Hospital in 1998.
22 MS PEREIRA: Yes, in July.
23 MR SHELDON: I believe last year you completed your
24 registered sick children's medical course in the North
25 Middlesex Hospital?
3
1 MS PEREIRA: Yes.
2 MR SHELDON: You are still on Rainbow Ward now?
3 MS PEREIRA: Yes, I am.
4 MR SHELDON: As far as child protection matters are
5 concerned, I believe it is right you received some
6 training in child protection matters during the course
7 of your registered sick children's nursing course?
8 MS PEREIRA: Yes.
9 MR SHELDON: You did the two-day course run by the NMH this
10 year?
11 MS PEREIRA: Yes.
12 MR SHELDON: Is that the course run by Dr Rossiter?
13 MS PEREIRA: Yes.
14 MR SHELDON: So I would be right to say, would I, as of
15 mid-1999 in the time with which we are principally
16 concerned any child protection training you had received
17 you would have received in Kenya?
18 MS PEREIRA: Yes.
19 MR SHELDON: As you say in your statement, child abuse is
20 not a big problem in Kenya?
21 MS PEREIRA: It is not taken as a big problem.
22 MR SHELDON: Does that mean it does not feature particularly
23 heavily in the training of nurses in Kenya?
24 MS PEREIRA: It does not.
25 MR SHELDON: In mid-1999, when Victoria was on the ward, if
4
1 you observed something that you thought might be
2 relevant to child abuse or child protection, what did
3 you think you had to do about it?
4 MS PEREIRA: The first thing would be to tell the nurse in
5 charge, because I was the nurse in charge, and the other
6 thing is to record it somewhere. So that if she does
7 not remember to write it down, I have written it down
8 somewhere.
9 MR SHELDON: You say record it somewhere. Whereabouts?
10 MS PEREIRA: We had two different records that we kept. One
11 is the log that is kept at the foot of the patient so
12 that anybody can read it. But for child protection
13 issues we had to write in another folder which we keep
14 in the office and only the professionals can see it.
15 MR SHELDON: Is that what is known as the critical incident
16 log?
17 MS PEREIRA: Yes.
18 MR SHELDON: When you came on to the ward in 1998 were you
19 made aware of Child Protection Guidelines that were in
20 force at the time?
21 MS PEREIRA: Yes, but not in a lot of detail.
22 MR SHELDON: I see. But you were aware of the obligation
23 contained within those guidelines to record matters that
24 might be relevant to the child protection?
25 MS PEREIRA: Yes.
5
1 MR SHELDON: I think as you made clear in one of your
2 previous answers just now, the fact that you told
3 a senior nurse or a doctor about those concerns did not
4 remove the obligation on you to also make a note of
5 them?
6 MS PEREIRA: No.
7 MR SHELDON: Let us turn firstly to 26th July and the first
8 encounter you say you had with Victoria. You were on
9 the night shift of 26th/27th July, is that right?
10 MS PEREIRA: Yes, and I think I was on night also on the --
11 I had a bit of confusion with my dates when I wrote the
12 statement.
13 MR SHELDON: Let us try and clear that up first of all.
14 When you wrote your statement presumably you had a look
15 at the Notes.
16 MS PEREIRA: Yes.
17 MR SHELDON: You used the notes to guide you as to when you
18 were on duty?
19 MS PEREIRA: Yes.
20 MR SHELDON: Perhaps you could be shown volume 37, please,
21 page 275, thanks.
22 Now that, Mrs Pereira, is a copy of the
23 communication/critical incident log sheet.
24 MS PEREIRA: Yes.
25 MR SHELDON: Is the first entry on that sheet in your
6
1 handwriting?
2 MS PEREIRA: Yes it is.
3 MR SHELDON: That is an entry dated 25th July 1999, is that
4 right?
5 MS PEREIRA: Yes.
6 MR SHELDON: Is that an indication that you were on duty on
7 25th July 1999?
8 MS PEREIRA: Yes, I was on night.
9 MR SHELDON: Glancing through that entry, you record there,
10 do you not, a visit to Victoria by mother and
11 a gentleman at about 10.30 and what you thought was
12 a master/servant attitude being observed between the
13 mother and the daughter.
14 MS PEREIRA: Yes.
15 MR SHELDON: That is also what you describe as happening in
16 your statement on 26th July. Are you saying that it
17 happened twice?
18 MS PEREIRA: It might have happened twice because on both
19 days -- I remember -- it might have happened twice but
20 the vivid -- the one I can remember vividly is when
21 I asked the doctor to go and see what was happening.
22 MR SHELDON: And which one was that?
23 MS PEREIRA: I think it was on the 25th.
24 MR SHELDON: So the incident that you recorded in the
25 critical incident log was the occasion on which you
7
1 asked the doctor to go and see Victoria and make up his
2 own mind about her injuries?
3 MS PEREIRA: I think so.
4 MR SHELDON: Because in your statement you say in
5 paragraph 21 that it was the incident of the 26th July
6 that prompted you informing Dr Reynders and him coming
7 to look at Victoria.
8 MS PEREIRA: I might be confused about the dates, the 25th
9 or the 26th, but the fact is that what I wrote in this
10 log is what I saw happening.
11 MR SHELDON: Is the more likely explanation not this: that
12 there was one incident, the incident you recorded in the
13 critical incident log, but in fact that took place on
14 25th July rather than 26th July as you have recorded in
15 your statement?
16 MS PEREIRA: Maybe.
17 MR SHELDON: So you think you may be mistaken about the date
18 in your statement?
19 MS PEREIRA: The 25th I am not mistaken because I wrote this
20 date.
21 MR SHELDON: Yes.
22 MS PEREIRA: What actually confused me is when you are
23 looking after a patient you go over two dates if you are
24 on night. You start on the 25th and you go to the 26th
25 because you go on up to the next morning.
8
1 MR SHELDON: I understand that but I just need to understand
2 what your evidence is about this point. You have
3 a clear recollection of one incident when you bathed
4 Victoria, saw marks on her body, then subsequently
5 observed a visit by her mother at which a master/servant
6 relationship was displayed; yes?
7 MS PEREIRA: That is what I am saying, that it may not be
8 the same day that I bathed Anna -- I mean Victoria, and
9 saw the mother -- I mean the mother interacting with
10 her.
11 MR SHELDON: I see. So are you saying that there was one
12 occasion that you bathed, one occasion that you saw the
13 interaction in a master/servant way, they may have
14 happened on the same night or they may not?
15 MS PEREIRA: They likely to have happened on two different
16 nights.
17 MR SHELDON: Can you say which happened on which night?
18 MS PEREIRA: I think the master/servant relationship
19 happened on one night and I bathed her on the next
20 night.
21 MR SHELDON: I see. So in that case master/servant
22 relationship on 25th July, bathing on the 26th?
23 MS PEREIRA: Yes.
24 MR SHELDON: So when you say the master/servant relationship
25 happened on the 26th in your statement, that is
9
1 a mistake?
