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Archived Transcript for 12 November 2001: Pages 1 to 50
1
1 Monday, 12th November 2001
2 (10.00 am)
3 THE CHAIRMAN: Good morning Mr Garnham, ladies and
4 gentlemen. Mr Garnham, ladies and gentlemen, I need to
5 make a statement. After adjourning the proceedings of
6 the Inquiry last Friday afternoon I received a letter
7 addressed to me personally and marked for my attention
8 from the solicitor for Haringey Council. In that letter
9 it was suggested there was unevenness of treatment in
10 the Inquiry's approach to social workers and the staff
11 of other agencies. I was asked "to redress the
12 balance".
13 In my view that letter should never have been
14 written. I made it abundantly clear at the outset that
15 this Inquiry would be transacted in an open and
16 transparent manner. I regard any attempt by an
17 interested party to influence the conduct of this
18 Inquiry by means of private correspondence to me
19 personally to be wholly incompatible with such an
20 approach.
21 Let me therefore make the position plain for the
22 benefit of all those here. I will not enter into
23 personal correspondence concerning the conduct of this
24 Inquiry with any interested party or witness. I will
25 not tolerate any covert attempt to influence the way in
2
1 which the Inquiry is conducted. If anyone has
2 representations to make on the manner in which this
3 Inquiry is conducted which cannot be dealt with through
4 the Secretariat or the legal team, they may do so in
5 public during the course of the hearings as has hitherto
6 been done. I will then consider such representations
7 and deliver my response in public. I hope that this is
8 sufficiently clear to avoid any unfortunate
9 misunderstanding of this sort happening again.
10 I will deal with the letter that I have received
11 from the solicitor to Haringey as follows. His letter
12 made two points. The first was, and I quote, "Two
13 weights and measures are being applied in judging the
14 actions of the health service staff and those of the
15 social work staff." The second was to query the letter
16 of potential criticism served by this Inquiry on the
17 North Middlesex Hospital.
18 The first point, that is of the different levels of
19 questioning, I reject completely. The second, about
20 potential letters of criticism, is totally out of order.
21 Potential criticisms are a matter entirely for this
22 Inquiry. As has been made clear, where we can we will
23 give advance notice of potential criticism. The Inquiry
24 has reserved the right however to serve notices of
25 potential criticism as matters progress. I have neither
3
1 sought nor do I seek comment on them from other parties.
2 That is the limit of the response I propose to make
3 to the letter from Haringey. I have passed it to the
4 Solicitor to the Inquiry to reply in writing on the
5 Inquiry's behalf. I should however emphasise that there
6 will be no change in the Inquiry's approach as a result
7 of Haringey's letter. On the contrary, I am firmly of
8 the view that the Inquiry must continue to pursue with
9 vigour any possible errors of practice by any agency
10 whenever they emerge in the evidence. Mr Garnham.
11 I would be grateful if you and your team would conduct
12 the Inquiry as you have from the outset.
13 MR GARNHAM: Thank you sir. Sir, before I ask for
14 Nurse Norman to be recalled there is one matter of
15 housekeeping I would like to draw to your attention and
16 to that of interested parties. Interested parties are
17 now supplying us with suggested questions in a detailed
18 and helpful manner and I am grateful for those
19 suggestions. We had asked for them to be given to us at
20 least two days in advance.
21 In respect of Dr Rossiter, who is to be called later
22 today, I have received I think in excess of 30 pages of
23 questions, probably totalling over 240 suggested
24 questions. Inevitably, and this is no criticism at all,
25 a large number of those questions overlap because they
4
1 come from different people and they overlap with
2 questions that in any event I would have wanted to put.
3 That is no problem sir, provided that we have time to
4 deal with it. Then this morning I received another page
5 of suggested questions for Dr Rossiter and it is
6 extremely difficult to build that chain of questions
7 into what is I hope at least a roughly coherent series
8 of questions, and so I would make a plea to my
9 colleagues if they would be kind enough to let me have
10 suggested questions at least two days in advance so that
11 it is possible for me to read them intelligently before
12 we start.
13 THE CHAIRMAN: Thank you Mr Garnham. I fully understand the
14 point that you make and I hope that the request that you
15 have made will be acted upon.
16 MR GARNHAM: Then can I recall Nurse Norman please.
17 MS BEATRICE NORMAN (continued)
18 MR GARNHAM: Sir, Nurse Norman is already on oath but may
19 I have a moment before I start?
20 THE CHAIRMAN: Sure.
21 MR GARNHAM: Thank you, sir. Good morning Miss Norman.
22 MS NORMAN: Good morning Mr Garnham.
23 MR GARNHAM: We ended on Friday with me asking you questions
24 about kettles.
25 MS NORMAN: Yes.
5
1 MR GARNHAM: The next thing I want to ask you about is this.
2 Whatever the mechanism by which Victoria came to be
3 injured with the burns, did it not concern you that
4 there had been a substantial delay in bringing Victoria
5 into the hospital?
6 MS NORMAN: Yes.
7 MR GARNHAM: Did you record that concern in the records?
8 MS NORMAN: No I did not because it was already in the
9 notes.
10 MR GARNHAM: It was already in the notes and where do you
11 refer to it? Are you talking about the CP forms?
12 MS NORMAN: The notes that the doctors use on admission.
13 MR GARNHAM: I wonder if we could have a look at those,
14 volume 37. Are you referring to the history notes that
15 we find at page 260 and onwards, if you have a look at
16 that, please. Is it in these history notes that we find
17 the reference to which you have referred?
18 MS NORMAN: The clerking notes from Dr Forlee.
19 MR GARNHAM: The clerking notes from Dr Forlee. Do you mean
20 the CP forms or the A&E forms?
21 MS NORMAN: You have clerking notes that the physician fills
22 in when the child is admitted.
23 MR GARNHAM: I am sure it is me not finding the correct
24 ones. If you go back to 37/252, we have what I think
25 are clerking forms but not filled in by Dr Forlee. I am
6
1 grateful for the suggestion. I had asked the witness
2 whether she thought it was on the child protection
3 forms. Might it be the child protection forms
4 Nurse Norman?
5 MS NORMAN: It might be but usually it would also be in the
6 clerking notes.
7 MR GARNHAM: Let us deal with the clerking notes first. Can
8 you find reference to this point in the clerking notes?
9 Perhaps we can deal with it this way. So far I have
10 only found reference to it in the CP forms. Doubtless
11 if I have missed it in the clerking notes it will be
12 pointed out to me. Can we look at what is in the CP
13 forms first, page 54?
14 MS NORMAN: Thank you.
15 MR GARNHAM: If you look at CP2 we see there between the two
16 punchholes:
17 "Mum says she brought her straight to hospital but
18 mum cannot say exactly what time the incident happened.
19 Initially said 12 pm, then 1 to 3."
20 Now, what is it that you say we should look at?
21 Anything else there?
22 MS NORMAN: No, that is correct.
23 MR GARNHAM: Is there anywhere else that we find recorded,
24 as far as you can recall, that there had been
25 a substantial delay in bringing Victoria into hospital?
7
1 MS NORMAN: I was just looking at the clerking notes to see
2 if she said that.