2 MS PEREIRA: Wrong, yes.
3 MR SHELDON: That is strange one might think given that that
4 is exactly the same mistake that Isobel Quinn made in
5 her statement, coincidentally. Now did you read her
6 statement before you wrote yours?
7 MS PEREIRA: No, I did not --
8 MR SHELDON: Are you aware of whether she read yours before
9 she wrote hers?
10 MS PEREIRA: No, she has been living in Ireland and I never
11 saw her statement.
12 MR SHELDON: So if it is a mistake you made about the date
13 of the master/servant relationship and you bringing that
14 to Nurse Quinn's attention, then it is just
15 a coincidence that you made the same mistake in your two
16 statements, is it?
17 MS PEREIRA: I did not speak to Isobel when I worked with
18 her about this case and until -- just recently when
19 I saw her statement, after I had written mine.
20 MR SHELDON: Did you read the ward allocation book to find
21 out when you were on duty before you made your statement
22 or did you look solely at the notes?
23 MS PEREIRA: I looked at the notes but I have also looked at
24 the allocation, afterwards, after I wrote my statement.
25 MR SHELDON: And you are confident you were on duty on both
10
1 25th and 26th July?
2 MS PEREIRA: Yes.
3 MR SHELDON: Night shifts on both occasions?
4 MS PEREIRA: Yes.
5 MR SHELDON: Let us deal with the incident when you bathed
6 Victoria first of all, what you now think was the 26th.
7 In fact you thought it was the 26th all along.
8 MS PEREIRA: Yes.
9 MR SHELDON: You would have received a handover in the usual
10 way, is that right?
11 MS PEREIRA: Yes.
12 MR SHELDON: And you describe the course of that handover in
13 paragraph 10 of your statement.
14 MS PEREIRA: Yes.
15 MR SHELDON: You say about halfway down paragraph 10 that
16 during the course of that handover you were:
17 "... not aware of any specific child protection
18 issues, but from the staff on duty I got the impression
19 there was some doubt as to whether or not the burns on
20 her head were self-inflicted."
21 Is that right?
22 MS PEREIRA: Yes.
23 MR SHELDON: You say you were not aware of any specific
24 child protection issues but you had made a note in the
25 critical incident log the night before indicating that
11
1 the master and servant relationship had been observed in
2 relation to Victoria. So you must have been aware of
3 child protection issues, must you not?
4 MS PEREIRA: Yes, but because she had been admitted with
5 burns, she had been admitted with burns. I did not know
6 that -- I did not know specifically that there was
7 a case going on until that night because after the
8 report that is when I read her notes.
9 MR SHELDON: Well, the master/servant relationship incident
10 that you explain and expand on in your statement --
11 I will take you to paragraph 20 -- that is the incident
12 you now say happened on the 25th July and recorded in
13 the critical incident log, yes?
14 MS PEREIRA: Yes.
15 MR SHELDON: Look what happened, according to you, when you
16 draw that relationship to the attention of the nurse in
17 charge and the doctor, paragraph 20. First of all --
18 MS PEREIRA: I do not have what you are referring to --
19 MR SHELDON: You do not have your statement in front of you.
20 I am extremely sorry, that is my fault. You should have
21 it. Firstly, check that that is your statement.
22 MS PEREIRA: Yes it is.
23 MR SHELDON: Are you happy the facts in it are true?
24 MS PEREIRA: Yes.
25 MR SHELDON: With the exception of the amendment that you
12
1 now make?
2 MS PEREIRA: The dates, yes.
3 MR SHELDON: Turn to paragraph 21 of it, please. Here you
4 are describing the incident of master/servant
5 relationship and you say that as you were explaining the
6 situation to Sister, Dr Reynders the paediatric SHO came
7 in.
8 "I explained to him about the injuries I had seen on
9 Victoria's body and how she and Ms Kouao did not have
10 a normal mother/child relationship. Dr Reynders told me
11 they were going to have photographs taken the next day.
12 I said that I would like him to observe what was going
13 on."
14 And in subsequent paragraphs you explain he did
15 observe and eventually said that he would do a drawing.
16 MS PEREIRA: Yes.
17 MR SHELDON: When do you say that conversation with
18 Dr Reynders took place?
19 MS PEREIRA: On the 26th.
20 MR SHELDON: But that conversation was prompted by your
21 concerns recorded in paragraph 20 of your statement that
22 you have seen a master/servant relationship between
23 Victoria and her mother, and that you say was something
24 you observed on the 25th. Can you account for that?
25 MS PEREIRA: I cannot. Looking at this now I cannot.
13
1 MR SHELDON: You are clear though, are you, there are two
2 incidents: a bathing incident and a visiting incident?
3 MS PEREIRA: Yes. By the time I was telling Dr Reynders
4 about the relationship between the child and the mother,
5 I must have seen the injuries as well.
6 MR SHELDON: Well that would seem to be right, would it not,
7 because here you seem to be telling Dr Reynders not only
8 about the master/servant relationship but also about the
9 injuries you saw while bathing.
10 MS PEREIRA: Yes.
11 MR SHELDON: So that would seem to suggest that the
12 conversation with Dr Reynders happened after the bath.
13 If you cannot remember, you cannot remember.
14 MS PEREIRA: I cannot.
15 MR SHELDON: What I am concerned to understand is this. How
16 confident are you of your recollection of these events
17 when you wrote your statement?
18 MS PEREIRA: The recollection of seeing this lady talking to
19 Anna and seeing the injuries on Anna I am sure I saw
20 them. I am very sure.
21 MR SHELDON: So you can be sure that you saw Anna's mother
22 talking to her on one occasion and you can be sure that
23 you bathed Anna on one occasion?
24 MS PEREIRA: Yes.
25 MR SHELDON: But aside from that the details are a bit hazy?
14
1 MS PEREIRA: They are.
2 MR SHELDON: Who you told and when and dates you are not
3 confident about?
4 MS PEREIRA: Who I told I am confident.
5 MR SHELDON: But when?
6 MS PEREIRA: When is the question.
7 MR SHELDON: Let us deal with the bathing incident first of
8 all. You received your handover as you say and Victoria
9 is one of the five or six children allocated to you on
10 the night in question, is that right?
11 MS PEREIRA: Yes.
12 MR SHELDON: One of the first things that you had to do was
13 persuade her to have a bath, is that right?
14 MS PEREIRA: Yes.
15 MR SHELDON: You came on duty at 7.30?
16 MS PEREIRA: Yes.
17 MR SHELDON: Do you recall how long after coming on duty you
18 gave her that bath?
19 MS PEREIRA: We normally stay in the handover for about
20 20 minutes, then you go around from patient to patient
21 for maybe another 10 minutes, then we go to the office
22 for the allocation and specific instructions from the
23 person in charge, saying, "The patients, you are looking
24 after are so and so and you need to do this, you need to
25 do the other one". He points out the most important
15
1 things. So that would have been about 8/8.30 maybe.