3 MR GARNHAM: Go back to that. I think Mr Mason is also
4 having a hunt at the same time, pen between teeth, ready
5 to help. Let us leave it to him if we may. He will
6 doubtless find it if it is there and we can look at it
7 again. My concern is this, that if you and the other
8 nurses had concerns about this delay, and one can well
9 see why you might have concerns, is it not something
10 that deserves separate mention during the course of your
11 note-making on Victoria as you come towards conclusion?
12 MS NORMAN: Yes.
13 MR GARNHAM: And all we see is that initial impression,
14 those initial times from the casualty officer.
15 MS NORMAN: That is right.
16 MR GARNHAM: You say that at the time you first saw Victoria
17 she was being treated in a separate cubicle?
18 MS NORMAN: Yes.
19 MR GARNHAM: For how long did that continue?
20 MS NORMAN: She stayed in the cubicle until we were quite
21 sure that the scabies had been treated --
22 MR GARNHAM: When was that?
23 MS NORMAN: -- was clear. She was seen by the dermatologist
24 on the Tuesday.
25 MR GARNHAM: So that would have been Tuesday?
8
1 MS NORMAN: 27th.
2 MR GARNHAM: 27th July?
3 MS NORMAN: Yes.
4 MR GARNHAM: Was there any real possibility that she still
5 had scabies?
6 MS NORMAN: The dermatologist had said that she was clear of
7 scabies when he saw her.
8 MR GARNHAM: Is it not right that scabies is treated by
9 a single application of a drug such as Derbac lotion?
10 MS NORMAN: That is right.
11 MR GARNHAM: You do not need to repeatedly apply that?
12 MS NORMAN: No, you do not.
13 MR GARNHAM: And that it works?
14 MS NORMAN: Yes.
15 MR GARNHAM: You do not continue to have it. The evidence
16 that was available to the hospital was that she had had
17 such a single application in CMH.
18 MS NORMAN: Yes.
19 MR GARNHAM: And in fact had then gone on having repeated
20 applications thereafter.
21 MS NORMAN: Yes.
22 MR GARNHAM: So the prospect of her still having scabies was
23 pretty non-existent, was it not?
24 MS NORMAN: She would have been cleared of scabies but we
25 could not really be sure of that because of the history,
9
1 we could not get a proper history from the mother, and
2 she also had the burns on the face which were weeping
3 and therefore needed to be protected.
4 MR GARNHAM: So there are two reasons for a separate
5 cubicle: apparent risk of scabies persisting despite
6 treatment?
7 MS NORMAN: Yes.
8 MR GARNHAM: And the need to treat the burns in isolation?
9 MS NORMAN: That is right.
10 MR GARNHAM: Would you have treated superficial burns in
11 isolation if there had not been any suggestion of
12 scabies?
13 MS NORMAN: They were quite weepy when she first came in so
14 we would have nursed in a cubicle until they were dry.
15 MR GARNHAM: How much do you remember about the decisions
16 that were made after the handover on the first morning?
17 MS NORMAN: On the Monday morning?
18 MR GARNHAM: Your first morning, which was the Monday, was
19 it not?
20 MS NORMAN: Yes.
21 MR GARNHAM: How much do you remember of that now?
22 MS NORMAN: I remember coming on, taking a report, we went
23 around to see the children as we always do. Victoria
24 was still asleep and we tend to leave them in bed until
25 they have -- until the breakfast is ready.
10
1 MR GARNHAM: I am going to ask you to concentrate on my
2 question rather than describing general practice. How
3 much do you actually remember of the handover in respect
4 of Victoria on that morning?
5 MS NORMAN: What I was told in report.
6 MR GARNHAM: Do you have any independent recollection of
7 that handover?
8 MS NORMAN: Yes.
9 MR GARNHAM: You can think back and you can remember it
10 happening and what occurred, can you?
11 MS NORMAN: Yes.
12 MR GARNHAM: Do you have your statement in front of you? If
13 not, could you be provided with it please.
14 Paragraphs 21 and 23, you repeatedly use expressions
15 such as what you would have done or what you would have
16 known.
17 MS NORMAN: Yes.
18 MR GARNHAM: I want to know why you have used the expression
19 "would have". It sounds as if you do not have any
20 recollection of it yourself.
21 MS NORMAN: Yes I do. We did discuss the injuries.
22 MR GARNHAM: Why have you phrased it as "would have"?
23 MS NORMAN: Because I was talking to someone else and
24 telling them what did happen that morning.
25 MR GARNHAM: It may simply be a peculiarity of expression
11
1 but people normally use the word "would have" when they
2 are describing a general practice whereas they use "did"
3 or a similar expression if they are describing what they
4 actually recollect. You are saying you have a clear
5 recollection of these matters as having happened?
6 MS NORMAN: Yes.
7 MR GARNHAM: You say that you remember one of the nurses
8 coming up to you explaining she had noticed some marks
9 on Victoria when she and a colleague were bathing her.
10 MS NORMAN: That is right.
11 MR GARNHAM: Can you help us clear up the confusion that
12 appears to have arisen about this? How often was
13 Victoria bathed?
14 MS NORMAN: On the Monday morning, she was bathed in the
15 morning.
16 MR GARNHAM: Looking as you did at the notes, can you tell
17 us, after her admission on the 24th, is it right that
18 she was in a somewhat dirty condition?
19 MS NORMAN: Yes.
20 MR GARNHAM: She had a dirty dress on, no underwear and so
21 on?
22 MS NORMAN: Yes.
23 MR GARNHAM: How long was it before she had her first bath?
24 MS NORMAN: Having looked at the notes, she got a bath on
25 the night she was admitted.
12
1 MR GARNHAM: She had a bath on the night she was admitted,
2 24th/25th?
3 MS NORMAN: She came in, got onto the ward about 11.30.
4 I know she definitely had a bath on the Sunday and she
5 might have had a bath on the Sunday because she did wet
6 her bed.
7 MR GARNHAM: Have a look at the history sheet, page 260 in
8 that volume. People write down significant events in
9 the course of a patient's life on the ward on this
10 sheet, do they not?
11 MS NORMAN: Yes.
12 MR GARNHAM: We can see there is a reference to a bath for
13 15.30 hours on 25th July, so that is --
14 MS NORMAN: That was the Sunday afternoon.
15 MR GARNHAM: There does not seem to be any reference to such
16 a bath either on the Saturday night or during the Sunday
17 morning. Would she have had a bath before 3.30 the day
18 after she was admitted?
19 MS NORMAN: She might have had a bath if she had a wet bed.
20 MR GARNHAM: But you cannot say?
21 MS NORMAN: I cannot tell because it does not say here.
22 MR GARNHAM: According to these notes, for the 15.30 hours
23 on 25th July Victoria had difficulty walking into the
24 bathroom. Do you see that, about four lines down on
25 that entry?
13
1 MS NORMAN: Yes.
2 MR GARNHAM: "Bruises all over her body, has felt much
3 better after her bath."
4 MS NORMAN: Yes.
5 MR GARNHAM: That appears to be a reference to whoever
6 helped her with her bath discovering in the bath that
7 Victoria was much bruised. Is that right?
8 MS NORMAN: That is right.
9 MR GARNHAM: So that is an incident that occurs at 15.30 on
10 25th July?
11 MS NORMAN: It does not necessarily mean that she had a bath
12 at 15.30. This was a report that was written for the
13 day so that she could have had a bath in the morning.
14 MR GARNHAM: I see. So that might refer to a bath that had
15 taken place earlier on in the day, even in the morning?
16 MS NORMAN: Yes.
17 MR GARNHAM: In her evidence to us Nurse Graham says that
18 she took part in that bathing and she noticed these
19 injuries.
20 MS NORMAN: Yes.
21 MR GARNHAM: So there appears to be one occasion, some time
22 before 15.30 hours on 25th July, when Victoria was
23 bathed and where, according to Nurse Graham, she and
24 Sharon -- who is Sharon?
25 MS NORMAN: One of the senior staff nurses on the ward.
14
1 MR GARNHAM: What is her surname?
2 MS NORMAN: Jones.
3 MR GARNHAM: -- saw these wounds and directed the attention
4 of Drs Rossiter and Reynders to them.
5 MS NORMAN: Yes.
6 MR GARNHAM: That is the first occasion. There then seems
7 to be a second event involving you, Nurses O'Boyce and
8 Watling, who say that there was a bath at about
9 lunchtime on the 26th July.
10 MS NORMAN: That bath was about 10.30 because they called me
11 in the room at about 11 o'clock in the morning. She had
12 a bath after breakfast.
13 MR GARNHAM: That was the bath, was it, that was
14 administered by Watling and O'Boyce?
15 MS NORMAN: That is right.
16 MR GARNHAM: That you say was about 10.30?
17 MS NORMAN: Must have been about 10.30.
18 MR GARNHAM: You were called into the room and you saw the
19 injuries on Victoria's body?
20 MS NORMAN: That is right.
21 MR GARNHAM: What did you do about it?
22 MS NORMAN: The doctors were on their round at that time.
23 MR GARNHAM: Which doctors? Rossiter and --
24 MS NORMAN: Reynders -- they were just beside the bed next
25 to Victoria's.
15
1 MR GARNHAM: Dr Reynders?
2 MS NORMAN: Yes.
3 MR GARNHAM: And Dr Rossiter?
4 MS NORMAN: Doctor Rossiter was on the round.
5 MR GARNHAM: Did both those doctors get to see these wounds
6 again?
7 MS NORMAN: Yes, Dr Reynders came and drew the pictures on
8 the diagrams.
9 MR GARNHAM: Those are the body maps we have in that volume
10 at page 60. He did some body maps, did he?
11 MS NORMAN: Yes.
12 MR GARNHAM: Then there appears to be a third description of
13 these events from Nurses Pereira and Quinn, who say that
14 as a result of a bath after 7.30 in the evening on the
15 26th, they saw these marks and pointed them out to
16 Drs Reynders and Rossiter. The difficulty that I have,
17 I wonder if you could help me with this, is we appear to
18 have three different descriptions of one event, or else
19 a very similar event taking place. Now, from your point
20 of view can you tell us whether there was one event, two
21 events, three events?
22 MS NORMAN: I think that every time they gave Victoria
23 a bath somebody saw these marks and I think they were
24 just noting them down every time she had a bath but
25 actually they were the same marks and it was the same
16
1 incident.
2 MR GARNHAM: Is your understanding that Dr Rossiter and
3 Dr Reynders had their attention drawn to these marks
4 three times?
5 MS NORMAN: They knew of the marks right at the beginning.
6 MR GARNHAM: The way I put my question was quite important.
7 Can you see if you can answer that. Is it your
8 understanding that Reynders and Rossiter had their
9 attention drawn to these marks on three occasions?
10 MS NORMAN: That I cannot say.
11 MR GARNHAM: Because you were only there for one of them?
12 MS NORMAN: Yes.
13 MR GARNHAM: Which was the one? In the morning of the 26th?
14 MS NORMAN: That is right.
15 MR GARNHAM: On the occasion when you were shown these
16 marks, you I think went back to the bathroom and
17 examined Victoria for yourself?
18 MS NORMAN: I came back to her cubicle.
19 MR GARNHAM: And you could see the shape of a belt buckle
20 mark?
21 MS NORMAN: That is right.
22 MR GARNHAM: And there were also other "strip marks" I think
23 is your expression.
24 MS NORMAN: She had other marks on the body.
25 MR GARNHAM: What do you mean by "strip mark", or is it
17
1 "stripe mark"?
2 MS NORMAN: It is quite difficult to describe, it just sort
3 of looks like a loop around on the body.
4 MR GARNHAM: Is this a different mark from the belt buckle
5 mark?
6 MS NORMAN: Yes.
7 MR GARNHAM: So there was certainly a belt buckle mark and
8 then there was some sort of loop mark?
9 MS NORMAN: That is right.
10 MR GARNHAM: Those must have been very disturbing for you.
11 MS NORMAN: Yes.
12 MR GARNHAM: Where do we find reference to those two marks
13 in any of these notes?
14 MS NORMAN: I asked the nurses to write everything down
15 after they had given her the bath and unfortunately they
16 wrote down the bath, described the bath but they left
17 the marks. They did not say anything.
18 MR GARNHAM: That was a serious error, was it not?
19 MS NORMAN: Yes.
20 MR GARNHAM: Never mind the bath, what matters is the fact
21 that you had found marks that would have been consistent
22 with some form of beating.
23 MS NORMAN: Yes.
24 MR GARNHAM: You know the importance of recording
25 observations like that in child protection cases?
18
1 MS NORMAN: Yes.
2 MR GARNHAM: Why did it not happen?
3 MS NORMAN: I did ask for everything to be documented.
4 I think I really cannot explain why it was not written
5 down.
6 MR GARNHAM: But it is the fault, is it, of the nurses
7 junior to you?
8 MS NORMAN: Yes, I take full responsibility for that.
9 MR GARNHAM: You do take responsibility for it?
10 MS NORMAN: Yes.
11 MR GARNHAM: Did you ever go back to these notes and look at
12 them again?
13 MS NORMAN: I did not check that day to see what they had
14 written.
15 MR GARNHAM: Did you ever go back to these notes and read
16 them?
17 MS NORMAN: Not those particular notes, no.
18 MR GARNHAM: So that you never had occasion to realise the
19 omission?
20 MS NORMAN: I knew that it had been entered in the notes by
21 the doctors and I knew that it had been put on the
22 diagrams which would be sent to the interested parties.
23 MR GARNHAM: Can we deal with the diagrams first? You are
24 absolutely right to say that Dr Reynders completed some
25 body maps and perhaps we ought to have a look at them in
19
1 volume 37, page 60. It is right I think that this form,
2 53/63B, is completed as part of the child protection
3 procedures, is it not?
4 MS NORMAN: That is right.
5 MR GARNHAM: Do you complete body mark maps in other
6 circumstances other than child protection?
7 MS NORMAN: If for burns, for example, a body map would be
8 used, or any other condition that needs to have a body
9 map.
10 MR GARNHAM: It is a slightly circular answer to my
11 question. What are the other conditions that might need
12 body maps apart from child protection?