2 MR SHELDON: Is it usual to give children baths at 8.30 or
3 later at night?
4 MS PEREIRA: It depends on the condition of the patient.
5 MR SHELDON: Was there anything particular about Victoria's
6 condition that made a bath particularly necessary?
7 MS PEREIRA: Yes, because of her burns.
8 MR SHELDON: I see. So it was not that she was dirty, it
9 was that you had to wash her burns?
10 MS PEREIRA: No, you do not wash a child because they are
11 dirty unless they make themselves so dirty during the
12 day you have to wash them.
13 MR SHELDON: Because we can see from the notes at page 261
14 in volume 37 that Anna, as she is called there, had had
15 a bath at lunchtime on the same day, the 26th, but she
16 needed another one because of her burns, is that right?
17 MS PEREIRA: Yes.
18 MR SHELDON: Prior to giving her this bath, lifting up her
19 dress and what you describe as the nightmare of her
20 injuries starting, you had no idea that this little girl
21 to whom you were allocated was covered in injuries, is
22 that right?
23 MS PEREIRA: I was not.
24 MR SHELDON: You had not been told that she had had a bath
25 earlier on that day and that a large number of
16
1 suspicious injuries had been found on her body?
2 MS PEREIRA: I cannot remember specifically hearing that.
3 MR SHELDON: You have a handover as you have described in
4 the nurses' office before you come on shift and is one
5 of the things that is covered in that handover whether
6 or not there are any child protection concerns about one
7 of the children you are going to be looking after?
8 MS PEREIRA: Yes.
9 MR SHELDON: If earlier that day on the shift being handed
10 over to you one of the children you had looked after had
11 been given a bath and had been found to be covered in
12 injuries, would you have expected to have been told that
13 at the handover?
14 MS PEREIRA: Yes.
15 MR SHELDON: If those injuries had caused sufficient concern
16 that a nurse and senior doctor had come along and looked
17 at them and documented them, you would have expected to
18 been told that, yes?
19 MS PEREIRA: Yes.
20 MR SHELDON: So you should not have been taken by surprise
21 when you lifted up Victoria's dress to see all these
22 injuries, should you?
23 MS PEREIRA: I would be because if you hear of an injury and
24 you have not seen, it and you have not seen the extent
25 of it, it makes a lot of difference when you see it
17
1 yourself.
2 MR SHELDON: We have heard evidence yesterday from a nurse
3 called Noelle O'Boyce that she bathed Victoria at
4 lunchtime with Clare Watling. She saw injuries all over
5 her body. She told Nurse Norman and Dr Reynders, who
6 was going to do some pictures of them. You came on duty
7 some hours after that and you heard nothing about this,
8 is that right?
9 MS PEREIRA: I cannot remember hearing. Specific injuries,
10 I cannot remember.
11 MR SHELDON: Can we take it that you heard nothing about it
12 from the fact that you say in paragraph 10 that when you
13 started your shift you were aware of no specific child
14 protection issues?
15 MS PEREIRA: Yes.
16 MR SHELDON: So despite the fact that there had been a very
17 serious child protection issue identified on the ward on
18 26th July at lunchtime, you when you came on the ward at
19 7 o'clock were told nothing about it?
20 MS PEREIRA: Maybe what I should say is the statement I have
21 written there, this was about a year afterwards. I am
22 trying to think back. You know what I mean?
23 MR SHELDON: I can well understand the difficulties in
24 recollecting details.
25 MS PEREIRA: The recollection of all that time which had
18
1 passed. I might have forgotten some things.
2 MR SHELDON: You understand the difficulty we have is what
3 weight we place on what you have said in your statement?
4 MS PEREIRA: Yes.
5 MR SHELDON: Do you think it is possible, looking back now,
6 can you be sure, whether you were told that these
7 injuries had been identified earlier on that day?
8 MS PEREIRA: I may have been told but not in the details
9 that I described them.
10 MR SHELDON: You had not looked at Victoria's notes that day
11 before you started to look after her, you did not have
12 time?
13 MS PEREIRA: No, I did not have time.
14 MR SHELDON: So would it be right to say that as far as you
15 were aware, when you put Victoria in the bath, you were
16 the first person to see those marks?
17 MS PEREIRA: When I put her in the bath I was the first
18 person?
19 MR SHELDON: Yes. Is that what you thought, "I am the first
20 person to see this"?
21 MS PEREIRA: Yes.
22 MR SHELDON: Did you ask her how she came by those marks?
23 MS PEREIRA: I did.
24 MR SHELDON: What did she say?
25 MS PEREIRA: She was saying just the word "scabies".
19
1 MR SHELDON: You noticed many scars on her body you thought
2 were indicative of non-accidental injury, is that right?
3 MS PEREIRA: Yes.
4 MR SHELDON: You saw marks you thought had been caused by
5 both ends of a belt, the buckle end and the other end?
6 MS PEREIRA: Yes.
7 MR SHELDON: You saw what you thought was a bite mark?
8 MS PEREIRA: Yes.
9 MR SHELDON: And you concluded that this child had been
10 physically abused, did you not?
11 MS PEREIRA: Yes.
12 MR SHELDON: And you came to that conclusion whilst she was
13 sitting in front of you in the bath and you were
14 examining her body. Is that correct?
15 MS PEREIRA: Yes.
16 MR SHELDON: It is right to say you did nothing about that
17 immediately, is it not? You put Victoria to bed first
18 of all?
19 MS PEREIRA: I finished with the bath and then I reported to
20 the nurse in charge.
21 MR SHELDON: Did you put Victoria to bed before you reported
22 them to the nurse in charge or did you go and get the
23 nurse in charge while Victoria was still in the bath?
24 MS PEREIRA: I cannot exactly remember but it would be more
25 normal for me to call her while she is in the bath to
20
1 show her the injuries. That would be the thing one
2 would do unless it is a very small child you cannot
3 leave in the bath alone. You would leave her and go and
4 call somebody to see.
5 MR SHELDON: That is what you would normally do, so in the
6 absence of any direct recollection that is the best
7 guess of what you did do?
8 MS PEREIRA: Yes.
9 MR SHELDON: Have a look at your statement, paragraph 15.
10 You say there at the end of the bath, or whilst the bath
11 was going on, that:
12 "I concluded that she had been physically abused.
13 I helped her to finish her bath, dressed her and put her
14 to bed with a drink. She went to sleep.
15 "I then went to carry out some other duties."
16 And the rest of your statement indicates it was only
17 after you observed the master/servant relationship that
18 you informed the doctor. It seems to suggest from there
19 you did not inform a nurse or a doctor while she was
20 still in the bath, does it not?
21 MS PEREIRA: It seems like that.
22 MR SHELDON: It seems you put her to bed first, went and did
23 some other duties, then later that evening informed a
24 nurse and a doctor.