13 MS NORMAN: Skin lesions, burns.
14 MR GARNHAM: If you had a road accident and came in with
15 cuts and bruises all over you, might a body map be
16 completed?
17 MS NORMAN: Yes.
18 MR GARNHAM: So is the position this, that somebody looking
19 at this map does not know simply because it is a body
20 map that those who completed it had child protection
21 concerns?
22 MS NORMAN: No, but the forms would have to be with the
23 child protection forms to connect.
24 MR GARNHAM: These maps would go with the child protection
25 forms?
20
1 MS NORMAN: Yes.
2 MR GARNHAM: The fact that they go with it, does that
3 indicate to those reading them that what are shown on
4 these maps are evidence of child abuse?
5 MS NORMAN: There they would have been described on the
6 child protection form.
7 MR GARNHAM: So we have to look elsewhere on the child
8 protection form to ascertain that these marks are
9 thought to have been the result of abuse.
10 MS NORMAN: It would say that on the child protection form
11 that the diagrams are included.
12 MR GARNHAM: Does it say that in these child protection
13 forms? I mean, so there is no misunderstanding let me
14 explain why this might be important. It is one thing to
15 record marks on a body map like this when the maps do
16 not make reference to the cause of the injuries. It is
17 quite another to say that these marks are all
18 potentially the result of abuse. Do you see what
19 I mean?
20 MS NORMAN: Yes.
21 MR GARNHAM: Now, do we find anywhere in the child
22 protection forms a comment to the effect: "All the marks
23 described on the body maps are the result potentially of
24 abuse"? Let me put the question another way. How is
25 a social worker or a policeman who receives a copy of
21
1 these forms including the body map supposed to know that
2 what is being put on the body map are signs which are
3 thought might be signs of physical abuse?
4 MS NORMAN: Because there will be a description that the
5 child has got marks, scars on their body.
6 MR GARNHAM: Take us to where that is please in these forms.
7 You see, it is very unlikely that we will find it, is it
8 not, because the CP forms were completed by Dr Forlee on
9 the 24th and subject to one or two minor amendments they
10 are in that state when they go to social services,
11 whereas the maps are not completed until the 26th.
12 MS NORMAN: Dr Forlee had seen the marks on the body.
13 MR GARNHAM: So she might have done but there is nothing to
14 tie in, is there, the marks described on the map with
15 the description set out on the rest of the CP forms?
16 MS NORMAN: No, there is not on this form.
17 MR GARNHAM: Can you see how misleading that may be to
18 a social worker who comes to read these forms because
19 there is nothing, is there, to indicate that the purpose
20 of all the squiggles and lines on the body map is to
21 indicate signs of potential abuse?
22 MS NORMAN: Yes, I can see that.
23 MR GARNHAM: And to put it frankly that is hopeless, is it
24 not?
25 MS NORMAN: It is not very good.
22
1 MR GARNHAM: I go back to my earlier questions. You saw
2 a belt buckle mark and you saw a sign that suggested
3 a strike with some sort of instrument, some sort of
4 loop. Where do we find that on the notes that are sent
5 to social services?
6 MS NORMAN: I think the child protection forms had already
7 been done and this was a story that was evolving, we
8 would have to have another set of CP forms to describe
9 the new things that were happening.
10 MR GARNHAM: I can well see why that might be the case, so
11 where do we find the new set of CP forms?
12 MS NORMAN: They were not done.
13 MR GARNHAM: How are social services meant to discern this
14 important information that is in your head when they
15 look at what is given to them?
16 MS NORMAN: I think the communication was not very good.
17 MR GARNHAM: Photographs were taken of Victoria while she
18 was in NMH, were they not?
19 MS NORMAN: Yes.
20 MR GARNHAM: Will you turn, please, to page 271 in that
21 bundle and then go over a page and you see the
22 collection of photographs. We have seen some of them
23 before and I am not going to ask for them to be shown
24 again but they show first, the first five show
25 photographs of Victoria's face and then there were
23
1 photographs of her chest and then of her back and then
2 of her arms. Is that right?
3 MS NORMAN: That is right.
4 MR GARNHAM: When did you first see those photographs?
5 MS NORMAN: On the 2nd November.
6 MR GARNHAM: On 2nd November which year?
7 MS NORMAN: This year.
8 MR GARNHAM: So you were not shown these during the course
9 of the time that Victoria was on the ward?
10 MS NORMAN: No.
11 MR GARNHAM: Nonetheless, you had seen the real thing, you
12 had seen Victoria?
13 MS NORMAN: Yes.
14 MR GARNHAM: Do these photographs accurately represent what
15 could be seen on her body?
16 MS NORMAN: Yes, they do.
17 MR GARNHAM: Was it your own viewing of Victoria's body or
18 your much later viewing of these photographs in November
19 last year that led you to think a belt had been used on
20 her?
21 MS NORMAN: I did not see the photographs in November last
22 year.
23 MR GARNHAM: I am sorry, I must have misheard you.
24 2nd November this year.
25 MS NORMAN: Yes.
24
1 MR GARNHAM: Two weeks ago.
2 MS NORMAN: Yes.
3 MR GARNHAM: It must follow from that then that it was what
4 you saw on the ward rather than sight of these
5 photographs that led you to put what you did in your
6 statement about seeing belt buckle marks.
7 MS NORMAN: Yes, I did my statement way back in June.
8 MR GARNHAM: Yes, that is right. What happened to these
9 photographs after they were developed? Do you know?
10 MS NORMAN: They should go to the consultant.
11 MR GARNHAM: Do you know whether they did?
12 MS NORMAN: I am not sure if they did.
13 MR GARNHAM: What is the normal process? How do you get
14 from a request for photographs being made by a doctor to
15 the doctor actually getting sight of them?
16 MS NORMAN: The photographer usually comes, takes the
17 photographs and sends them back to the consultant.
18 MR GARNHAM: What then happens to the photographs in a child
19 protection case? Are they shown to social services?
20 MS NORMAN: Yes, they should be shown to social services.
21 MR GARNHAM: Do you know whether these were?
22 MS NORMAN: I do not know.
23 MR GARNHAM: Would they normally be shown to the police if
24 there were serious concerns about child protection?
25 MS NORMAN: Yes, the police would be involved.
25
1 MR GARNHAM: Do you know if these were shown to the police?
2 MS NORMAN: I do not know if they were shown to the police.
3 MR GARNHAM: You say in paragraph 29 of your statement that
4 you asked the doctor to come and see Victoria once you
5 had examined her. Dr Reynders then came and examined
6 Victoria, is that right.
7 MS NORMAN: That is right.
8 MR GARNHAM: And you believe, you tell us, that he reported
9 his findings to Dr Rossiter?
10 MS NORMAN: He was in the middle of doing the diagrams so he
11 looked at Victoria, went back and put everything on the
12 diagrams. I do not know if he spoke to Dr Rossiter or
13 not.
14 MR GARNHAM: Do you know whether Dr Rossiter saw Victoria on
15 that occasion?