25 MS PEREIRA: Yes.
21
1 MR SHELDON: Which do you think is right, your evidence now
2 or your evidence in the statement?
3 MS PEREIRA: I think I do not know.
4 MR SHELDON: Did you not think it was important, whenever
5 you informed the doctor or the nurse, to make a record
6 of what you saw on Victoria's body?
7 MS PEREIRA: I knew it was important and when I talked to
8 Dr Reynders he said he was going to put it on the body
9 map.
10 MR SHELDON: So you spoke to Dr Reynders the night of the
11 bath?
12 MS PEREIRA: Pardon?
13 MR SHELDON: You spoke to Dr Reynders the night of the bath
14 rather than the night of the master/servant
15 relationship?
16 MS PEREIRA: I do not know.
17 MR SHELDON: Because you give quite a detailed account of
18 your interaction with Dr Reynders on the night of the
19 master/servant relationship incident because you say you
20 specifically got him to come and have a look at the way
21 in which they were interacting with each other and you
22 go into some detail about this in your statement. So
23 that would seem to suggest that it was on the night of
24 the master/servant relationship visit that you have
25 recorded on the 25th that you spoke to Dr Reynders. Are
22
1 you saying you also spoke to him the night of the bath
2 on the 26th? If you cannot remember Miss Pereira, you
3 cannot remember.
4 MS PEREIRA: I cannot.
5 MR SHELDON: You are confident, are you, that you told
6 somebody, though, about the marks on the body that you
7 saw whilst you were bathing Victoria?
8 MS PEREIRA: Yes.
9 MR SHELDON: Can you remember who?
10 MS PEREIRA: The nurse in charge and the next morning we
11 talked about it to the other nurses when they came on
12 duty.
13 MR SHELDON: Why did you not note them down?
14 MS PEREIRA: I do not know why I did not write it down but
15 I wrote in my notes she was sore -- I did not write the
16 specific things I saw on her but I wrote she was sore
17 all over.
18 MR SHELDON: You have just seen some marks, you think for
19 the first time anybody has observed these: belt buckles,
20 belt ends and a bite mark on a child. Why do you not
21 note them down? That is what the critical incident log
22 is for, is it not?
23 MS PEREIRA: Yes. I think by -- you know, because I was
24 a junior staff nurse in the ward by that time, and this
25 is a case where I was told, by the time I reported to
23
1 Isobel and the doctor I was told that this is a case for
2 non-accidental injury and there is a folder in
3 Dr Rossiter's office with all the details. So when
4 I reported this, I expect this will -- I did not know
5 I had to write it down word for word. Now I know you
6 have to write down these issues but by then I did not
7 know you had to write down these things in detail.
8 MR SHELDON: You say you are a junior staff nurse
9 Miss Pereira but you have been nursing for 30 years.
10 MS PEREIRA: But the non-accidental issues were completely
11 new to me.
12 MR SHELDON: You are one of the senior nurses in your
13 country.
14 MS PEREIRA: Yes.
15 MR SHELDON: You have seen bite marks and evidence of
16 a person beaten with a belt and the only thing we have
17 from you from that incident is a note on page 262: "Anna
18 bathed, head shampooed, sore all over body". That is
19 it.
20 MS PEREIRA: I handed over this information to somebody.
21 I specifically said where the injuries were and I said
22 what kind of injuries these were. I handed over to
23 somebody, I did not just keep quiet.
24 MR SHELDON: But you said at the beginning of your evidence
25 you fully understood even at July 1999 that the fact you
24
1 passed on your knowledge to somebody else did not remove
2 the obligation to write them down. Do you remember
3 saying that?
4 MS PEREIRA: Yes.
5 MR SHELDON: And we have nothing in the notes, do we, about
6 the nightmare you say you endured when you saw
7 Victoria's body, do we?
8 MS PEREIRA: No.
9 MR SHELDON: And whoever you told about this bite mark and
10 these belt buckle marks, they did not write it down
11 either, did they?
12 MS PEREIRA: No.
13 MR SHELDON: You say in paragraph 13 of your statement that
14 you were sure, and you have some experience of this,
15 that Victoria did not have scabies at the time you were
16 bathing her. Is that right?
17 MS PEREIRA: Yes.
18 MR SHELDON: But you were aware at the time, and this I take
19 from paragraph 10 of your statement, that she was being
20 barrier-nursed on the ward because of fears she had
21 scabies and might be contagious, is that right?
22 MS PEREIRA: Yes.
23 MR SHELDON: Presumably a nurse or a ward would not
24 barrier-nurse a child unless it was thought necessary,
25 is that correct?
25
1 MS PEREIRA: Yes.
2 MR SHELDON: Is that because firstly it is extra work that
3 would not be needed and presumably it is unpleasant for
4 the child as well?
5 MS PEREIRA: Yes.
6 MR SHELDON: Did you tell anybody that Victoria was being
7 barrier-nursed unnecessarily?
8 MS PEREIRA: Yes, I said that I do not think she has scabies
9 and I cannot remember who it was but somebody said
10 Dr Mann was coming to review her to check whether she
11 was scabies or not. So I would not have removed her --
12 I would not have said definitely she does not have
13 scabies and taken out of isolation, it had to be the
14 decision of the doctor.
15 MR SHELDON: But you did pass on your concerns about the
16 diagnosis to somebody else?
17 MS PEREIRA: Yes, I did.
18 MR SHELDON: And your concerns were met by the fact that
19 there was a consultant dermatologist on the way?
20 MS PEREIRA: Yes.
21 MR SHELDON: You do not note your concerns about the
22 diagnosis anywhere, do you?
23 MS PEREIRA: No. I would not do that. I could say it but
24 the diagnosis is made by doctors, so if I have any
25 suggestion, I cannot put it in writing, I do not think,
26
1 this, because I am not an expert in that field. It is
2 just my opinion.
3 MR SHELDON: You say in the note that you did make, and the
4 note that we have read already on page 262, that when
5 you bathed Anna she was sore all over her body.
6 MS PEREIRA: Yes.
7 MR SHELDON: Did you form a view as to what was the cause of
8 the soreness?
9 MS PEREIRA: Yes.
10 MR SHELDON: What did you think it was?
11 MS PEREIRA: The non-accidental injuries.
12 MR SHELDON: I see. You did not get the impression that she
13 felt irritation with her skin?
14 MS PEREIRA: No, because when I touched her skin it felt
15 like there were -- she had been -- like if you are
16 banged with something and the outside looks okay but
17 when you touch it it is hard inside and sore.
18 MR SHELDON: There is some suggestion that perhaps Victoria
19 had been overtreated with a cream called Derbac and that
20 overtreatment irritated her skin. Did you see evidence
21 of that?
22 MS PEREIRA: It did not look like that.
23 MR SHELDON: How confident are you that what you saw on
24 Victoria's body whilst you were giving her a bath was
25 a bite mark?