16 MS NORMAN: I am not sure because I was not there.
17 MR GARNHAM: You tell us in paragraph 31 of your statement
18 that in the light of concerns as to how Victoria
19 sustained burns and the marks on her body that you had
20 seen, it was reinforced to nursing staff at each
21 handover that they needed to keep a careful eye on
22 Victoria and her interactions with her mother.
23 MS NORMAN: Yes.
24 MR GARNHAM: So there were therefore sufficient concerns in
25 the minds of you and other senior nurses that you felt
26
1 you had to make a point of telling nurses at each
2 changeover to keep an eye on Victoria.
3 MS NORMAN: It is a procedure that we do for every child
4 protection case, it is in the guidelines.
5 MR GARNHAM: That is standard, is it?
6 MS NORMAN: Yes.
7 MR GARNHAM: We have heard from a number of nurses that they
8 had concerns about the interreaction of Kouao and
9 Victoria.
10 MS NORMAN: Yes.
11 MR GARNHAM: If you are right that the nurses were
12 instructed to report anything odd about that
13 relationship, why is there no mention of those occasions
14 when nurses did see something odd in the notes?
15 MS NORMAN: I do not really know because Kouao always used
16 to come in quite late at night. We did not get an
17 opportunity to really get to see her that often. It was
18 very rare that she came to visit. If she did it was
19 only for a very short time. The few occasions that the
20 nurses observed what she did were the only times that
21 they recorded anything.
22 MR GARNHAM: So you say that on each occasion when something
23 was noticed by the nurse it was recorded?
24 MS NORMAN: Yes.
25 MR GARNHAM: So we can read the notes and we will get a full
27
1 account of all the observations of the nurses that they
2 thought strange?
3 MS NORMAN: Whenever she visited, which was not very often.
4 MR GARNHAM: That is not quite the impression that we have
5 been left with from the evidence of other nurses who
6 suggest that they had additional concerns other than
7 those in the notes, but you were not aware of that?
8 MS NORMAN: They had suspicions. There were suspicions. We
9 did not have any proof or anything. Everything was
10 suspicion.
11 MR GARNHAM: But those suspicions do not find their way into
12 the notes.
13 MS NORMAN: They should have found their way in the notes.
14 MR GARNHAM: But they do not.
15 MS NORMAN: No.
16 MR GARNHAM: And the result is that that information that
17 might be relevant to others looking at this case is not
18 recorded.
19 MS NORMAN: No, I think that could be because nurses do
20 not -- you are not really supposed to judge people. You
21 should not write down anything unless you have got the
22 facts. We did not really have any facts.
23 MR GARNHAM: No, but in child protection cases you will
24 often not have facts, will you?
25 MS NORMAN: No.
28
1 MR GARNHAM: You will often only have suspicions.
2 MS NORMAN: Most of that was suspicions, yes.
3 MR GARNHAM: And if that is to be used, it is vital it is
4 recorded, is it not?
5 MS NORMAN: Yes.
6 MR GARNHAM: And this is not some bureaucratic nicety,
7 people wanting to fill forms for the sake of it. It is
8 because that is the only way to build up a complete
9 picture about what professionals working with a patient
10 fear might have happened to her, is that not right?
11 MS NORMAN: That is right.
12 MR GARNHAM: So the failure to record this information is in
13 fact quite serious?
14 MS NORMAN: Yes.
15 MR GARNHAM: Can I turn to the events of 28th July next
16 please. You tell us that on that day Karen Johns took
17 the child protection forms, the diagrams and the A&E
18 card to photocopy to pass on to Haringey Social
19 Services.
20 MS NORMAN: That is right.
21 MR GARNHAM: You also tell us on that day that you received
22 comments about Victoria's irregular eating habits.
23 MS NORMAN: That is right.
24 MR GARNHAM: Again on 28th July it is right to say there was
25 a strategy meeting, was there not?
29
1 MS NORMAN: I did not know anything about a strategy
2 meeting.
3 MR GARNHAM: Who normally attends strategy meetings on
4 behalf of the hospital?
5 MS NORMAN: The nurses on the ward must attend the strategy
6 meeting.
7 MR GARNHAM: You knew nothing about it?
8 MS NORMAN: No, I was not invited to the strategy meeting.
9 MR GARNHAM: Does that mean that other nurses did know about
10 it and that you did not or does it mean that none of you
11 knew about it?
12 MS NORMAN: None of us knew about the strategy meeting.
13 MR GARNHAM: How are you normally informed?
14 MS NORMAN: We normally have a phone call to tell us when
15 the strategy meeting would be and the time.
16 MR GARNHAM: I wonder if you could have volume 5 please.
17 Can we start with page 250 please. Do you see there the
18 beginning of what is entitled "An Ongoing Recording
19 Sheet" prepared by Karen Johns? Is that what you have
20 there?
21 MS NORMAN: Yes.
22 MR GARNHAM: Those appear to be Karen Johns' notes of her
23 involvement with this case.
24 MS NORMAN: Yes.
25 MR GARNHAM: Then go to page 254 and we see reference to
30
1 a strategy meeting that took place on 28th July. Do you
2 see that?
3 MS NORMAN: Yes, I do.
4 MR GARNHAM: But you knew nothing about that and nor, as far
5 as you are aware, did any other nurses on the ward in
6 advance of it taking place?
7 MS NORMAN: No, we did not.
8 MR GARNHAM: You had not been informed by Karen Johns or by
9 anybody else?
10 MS NORMAN: No.
11 MR GARNHAM: According to that note Karen Johns was given
12 five tasks at that strategy meeting. The first four
13 relate to activities on the ward. Do you see those:
14 "Seek report from ward staff.
15 "Check with Dr Meates whether photographs had been
16 passed to police.
17 "Alert ward staff to call the police.
18 "Ask ward staff to monitor mother/daughter
19 interaction".
20 Do you see that?
21 MS NORMAN: Yes.
22 MR GARNHAM: According to the notes Miss Johns visited
23 Rainbow Ward and updated Staff Nurse Sue -- I think
24 Sue Jennings.
25 MS NORMAN: Yes.
31
1 MR GARNHAM: -- on the outcome of that meeting.
2 MS NORMAN: I did not know about that.
3 MR GARNHAM: You did not know about that?
4 MS NORMAN: No.
5 MR GARNHAM: Did you know nothing about the fact that this
6 strategy meeting had taken place?
7 MS NORMAN: I had no idea whatsoever the strategy meeting
8 had taken place. We were waiting for a strategy
9 meeting.
10 MR GARNHAM: That seems on the face of it extraordinary that
11 one of your colleagues, Nurse Jennings, knew and you did
12 not.
13 MS NORMAN: I did not know that the meeting had taken place.
14 MR GARNHAM: Does that surprise you?
15 MS NORMAN: Yes, it does.
16 MR GARNHAM: Given how things normally work on the ward?
17 MS NORMAN: She would normally, first of all she would have
18 been very surprised the strategy meeting took place
19 without the nurses and she would have told me what had
20 been decided at the meeting.
21 MR GARNHAM: Could you have volume 38 please, page 161.514.
22 This is a document that we received from those acting
23 for your hospital a few days ago and it is I think
24 called "The Allocation Book"; you know what that book
25 is?
32
1 MS NORMAN: Yes, I do.
2 MR GARNHAM: You are now being passed that page. That is
3 a photocopy of The Allocation Book and one needs to read
4 across from the previous page to see the line that
5 refers to Anna as she is there described, but we see
6 there a note for 28th July: "Haringey social worker
7 today". Do you know what that means?