27
1 MS PEREIRA: It looked like a bite mark to me because there
2 were two lines of -- it looked like a bite mark and when
3 I saw it in the court it still looked to me like a bite
4 mark in the picture.
5 MR SHELDON: Have you received any training in the
6 identification of injuries?
7 MS PEREIRA: No.
8 MR SHELDON: And identifying their causes?
9 MS PEREIRA: No.
10 MR SHELDON: Sir, I do not propose to take Mrs Pereira to it
11 but we do have a statement from Mr Lewin, a forensic
12 scientist, in volume 7 of the green files, page 96.104.
13 Mrs Pereira, we have received a statement from
14 a forensic scientist who said there were no bite marks
15 on Victoria's body. That is why I ask you are you
16 confident what you saw was a bite mark?
17 MS PEREIRA: I do not say I am sure, I say it looked like
18 a bite mark. Because it looked like a bite mark, looked
19 like the buckle of the belt -- I would not say
20 specifically it is a bite mark unless I have seen
21 somebody bite her. I say it looks like a bite mark.
22 MR SHELDON: But you would say your recollection and your
23 expertise of this particular field is not sufficient to
24 disagree with a forensic scientist?
25 MS PEREIRA: No, it is not. I cannot, I cannot disagree
28
1 with him.
2 MR SHELDON: Let us move on to the visit you observed from
3 Ms Kouao and a man. The man you identified at the trial
4 as Mr Manning, is that right?
5 MS PEREIRA: Yes.
6 MR SHELDON: You saw them sitting in the cubicle with
7 Victoria standing in front of them to attention, is that
8 right?
9 MS PEREIRA: Yes.
10 MR SHELDON: You could see that Victoria was very scared of
11 Ms Kouao?
12 MS PEREIRA: Yes.
13 MR SHELDON: And you had some conversation with Ms Kouao
14 about her children, is that right?
15 MS PEREIRA: Yes.
16 MR SHELDON: She tried to get out of washing Victoria's
17 clothes, from what you say in your statement.
18 MS PEREIRA: When we discussed about clothes, because
19 I looked in her locker, she did not have clean clothes
20 to wear, so I put her into a hospital gown. The clothes
21 I removed from her, I asked her if she could take them
22 home to wash them and she said she would not.
23 MR SHELDON: She said she would not, firstly she could not
24 because of the scabies, yes?
25 MS PEREIRA: She did not say because of the scabies.
29
1 MR SHELDON: Let us have a look at your statement.
2 Paragraph 19:
3 "I asked Ms Kouao if she would like to take them
4 home and wash them. She said no."
5 Oh, sorry: "I explained that we could not wash them
6 with the other children's clothes because of the skin
7 condition."
8 She denied they were hers at all.
9 MS PEREIRA: Yes, she said, "These clothes are not hers and
10 I would know my child's clothes if I saw them, so they
11 are not hers".
12 MR SHELDON: Is it fair to say you did not like Ms Kouao
13 very much from what you saw of her?
14 MS PEREIRA: When I first saw her she looked like a likeable
15 person but the way she was treating this child I did not
16 like her.
17 MR SHELDON: Did you challenge her about the marks that you
18 had seen on Victoria's body, if you had seen any marks
19 by that stage?
20 MS PEREIRA: I would not have done that.
21 MR SHELDON: Had you seen any marks on Victoria's body by
22 the time you saw Ms Kouao?
23 MS PEREIRA: I cannot remember because this is not something
24 I would discuss with a patient. I mean with a parent.
25 MR SHELDON: Certainly. Maybe it is something you would not
30
1 discuss with them but can you remember at the time when
2 you were speaking to Ms Kouao you were aware that on
3 Victoria's body there were belt buckle marks and bite
4 mark potentially? Can you remember whether that was
5 going through your mind?
6 MS PEREIRA: I do not think so.
7 MR SHELDON: Because that might be --
8 MS PEREIRA: I am not sure about that.
9 MR SHELDON: You watched them together and you saw what you
10 regarded to be a master/servant relationship, is that
11 right?
12 MS PEREIRA: Yes.
13 MR SHELDON: That they did not seem to be mother and child?
14 MS PEREIRA: They did not look to me like mother and child.
15 MR SHELDON: Did Ms Kouao seem to be telling Victoria off,
16 as far as you could see?
17 MS PEREIRA: I cannot say that because they were talking in
18 a different language but the way she was talking to her
19 is like she was -- she did not look like a way a child
20 would be talking to her mum.
21 MR SHELDON: You were not able to discern what they were
22 saying to each other though?
23 MS PEREIRA: No, it was in French.
24 MR SHELDON: So you were not able to determine for example
25 whether Ms Kouao was telling Victoria off for wetting
31
1 the bed? You could not say?
2 MS PEREIRA: She might have been telling her off or telling
3 her to be a good girl or whatever but it did not look
4 like -- it did not.
5 MR SHELDON: You thought they may have been from different
6 tribes, is that right?
7 MS PEREIRA: They looked so different from each other.
8 MR SHELDON: It would be possible though in your experience
9 for a child to have a slightly different skin tone to
10 its mother and still be mother and daughter?
11 MS PEREIRA: Yes, but they would not be so different.
12 MR SHELDON: I see. How strong were your suspicions that
13 they were not related?
14 MS PEREIRA: I felt -- I do not know why but somehow
15 I strongly felt that this child was not this woman's
16 child.
17 MR SHELDON: I see. And you were so concerned that you went
18 and got Dr Reynders and asked him to come back and have
19 a look as well, is that right?
20 MS PEREIRA: Not to prove they were not mother and child but
21 to prove the way they were interacting was not okay.
22 MR SHELDON: Yes. And when you went back into the room with
23 Ms Kouao you observed Victoria jump out the bed, throw
24 off her blanket and stand to attention, is that right?
25 MS PEREIRA: Yes.
32
1 MR SHELDON: This is the incident you made a note of in the
2 critical incident log at page 275 that we have already
3 seen, is that right?
4 MS PEREIRA: Yes.
5 MR SHELDON: Dated 25th July 1999?
6 MS PEREIRA: Yes.
7 MR SHELDON: Are you happy that is a full and accurate
8 record of what you saw?
9 MS PEREIRA: It is a good record of what I saw.
10 MR SHELDON: Dr Reynders said that he would make a drawing,
11 you say in your statement, as a result of the
12 conversation about the marks. You cannot be sure about
13 that now, can you?
14 MS PEREIRA: I am sure that I told Dr -- I am sure about
15 somebody saying they are going to put the marks on the
16 body map.
17 MR SHELDON: Have a look at paragraphs 23 and 24 of your
18 statement. Here you are describing when you took
19 Dr Reynders back into the cubicle so he could see the
20 way Victoria and her mother were interacting.
21 Paragraph 24:
22 "Ms Kouao and Mr Manning then left and Victoria got
23 back into bed and covered herself with the blankets.