8 MS NORMAN: I am still looking for it.
9 MR GARNHAM: Open up the previous page. Can you see
10 reference to Anna?
11 MS NORMAN: Yes.
12 MR GARNHAM: Read across parallel with that on to the next
13 page and do you see there a note: "Haringey SW today"?
14 Do you know what that note is intended to refer to?
15 MS NORMAN: SW is social worker.
16 MR GARNHAM: Yes. Do you know what that means?
17 MS NORMAN: "Haringey social worker today", I presume that
18 she will be visiting. I am not sure.
19 MR GARNHAM: That is not a reference to the strategy
20 meeting?
21 MS NORMAN: No, it would definitely say "strategy meeting"
22 and the time.
23 MR GARNHAM: Go back if you would to Miss Johns' notes.
24 Bottom of page 254:
25 "Visit to Rainbow Ward, updated Staff Nurse Sue on
33
1 outcome of the strategy meeting and left memo for ward
2 notes."
3 First of all, did you know about that visit?
4 MS NORMAN: No, I did not.
5 MR GARNHAM: Secondly, did you see the memo that it is said
6 was left?
7 MS NORMAN: No, I did not.
8 MR GARNHAM: Over the page, the following day, according to
9 the notes, Karen Johns again visited Rainbow Ward:
10 "... to return the child protection forms. Spoke
11 briefly to Sister Beat", who I think is you?
12 MS NORMAN: Yes.
13 MR GARNHAM: Did you have a conversation with Karen Johns?
14 MS NORMAN: I did not have a conversation with Karen about
15 Victoria.
16 MR GARNHAM: "She is aware of the situation". Not true?
17 MS NORMAN: No.
18 MR GARNHAM: So this note apparently made contemporaneously
19 is simply inaccurate?
20 MS NORMAN: I did not even know she had taken the child
21 protection forms.
22 MR GARNHAM: Let us be clear about this. You are saying
23 that this apparently contemporaneous note is simply
24 untrue?
25 MS NORMAN: Yes.
34
1 MR GARNHAM: It is not a matter that you do not remember it,
2 you are saying this did not happen?
3 MS NORMAN: I did not speak to Karen Johns about Victoria.
4 MR GARNHAM: Did you know what was required as a result of
5 the strategy meeting?
6 MS NORMAN: No, because I was not at the meeting.
7 MR GARNHAM: Or from what it is said you learned afterwards?
8 MS NORMAN: What I learned afterwards.
9 MR GARNHAM: Did you learn what was required of the ward
10 staff from the strategy meeting after the strategy
11 meeting had taken place?
12 MS NORMAN: Quite much later.
13 MR GARNHAM: How much later? When?
14 MS NORMAN: I cannot remember but it must have been almost
15 after Victoria had gone home I realised that there had
16 been a meeting.
17 MR GARNHAM: You go on in paragraph 35 to describe what you
18 did in consequence of the fact that Victoria spoke no
19 English.
20 MS NORMAN: Yes.
21 MR GARNHAM: You say that you decided to ask Nurse
22 Lucienne Taub to chat to Victoria.
23 MS NORMAN: To befriend her, yes.
24 MR GARNHAM: And you say that you asked her, that is Taub,
25 if she could find out how the burns happened.
35
1 MS NORMAN: Because that would be a start to conversation.
2 MR GARNHAM: Lucienne Taub told us last week that it was
3 Dr Rossiter and it was not you who asked her to speak to
4 Victoria.
5 MS NORMAN: I might have spoken to her after Dr Rossiter had
6 spoken to her because I went up to the ward where she
7 worked.
8 MR GARNHAM: You say that Ms Taub told you that Victoria had
9 told her that she had taken the kettle herself and
10 poured water over her head.
11 MS NORMAN: After she had spoken to Victoria I wanted to
12 know what Victoria had said and she described, she said
13 it was difficult but she described what Victoria had
14 said.
15 MR GARNHAM: And I think we find a note you made of that at
16 page 275 in volume 37. The fourth entry down:
17 "Anna wishes would like to communicate. A French
18 link worker would be a good idea. Expresses herself
19 quite good in English/French."
20 And then 29th July:
21 "Anna says that she took the kettle herself and
22 poured it over her forehead. She told the French nurse
23 from SCBU," who I think is Nurse Taub, is it not?
24 MS NORMAN: That is right.
25 MR GARNHAM: Ms Taub told us that Victoria's response to the
36
1 questions about how her injuries occurred was imprecise
2 and she ended up not having any clear picture of what
3 Victoria was saying.
4 MS NORMAN: She did not describe that to me.
5 MR GARNHAM: Who made that entry on 29th July?
6 MS NORMAN: I did.
7 MR GARNHAM: You did?
8 MS NORMAN: Yes.
9 MR GARNHAM: And you say that that is because Nurse Taub was
10 able to give you so precise a description of events?
11 MS NORMAN: That is what I understood when I spoke to her.
12 MR GARNHAM: There seems to be really precious little
13 evidence that water was poured over Victoria's head from
14 a kettle. Is it possible that this note that we have
15 just looked at that you have made is simply an
16 assumption on your part as to how the injury must have
17 happened?
18 MS NORMAN: I do not think so because I did speak to her to
19 find out what had happened.
20 MR GARNHAM: Is it possible that there was already an
21 assumption in your mind and that coloured what you heard
22 Nurse Taub telling you?
23 MS NORMAN: I do not think so because that was quite a few
24 days after.
25 MR GARNHAM: Might it not be that all Ms Taub told you was
37
1 that Victoria poured hot water over her head rather than
2 boiling water from a kettle?
3 MS NORMAN: I remember writing this down after she left.
4 MR GARNHAM: Because what I want to suggest to you is that
5 you made a false assertion about how this injury had
6 happened to Victoria and you allowed Dr Rossiter to take
7 away the same impression, namely that it was boiling
8 water from a kettle.
9 MS NORMAN: It was hot water, it was hot enough to burn the
10 skin. It is difficult to tell whether it was boiling.
11 I said hot water.
12 MR GARNHAM: But that it was from a kettle?
13 MS NORMAN: That is what I was told, yes.
14 MR GARNHAM: Is it possible that you are the originator of
15 the suggestion that it was from a kettle?
16 MS NORMAN: I do not think I was the originator, I was told
17 the kettle.
18 MR GARNHAM: All you understood was that it was hot water?
19 MS NORMAN: Yes, the water was hot enough to burn.
20 MR GARNHAM: Not that it was boiling water. You had no
21 positive assertion that it was boiling water?
22 MS NORMAN: No.
23 MR GARNHAM: Because you see when Dr Rossiter completes the
24 discharge summary after Victoria has left she talks
25 about Victoria having poured boiling water on herself
38
1 and I am wondering where that came from. Not from you?
2 MS NORMAN: No.
3 MR GARNHAM: And do you know where it came from, the
4 suggestion about boiling water?
5 MS NORMAN: I do not know. I think everybody just assumed
6 that the water was hot enough to burn the skin.
7 MR GARNHAM: Can I go on to the events as they were on
8 3rd August. By that date what were your concerns about
9 Victoria, by 3rd August?
10 MS NORMAN: My concerns were that this was a child that was
11 abused.