24 I spoke to Dr Reynders and he agreed that there was
25 something definitely wrong. He told me that he would do
33
1 a drawing to show the scars."
2 Now I took it from your previous answers that on the
3 25th July when this incident happened the scars had not
4 been identified by you at least, is that right?
5 MS PEREIRA: Yes.
6 MR SHELDON: So Dr Reynders could not have said what you say
7 he had said in paragraph 24 of your statement, can he,
8 on the 25th?
9 MS PEREIRA: I remember him saying that maybe -- I do not
10 know.
11 MR SHELDON: Could you be shown volume 46, please, page 165.
12 This is the statement that you made to the Crown
13 Prosecution Service in preparation of the criminal
14 trial. You explain towards the bottom of that page that
15 you wanted the doctor -- three lines up -- to take
16 a note of what was happening.
17 "... so I asked the mother to go back to Anna who
18 had got into bed and covered her head, to ask her what
19 she wanted to be brought the next day. We followed her
20 to the room and as soon as she called Anna's name she
21 jumped out of bed and stood to attention. Both me and
22 the doctor wrote this down in the notes."
23 Do you remember saying that?
24 MS PEREIRA: Yes.
25 MR SHELDON: We have seen where you wrote it down in the
34
1 notes in the critical incident log. Where did the
2 doctor write it down?
3 MS PEREIRA: I do not know.
4 MR SHELDON: But you said here he did write it down so you
5 must have seen him write it down.
6 MS PEREIRA: I did not see him writing it down but
7 I remember him saying he was going to write it down.
8 MR SHELDON: That is not what you say here. You say you saw
9 him write it down.
10 MS PEREIRA: I did not see him write.
11 MR SHELDON: It is important that we understand,
12 Mrs Pereira, exactly what you are sure you remember.
13 MS PEREIRA: Yes.
14 MR SHELDON: You are sure that you bathed Victoria, is that
15 right?
16 MS PEREIRA: Yes.
17 MR SHELDON: You are sure that you saw marks on her body of
18 the type you have described?
19 MS PEREIRA: Yes, and I am sure she is sore, not just the
20 marks I saw, her body was sore as well.
21 MR SHELDON: You are sure those marks were as such as to
22 cause you significant concern?
23 MS PEREIRA: Yes.
24 MR SHELDON: And you are sure you made no note of those
25 marks whatsoever?
35
1 MS PEREIRA: Yes.
2 MR SHELDON: Remind us of why that was.
3 MS PEREIRA: Because I reported them to the nurse in charge.
4 MR SHELDON: You are sure about that?
5 MS PEREIRA: Yes.
6 MR SHELDON: You are not sure that you reported them to the
7 doctor?
8 MS PEREIRA: When you asked it so many times, so many times,
9 I kind of think now maybe I did not. Because you have
10 asked so many times I feel maybe I did not. Thinking
11 about it I know I did but when you ask it so many times
12 I feel maybe I did not then. But I remember talking
13 about them to the doctor and I remember him saying they
14 are going to do pictures of the child and I remember
15 telling the doctor, "The lady is there now if you would
16 like to go and get a consent from her for the pictures".
17 So I knew these marks I am talking about were going to
18 be pictured, they are going to be put on the body map.
19 I do not know. I am sure about those things I am saying
20 now.
21 MR SHELDON: You are sure you spoke to the doctor about the
22 injuries?
23 MS PEREIRA: I am sure I did.
24 MR SHELDON: On what occasion?
25 MS PEREIRA: The occasion is what I am telling you, I am
36
1 confused about those dates, but I know I talked to the
2 doctor about it. I did not just keep it quiet. And we
3 discussed it between me and the nurse who was in charge
4 and the doctor.
5 MR SHELDON: Are you now confident in your recollection that
6 what you described as one day in your notes, in your
7 statement to this Inquiry, was in fact two days,
8 a bathing day and an observing visit day?
9 MS PEREIRA: Most probably.
10 MR SHELDON: Most probably two?
11 MS PEREIRA: Yes.
12 MR SHELDON: And the observing visit day was the first one,
13 the 25th, which you have noted in the critical incident
14 log; yes?
15 MS PEREIRA: Yes.
16 MR SHELDON: And the bathing day was the 26th because we
17 have your note of the 26th --
18 MS PEREIRA: Maybe I bathed her more than once. I do not
19 know now. I do not know.
20 MR SHELDON: Well, you understand that the matters we are
21 inquiring into are important, Mrs Pereira. It is
22 important that you try as hard as you can to remember
23 what you can. If you cannot remember then simply say
24 "I cannot remember".
25 MS PEREIRA: I cannot remember. What I am sure of is that
37
1 there is the incident of the mum talking to the child
2 and there was the incident of bathing where I saw the
3 injuries.
4 MR SHELDON: But where you are not clear is whether they
5 happened on two separate days or one day?
6 MS PEREIRA: Yes. I cannot remember that.
7 MR SHELDON: You accept on any view, do you not, that you
8 should have noted down the injuries that you saw on
9 Victoria's body when you bathed her?
10 MS PEREIRA: Knowing what I know now about child protection
11 I should have done that. I should have written that
12 down in detail like I did in my police statement.
13 MR SHELDON: You made your statement to this Inquiry after
14 the criminal trial, is that right?
15 MS PEREIRA: Yes.
16 MR SHELDON: After seeing the photographs of Victoria's
17 body?
18 MS PEREIRA: But the police statement I did before seeing
19 the pictures.
20 MR SHELDON: I am not asking you about the police statement
21 for the moment, I am asking about your statement to the
22 Inquiry. You made that after the criminal trial?
23 MS PEREIRA: Yes.
24 MR SHELDON: After you found out what happened to Victoria?
25 MS PEREIRA: Yes.
38
1 MR SHELDON: After you found out the person who you thought
2 was her mother had tortured her to death?
3 MS PEREIRA: Yes.
4 MR SHELDON: Is it possible that, in light of that
5 knowledge, you have attached rather more significance to
6 some of the things you record in your statement than you
7 thought at the time?
8 MS PEREIRA: In the first statement I was told to write
9 facts but these are the statements I was writing my
10 thoughts and what I concluded.
11 MR SHELDON: I am still not asking you about your CPS
12 statement. I am trying to understand whether what you
13 have put in your statement to this Inquiry has been
14 coloured or affected by what you now know happened to
15 Victoria after she left your hospital.
16 MS PEREIRA: No.
17 MR SHELDON: So the fact that you describe in your statement
18 that the injuries you saw on Victoria were such as to
19 make viewing them a nightmare for you, you felt it to be
20 a nightmare at the time, did you?
21 MS PEREIRA: Yes.
22 MR SHELDON: You were on the day shift on 1st August 1999,
23 is that right?
24 MS PEREIRA: Yes.
25 MR SHELDON: You have helpfully transcribed your note of
39
1 that occasion at paragraph 26 of your statement. In
2 summary it seems as if it was a good and uneventful day
3 on the ward, is that right?
4 MS PEREIRA: As far as I could remember.
5 MR SHELDON: Given the fact that on the previous occasion
6 that you had looked after Victoria you had seen these
7 horrific and deeply disturbing injuries, did you ask for
8 an update from anyone on the ward as to the child
9 protection issues surrounding her?
10 MS PEREIRA: Yes.
11 MR SHELDON: Who did you ask?
12 MS PEREIRA: I cannot remember the specific person.
13 MR SHELDON: What were you told?
14 MS PEREIRA: That the case is being handled by the social
15 services and the police are involved.
16 MR SHELDON: You were told on the 1st August 1999 that
17 social services and the police were involved.
18 MS PEREIRA: Yes.
19 MR SHELDON: Right. But you cannot remember by whom?
20 MS PEREIRA: No.
21 MR SHELDON: Were you told what if anything the police and
22 social services had done?
23 MS PEREIRA: No. This is -- during the report when we are
24 doing the handover they report these things. But
25 I cannot remember specifically.
40
1 MR SHELDON: You are sure you were told the police were
2 involved?
3 MS PEREIRA: Somewhere along the line I was told but
4 I cannot remember specifically whether it was the 1st or
5 which other day.
6 MR SHELDON: I see. At some point you were told that the
7 police were involved in Victoria's care but you are not
8 sure if it is the 1st?
9 MS PEREIRA: Yes, because even the dates you are not looking
10 after the patient you are still told of the things going
11 on.
12 MR SHELDON: You subsequently learned that Victoria had been
13 discharged from North Middlesex Hospital.
14 MS PEREIRA: Yes.
15 MR SHELDON: Can you remember when you first learned that?
16 MS PEREIRA: I cannot remember the exact date but it is when
17 I next came back to work.
18 MR SHELDON: What you can remember, according to your
19 statement at paragraph 29, is that you said:
20 "I hope she has not gone home with that woman
21 because that woman is going to kill that girl".
22 Did you say that?
23 MS PEREIRA: Yes.
24 MR SHELDON: Is the "that woman" in that sense whom we now
25 know to be Ms Kouao?
41
1 MS PEREIRA: Yes.
2 MR SHELDON: Who else did you think she might go home with?
3 MS PEREIRA: I was expecting from the injuries she had had
4 and the case having been taken over by the social
5 services that she would go into care, because I thought
6 she had been mistreated. So I did not expect her to go
7 home with that lady.
8 MR SHELDON: But you found out that she had?
9 MS PEREIRA: Yes.
10 MR SHELDON: Did you mean what you said there?
11 MS PEREIRA: I did.
12 MR SHELDON: What did do you about it?
13 MS PEREIRA: I asked her why did they let her go with her
14 and somebody said that the social services have done
15 a visit and they have -- they think it is all right and
16 Dr Rossiter was going to follow up the case and the case
17 is not closed.
18 MR SHELDON: Mrs Pereira, you are a nurse of enormous
19 experience and have held a number of extremely
20 responsible posts in Kenya.
21 MS PEREIRA: Yes.
22 MR SHELDON: You thought that this woman was going to kill
23 this child. What did do you about it?
24 MS PEREIRA: I asked the others what -- I mean, that is the
25 way I felt in my heart. I had also expressed that I did
42
1 not think she was the mother, she was treating her like
2 this child had come to her as a servant and still they
3 discharged the child to the woman. So I asked, why
4 would they let her go with her -- and everybody believes
5 she was mistreating her. Everybody believed on the ward
6 she was being mistreated and we believed because she
7 lived with her she was the one who was mistreating her.
8 So I was told the social services and the police are
9 involved and the case is not closed. So what else would
10 I have done, honestly?
11 MR SHELDON: Well, you thought that Victoria was going home
12 to a woman that was going to kill her and we know that
13 she did kill her. Did you phone social services and
14 tell them your concerns?
15 MS PEREIRA: I did not think it was in my place to do that.
16 MR SHELDON: Did you phone the police?
17 MS PEREIRA: The police were already involved in it and they
18 also knew these details.
19 MR SHELDON: But notwithstanding their involvement they let
20 her go back home with a woman you thought was going to
21 kill her.
22 MS PEREIRA: Yes, then I heard they had already investigated
23 and found she is fit to go back with her so I thought
24 maybe I was mistaken, because I did not have any
25 specific evidence to prove that she was not the mum and
43
1 that she was mistreating her. This was just based on
2 observations.
3 MR SHELDON: Of course when you wrote this paragraph 29 of
4 your statement you wrote it in the knowledge that in
5 fact she did kill her. Are you sure that that is what
6 you thought at the time, not what you have subsequently
7 come to think?
8 MS PEREIRA: I am sure I did.
9 MR SHELDON: I am not suggesting, for the purposes of this
10 question, Mrs Pereira, that you have made anything up in
11 your statement, but is it not possible that knowing what
12 you know, hearing the harrowing evidence you must have
13 heard at the trial and everything you have heard since,
14 that you have attached more significance to some of the
15 things you saw on the ward in 1999 than you did at the
16 time?
17 MS PEREIRA: I do not believe that.
18 MR SHELDON: And that you were not quite as concerned about
19 Victoria then as you say you are now?
20 MS PEREIRA: I was concerned but now I am more knowledgeable
21 what I should do if I am concerned than I was then.
22 MR SHELDON: Because that would provide an explanation,
23 would it not, for why you did not record the extremely
24 worrying marks you saw when you bathed her in the notes?
25 MS PEREIRA: Like I told you before, I thought because
44
1 I have handed them over to the nurse in charge and the
2 nurse in charge -- the nurses who are seen at the F and
3 G grades are the ones who go to the meetings for the
4 child protection issues. So having handed it over to
5 her and told her exactly what I thought about it,
6 I thought I was represented.
7 MR SHELDON: It would also explain, would it not, why you
8 did not follow up your concerns about Victoria after she
9 was discharged from the hospital?
10 MS PEREIRA: Yes, because I was told the police and the
11 social services have visited and they think she should
12 go back to her. So I thought maybe I was mistaken.
13 MR SHELDON: Yes. Thank you.
14 THE CHAIRMAN: Thank you Mr Sheldon. Mr Mason.
15 MR MASON: Thank you. Mrs Pereira can I first try and sort
16 out this question of the dates. I will just start by
17 working out who was on duty on what days. So can
18 I please do the easy bit which is take you to volume 37,
19 please, page 50. Hopefully you have the paediatric rota
20 of on-call for the month of August. Sorry, sir, it is
21 my mistake, it is page 49 of the July rota. If you look
22 down the left-hand column we have the dates and near the
23 bottom you have Sunday 25th.
24 MS PEREIRA: Yes.
25 MR MASON: And going across the column to 2 and 3 we have
45
1 two columns for SHOs on duty, one for A&E wards and one
2 for neonates, is that correct?