12 MR GARNHAM: And when you use the word "abuse" are you
13 talking about sexual abuse, emotional abuse, physical
14 abuse?
15 MS NORMAN: I think it was a mixture, she had physical
16 abuse, physical, emotional.
17 MR GARNHAM: A mixture of physical and emotional?
18 MS NORMAN: Yes.
19 MR GARNHAM: No suggestion of sexual, was there?
20 MS NORMAN: Not at that time, no.
21 MR GARNHAM: Were you concerned, given your understanding of
22 the mechanics of this accident, how it would have been
23 possible for a child physically to lift a kettle to pour
24 hot water over her head?
25 MS NORMAN: I could not understand how she could have done
39
1 that.
2 MR GARNHAM: And you were concerned as to how it could be
3 possible that a child could carry on pouring hot water
4 over her head once she had felt it burn?
5 MS NORMAN: Yes.
6 MR GARNHAM: You were concerned, were you not, about the
7 delay in Kouao getting Victoria to hospital?
8 MS NORMAN: Yes.
9 MR GARNHAM: You were concerned about the existence of
10 a belt buckle mark on Victoria's shoulder?
11 MS NORMAN: Yes.
12 MR GARNHAM: You were concerned about other stripe or loop
13 marks on Victoria's body?
14 MS NORMAN: That is right.
15 MR GARNHAM: You were concerned that she had been
16 over-treated for scabies?
17 MS NORMAN: The dermatologist had told us that she had
18 over-used the Derbac treatment.
19 MR GARNHAM: You were concerned about the relatively short
20 visits that her mother was paying to see this poor
21 child?
22 MS NORMAN: Yes.
23 MR GARNHAM: You were concerned about unusual eating
24 patterns?
25 MS NORMAN: Yes.
40
1 MR GARNHAM: The overall effect of all that must have been
2 that you were really very worried about Victoria.
3 MS NORMAN: I was very worried.
4 MR GARNHAM: And you were worried whether she had been the
5 victim of physical abuse?
6 MS NORMAN: Yes.
7 MR GARNHAM: You tell us in paragraph 38 that Dr Rossiter
8 was pursuing your concerns.
9 MS NORMAN: Yes.
10 MR GARNHAM: Apart from Dr Rossiter was anybody else doing
11 anything about these concerns?
12 MS NORMAN: This is something that you have to do in a team.
13 One individual cannot do it. All the information has to
14 be collected and the investigations have to be done.
15 MR GARNHAM: But you understood that Dr Rossiter was
16 pursuing the matter?
17 MS NORMAN: She is the person in charge and we follow her
18 instructions.
19 MR GARNHAM: How was she pursuing it? What was she going to
20 do?
21 MS NORMAN: By making sure that the doctors go to all the
22 forms filled in, sent to social services and then we
23 wait to see what social services are going to do.
24 MR GARNHAM: So your understanding was that Dr Rossiter was
25 pursuing the matters by ensuring the forms were
41
1 completed and then relaying that information to social
2 services?
3 MS NORMAN: Making sure the doctors sent all the necessary
4 information to social services.
5 MR GARNHAM: Because all these concerns are only going to be
6 pursued if all this information reaches social services?
7 MS NORMAN: That is right.
8 MR GARNHAM: And you understood that Dr Rossiter had taken
9 it upon herself to ensure that that was done?
10 MS NORMAN: No, she is in charge and she makes sure that all
11 the information -- the doctors know following the Child
12 Protection Guidelines to get all the information and
13 send all the necessary information to the people
14 concerned.
15 MR GARNHAM: Did you not see it as part of the nursing
16 function to ensure that that information reached social
17 services?
18 MS NORMAN: It is also our responsibility.
19 MR GARNHAM: I am concerned about answers like that where
20 there appear to be two people who have responsibility
21 because there is always a danger that each of them
22 leaves it to the other.
23 MS NORMAN: We work in a team.
24 MR GARNHAM: I am sure you do but that does not quite deal
25 with the point, does it? If you have two people with
42
1 responsibility, for example, for passing information to
2 social services, there is a danger that each of them
3 leave it to the other, is there not?
4 MS NORMAN: Yes.
5 MR GARNHAM: Who was going to do it in Victoria's case, you
6 or Rossiter?
7 MS NORMAN: Um, on the ward the person in charge on the ward
8 would have done it.
9 MR GARNHAM: Dr Rossiter?
10 MS NORMAN: Dr Rossiter if she was on the ward that week.
11 MR GARNHAM: So if it turns out that Dr Rossiter is the
12 treating consultant --
13 MS NORMAN: Yes.
14 MR GARNHAM: -- then it is her job to ensure that that
15 information passes, not nursing staff?
16 MS NORMAN: The nursing staff have to get all the
17 information together to make sure that Dr Rossiter has
18 got all the necessary information.
19 MR GARNHAM: But it is Dr Rossiter's job, you say, to ensure
20 that it reaches the hands of social services.
21 MS NORMAN: Overall the consultant in charge has the overall
22 responsibility.
23 MR GARNHAM: With respect that is not quite the point. I am
24 sure you are right that the consultant has
25 responsibilities. I am interested in discovering how
43
1 physically it happens.
2 MS NORMAN: What normally happens is that all the CP forms
3 are filled in, all the information is gathered together
4 and everything is sent to social services.
5 MR GARNHAM: Where you have a case like this where the
6 information is coming in bit by bit during the course of
7 the stay, how do you ensure that social services do not
8 just get the snapshot at the beginning of the period
9 rather than the full history gathered throughout?
10 MS NORMAN: Then the nurse who is in charge on that
11 particular day would make sure that if there is any new
12 information it is passed on to the social services.
13 MR GARNHAM: I see, so it is nurses who have responsibility
14 to pass that additional information, not Dr Rossiter.
15 MS NORMAN: If there is any additional information.
16 MR GARNHAM: So who passed the additional information that
17 was being gathered about Victoria to social services?
18 MS NORMAN: As far as I know, whenever there was a phone
19 call the information was passed on. If there was
20 anything you rang and passed on the information.
21 MR GARNHAM: So tell us which phone call it was when all
22 this information was passed to social services then.
23 MS NORMAN: I know that Sharon Jones filled in the social
24 worker referral form which was faxed on to social
25 services.
44
1 MR GARNHAM: That does not tell us a great deal more than we
2 get from the CP forms, does it?
3 MS NORMAN: I know that Isobel Quinn also spoke to them and
4 raised the child abuse suspicions.
5 MR GARNHAM: Anything more?
6 MS NORMAN: I cannot remember offhand without looking.
7 MR GARNHAM: You say that on 3rd August nursing staff were
8 informed by Karen Johns that Victoria's case had been
9 referred to North Tottenham Social Services.
10 MS NORMAN: Yes.
11 MR GARNHAM: And that the plan was that the area social
12 workers would carry out a home visit with the police to
13 where Kouao was staying.
14 MS NORMAN: Yes.
15 MR GARNHAM: Did you know when that home visit was to take
16 place?
17 MS NORMAN: No, we did not know.
18 MR GARNHAM: Were you confident that there were arrangements
19 in place to ensure that you heard the results of that
20 home visit?
21 MS NORMAN: Well, we knew that they would ring and let us
22 know about the home visit and what would and what had
23 happened.
24 MR GARNHAM: How would a home visit reassure you about the
25 concerns that you had for Victoria?
45
1 MS NORMAN: The home visit would not have reassured me.
2 MR GARNHAM: It could not do, could it?
3 MS NORMAN: No.
4 MR GARNHAM: Looking at the physical premises would not have
5 answered all these questions?
6 MS NORMAN: No.
7 MR GARNHAM: So there we are with a series of concerns that
8 are mounting during this period. You know that social
9 services are planning, or you understand that social
10 services are planning to do a home visit and you know
11 that that home visit will not satisfy you of your
12 concerns.
13 MS NORMAN: Yes.
14 MR GARNHAM: How were your concerns going to be satisfied
15 then?
16 MS NORMAN: I expected a meeting, a strategy meeting, a case
17 conference.
18 MR GARNHAM: You have the power, do you not, to call for
19 a case conference?
20 MS NORMAN: Yes.
21 MR GARNHAM: Did you do so?
22 MS NORMAN: No, I did not because according to Haringey ACPC
23 they prefer to organise the case conferences for all
24 child protection cases.
25 MR GARNHAM: That may be right, but if it ain't happening,
46
1 do you not do it?
2 MS NORMAN: After the home visit I really believed that it
3 was going to be done, that there would be a case
4 conference.
5 MR GARNHAM: What was the basis of that belief?
6 MS NORMAN: I was quite pleased when I heard that they were
7 going to meet the parents because I felt then that the
8 case conference would come out of that, after they had
9 seen the parents.
10 MR GARNHAM: But it did not.
11 MS NORMAN: No.
12 MR GARNHAM: And you did not call for one thereafter, did
13 you?
14 MS NORMAN: After she had gone home?
15 MR GARNHAM: At any time in fact.
16 MS NORMAN: No, I did not.
17 MR GARNHAM: And Victoria was then discharged into Kouao's
18 care without there being a case conference?
19 MS NORMAN: Yes.
20 MR GARNHAM: And without your concerns, which had been
21 mounting during this period, ever being addressed?
22 MS NORMAN: Yes.
23 MR GARNHAM: Why?
24 MS NORMAN: I did not expect her to go home.
25 MR GARNHAM: Were you in work on Friday 6th August?
47
1 MS NORMAN: Yes.
2 MR GARNHAM: Would you have had access to the nursing notes?
3 MS NORMAN: Yes.
4 MR GARNHAM: So you would have known, would you, that the
5 arrangements for a home visit had been changed?
6 MS NORMAN: I knew they were going to take place that day.
7 MR GARNHAM: But it was not going to be at the home.
8 MS NORMAN: I did not know it was not going to be at home.
9 MR GARNHAM: You were not aware then that Lisa Arthurworrey
10 had received advice that protective clothing would have
11 to be worn were she to visit Kouao's house?
12 MS NORMAN: No, I was not aware.
13 MR GARNHAM: Would it have surprised you had you been told
14 that Arthurworrey had received that advice to that
15 effect?
16 MS NORMAN: Very surprised.
17 MR GARNHAM: Because (a) the scabies was treated?
18 MS NORMAN: Yes.
19 MR GARNHAM: And (b) you do not need to wear a space suit to
20 visit a home with scabies?
21 MS NORMAN: No, you do not.
22 MR GARNHAM: Sir, it is an error by me but I cannot remember
23 where I have seen the reference to Lisa Arthurworrey
24 reporting that. Thank you.
25 Would you go to 37/108, please. This is part of the
48
1 history sheets and you have told us that you had access
2 to the nursing notes when you arrived on duty on
3 6th August. First entry for the 4th August, so two days
4 before the day we are talking about:
5 "1.30, Lisa Arthurworrey, social worker, phoned re
6 Anna Kouga [sic]. Lisa and police were to meet this
7 morning at 10 o'clock at Anna's home. On the advice of
8 medical staff Lisa and police were told protective
9 clothing should be worn in Anna's home because Anna was
10 admitted to ward with scabies which is highly
11 infectious. Message left by Lisa on Anna's mum's mobile
12 phone. Arrangements made for meeting to take place on
13 5th August at 11 o'clock."
14 Did you know that?
15 MS NORMAN: Yes.
16 MR GARNHAM: Why did you tell me you were not aware of that
17 point about the protective clothing?
18 MS NORMAN: I was not aware that she had been told to wear
19 protective clothing -- no, sorry, I think that is my
20 mistake. I did not know she had been told.
21 MR GARNHAM: It is in there in the note.
22 MS NORMAN: I had not seen that.
23 MR GARNHAM: Why not? You said you had access to the notes
24 when you came on duty on the 6th. Do not you read them?
25 MS NORMAN: That was -- I have got the notes for the 4th and
49
1 the 5th.
2 MR GARNHAM: Yes. But you came to work on the 6th.
3 MS NORMAN: I came to work on the 6th.
4 MR GARNHAM: So that is after the 4th.
5 MS NORMAN: Yes.
6 MR GARNHAM: After these notes are made.
7 MS NORMAN: I did not read the notes on the 4th.
8 MR GARNHAM: I see, so you do not read back into the notes.
9 MS NORMAN: Sometimes. I do not always read the notes every
10 day because I am not always on the ward.
11 MR GARNHAM: But on the 6th you did not read that note?
12 MS NORMAN: No.
13 MR GARNHAM: But there was information available to you, if
14 you had looked at the notes, to the effect that
15 Lisa Arthurworrey was reporting that she had been told
16 that she needed protective clothing if she was to visit
17 Anna's home.
18 MS NORMAN: Yes.
19 MR GARNHAM: And that the date of the meeting had been
20 changed from the 4th to the 5th.
21 MS NORMAN: Yes.
22 MR GARNHAM: It is not clear from these notes, is it, that
23 there is to be, in the light of what has been said about
24 the protective clothing, any home visit? I agree it is
25 not clear but it might be thought, having read this,
50
1 that there was at least a question mark about whether
2 a home visit was ever going to take place.
3 MS NORMAN: Yes, now, having read the notes, yes.
4 MR GARNHAM: But you would say that the home visit did not
5 matter. What mattered?
6 MS NORMAN: I do not think a home visit would have made any
7 difference at all.
8 MR GARNHAM: You left work for the weekend on Friday, at the
9 end of your shift on Friday the 5th.
10 MS NORMAN: That is right.
11 MR GARNHAM: By that time what had the ward made available
12 to social workers and the police?
13 MS NORMAN: They were aware of the child abuse case, they
14 knew --
15 MR GARNHAM: Were they? How were they aware of the child
16 abuse case?
17 MS NORMAN: I know that one of the nurses had spoken to Lisa
18 and had expressed their concern about child abuse.
19 MR GARNHAM: Had there been any comprehensive up-to-date
20 report on Victoria's condition and the likely cause of
21 her injuries?
22 MS NORMAN: We did not have the likely cause of her injuries
23 so there would not have been a report.
24 MR GARNHAM: You had at the least some firm suspicions about
25 the possible cause.
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