3 MS PEREIRA: Yes.
4 MR MASON: We see there on the 25th the SHO covering A&E and
5 wards was Dr Jackson.
6 MS PEREIRA: Yes.
7 MR MASON: And neonates is Dr Powell?
8 MS PEREIRA: Yes.
9 MR MASON: So it does not seem as if Dr Reynders was on duty
10 on the 25th, is that correct?
11 MS PEREIRA: Yes.
12 MR MASON: If you go down one column, Monday the 26th, we
13 see that Dr Reynders is the SHO covering the A&E
14 department and the wards.
15 MS PEREIRA: Yes.
16 MR MASON: So if you spoke to Dr Reynders about Victoria on
17 one of these two days, will it have been the 26th?
18 MS PEREIRA: Yes.
19 MR MASON: Thank you. Sir, I want now to take the witness
20 to the allocation book. It is infinitely easier for the
21 witness to read from the original which I understand is
22 being obtained.
23 MR SHELDON: It is being obtained as we speak, sir.
24 MR MASON: I will see how we go. Mrs Pereira, if you find
25 the photocopies hard to work out and if there is any
46
1 uncertainty, please say so and I will move on to another
2 topic while the original is being obtained.
3 Is the allocation book, is that the definitive list
4 of who is on duty and who is looking after which child
5 for any given day?
6 MS PEREIRA: Yes, the allocation book.
7 MR MASON: Can the witness please have the allocation book,
8 volume 38, page 161.503. Sir, if I may explain briefly,
9 there are a number of blanks. In the original
10 allocation book the witness is getting there are
11 a number of Post-Its and there are also a number of
12 green tags I will refer the witness to. They were put
13 in by me. The Post-Its for reason of confidentiality
14 and the green tags because I have marked every page
15 where --
16 THE CHAIRMAN: I think this may be the book if this is any
17 help. I noticed green tabs.
18 MR MASON: These were put in by me marking every page where
19 Victoria is mentioned. (Handed). It is a double-paged
20 book so the photocopies do -- page 503 and page 504 is
21 a double page and the lines go across. Mrs Pereira,
22 please look for Sunday 25th July.
23 MS PEREIRA: Got it.
24 MR MASON: Look on the left-hand side. Can you see where in
25 fact Victoria is named down as Anna Kouao --
47
1 MS PEREIRA: Yes.
2 MR MASON: -- which was the name she was known as whilst on
3 the ward. Then you have her age, then we have three
4 columns. Is that with the names of nurses?
5 MS PEREIRA: Yes.
6 MR MASON: Are those nurses who had been looking after her?
7 MS PEREIRA: Yes, the morning, Wednesday afternoon and the
8 night.
9 MR MASON: Is that the early shift, late shift and night
10 shift?
11 MS PEREIRA: Yes.
12 MR MASON: So the morning we have Millie, would that be
13 Millie Graham?
14 MS PEREIRA: Yes.
15 MR MASON: Regina, Regina Tsiagbe?
16 MS PEREIRA: Yes, because they work half days.
17 MR MASON: I will not trouble you with the afternoon because
18 I cannot read the photocopy. And in the evening she was
19 looked after by Lucy Hinds?
20 MS PEREIRA: The night, yes.
21 MR MASON: You were not looking after Victoria on that
22 evening?
23 MS PEREIRA: Yes.
24 MR MASON: Go to the far right of that page, sir, page 504.
25 There are three columns of names, the first column
48
1 starts with Sharon T -- sorry, the same page
2 Mrs Pereira, the 25th. It is just on the right-hand
3 side of the double page. You see three columns of
4 names, in fact the first two columns, is it Sharon T or
5 Sharon J?
6 MS PEREIRA: J.
7 MR MASON: And in the first and the third column it says
8 "Comfort".
9 MS PEREIRA: Yes.
10 MR MASON: Is that Comfort Boafoa?
11 MS PEREIRA: Yes.
12 MR MASON: Are these lists the lists of nurses on duty on
13 the ward for the early, late and evening shift?
14 MS PEREIRA: Yes.
15 MR MASON: But this list does not relate to any individual
16 patient. The individual patient list is what you see on
17 the left-hand page which is our 503?
18 MS PEREIRA: Yes.
19 MR MASON: Thank you. So we see for the evening shift the
20 nurses on duty were Comfort Boafoa, who should be the
21 nurse in charge on that shift?
22 MS PEREIRA: Yes.
23 MR MASON: And there is Lucy Hinds, Grace, is that you?
24 MS PEREIRA: Yes.
25 MR MASON: Then there is another somebody C.
49
1 MS PEREIRA: Sinead.
2 MR MASON: Sinead C. Are you the only Grace that works on
3 the ward? Is there another Grace?
4 MS PEREIRA: Yes, another Grace, Grace O.
5 MR MASON: Thank you. So we now know on the evening of the
6 25th you were on duty but not looking after Victoria?
7 MS PEREIRA: Yes.
8 MR MASON: Dr Reynders was not on duty?
9 MS PEREIRA: Yes.
10 MR MASON: And Isobel Quinn was not on duty?
11 MS PEREIRA: Yes.
12 MR MASON: Could you please turn over the page to the 26th,
13 and sir that is 506 and 507. Two-thirds of the way down
14 the page we have Anna Kouao again and the morning is
15 Clare and then we have your name as Grace. Do you see
16 the left-hand page? Have you found it? It is bay
17 number 8, I think. Have you seen Anna's name?
18 MS PEREIRA: Yes.
19 MR MASON: Well Victoria's name is Anna Kouao and in the
20 morning she had been looked after by Clare.
21 MS PEREIRA: Yes.
22 MR MASON: Is that Clare Watling?
23 MS PEREIRA: Yes.
24 MR MASON: Then we have you, Grace.
25 MS PEREIRA: This is -- I looked after her at night.
50
1 Grace O O -- they have not written down the night
2 nurses.
3 MR MASON: So that is Grace O, is it?
4 MS PEREIRA: Yes, but I looked after her at night on that
5 night.
6 MR MASON: If we look at the right-hand page sir, which is
7 507. In the column for nurses on duty we see that
8 Grace O appears in the morning and the afternoon shift.
9 MS PEREIRA: Yes.
10 MR MASON: And the evening shift we have Isobel,
11 Isobel Quinn?
12 MS PEREIRA: Yes.
13 MR MASON: She should be the nurse in charge of that shift?
14 MS PEREIRA: Yes.
15 MR MASON: And Comfort, Comfort Boafoa again, then Grace P.
16 MS PEREIRA: Yes.
17 MR MASON: And Lucy, would that be Lucy Hinds?
18 MS PEREIRA: Yes.
19 MR MASON: But you say you were actually looking after
20 Victoria that evening?
21 MS PEREIRA: Yes.
22 MR MASON: So we know on the evening of the 26th you are on
23 duty, Isobel Quinn is on duty and Dr Reynders is on
24 duty, is that correct?
25 MS PEREIRA: Yes.
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