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Archived Transcript for 12 November 2001: Pages
51 to 100
51
1 MS NORMAN: Yes.
2 MR GARNHAM: Was any of that written down and sent to social
3 workers?
4 MS NORMAN: Not as far as I know.
5 MR GARNHAM: So they are relying entirely on what they are
6 told over the phone to update the original CP forms.
7 MS NORMAN: Yes.
8 MR GARNHAM: And you agree that the notes that were kept by
9 nursing staff on the ward were incomplete, were not --
10 MS NORMAN: They were not very good.
11 MR GARNHAM: Not as good as they should have been?
12 MS NORMAN: No.
13 MR GARNHAM: There is a pretty obvious danger that the
14 social workers do not get to know all the information
15 they need, is there not?
16 MS NORMAN: Yes.
17 MR GARNHAM: Who authorised Victoria's discharge from the
18 ward?
19 MS NORMAN: I do not know.
20 MR GARNHAM: Who normally gives the okay to a child's
21 discharge on your ward?
22 MS NORMAN: It is a multidisciplinary decision. The child
23 will be discussed and a decision would be made following
24 all the discussions.
25 MR GARNHAM: I am sorry, I do not quite understand that
52
1 jargon. What do you mean, it is a multidisciplinary
2 decision? Do you mean everybody concerned?
3 MS NORMAN: On a ward round you would be asked if a child is
4 ready for discharge, if everything is in place, if
5 everything is ready.
6 MR GARNHAM: Did that sort of multidisciplinary meeting take
7 place in respect of Victoria before she was
8 discharged?
9 MS NORMAN: I do not know.
10 MR GARNHAM: Who has the final say if there is a dispute
11 about whether a patient should leave the ward?
12 MS NORMAN: The consultant.
13 MR GARNHAM: Go to page 80, volume 37, please. It is
14 a letter from Dr Rossiter of 13th August. Third
15 paragraph, Dr Rossiter writes:
16 "Unfortunately the ward staff seem to think that
17 social workers can discharge patients who are under the
18 care of a doctor."
19 Is that right? Is that what you thought?
20 MS NORMAN: That is what I thought had happened and it
21 should not have happened.
22 MR GARNHAM: Is it right that members of your staff on that
23 ward believed in August 1999 that social workers could
24 decide whether or not a child should be discharged?
25 MS NORMAN: No, they did not.
53
1 MR GARNHAM: So Dr Rossiter is wrong about that?
2 MS NORMAN: Sorry?
3 MR GARNHAM: Dr Rossiter therefore is wrong in what she
4 writes?
5 MS NORMAN: Dr Rossiter is saying that social workers should
6 not discharge children.
7 MR GARNHAM: No, she is saying, read it:
8 "Unfortunately the ward staff seem to think that
9 social workers can discharge patients who are under the
10 care of a doctor."
11 Is she right in that or is she wrong? Did your
12 staff think that social workers could discharge
13 patients?
14 MS NORMAN: In 1999?
15 MR GARNHAM: Yes.
16 MS NORMAN: No.
17 MR GARNHAM: So she is wrong?
18 MS NORMAN: She is right, social workers do not discharge
19 patients.
20 MR GARNHAM: No, but did staff believe that they could?
21 MS NORMAN: Staff, the staff know that they do not discharge
22 patients.
23 MR GARNHAM: So Rossiter is wrong?
24 MS NORMAN: Why is she wrong? I do not understand.
25 MR GARNHAM: Because she says they seem to think that social
54
1 workers can. So she is wrong about that?
2 MS NORMAN: They seem to think. When I read that sentence
3 I understand that she clearly does not agree that the
4 ward staff should expect social workers to discharge
5 patients.
6 MR GARNHAM: Absolutely right but despite that they appear,
7 according to Dr Rossiter, to believe that they can.
8 MS NORMAN: Well, they should not.
9 MR GARNHAM: No. That is obvious with respect Miss Norman.
10 MS NORMAN: I am sorry, I am not quite understanding.
11 MR GARNHAM: It must be the way I am putting the question.
12 I will try again. The concern that Dr Rossiter is
13 expressing in the third paragraph of that letter is
14 about what is in the minds of ward staff. She appears
15 to believe that ward staff thought that it was okay for
16 social workers to discharge patients. It is implicit in
17 what Dr Rossiter says that she, Dr Rossiter, does not
18 think that. So my question is is Dr Rossiter right when
19 she says that ward staff appeared in 1999 to believe
20 that social workers could discharge patients?
21 MS NORMAN: Yes.
22 MR GARNHAM: She is right?
23 MS NORMAN: Yes.
24 MR GARNHAM: Why is it that your staff believe that social
25 workers can discharge patients?
55
1 MS NORMAN: I really do not know why they believed that
2 because that is not the practice.
3 MR GARNHAM: Did it happen in this case from what you have
4 seen of the notes? Was the discharge effectively
5 authorised by social workers?
6 MS NORMAN: From what I was told the social workers came to
7 the ward and spoke to Victoria and they told the nurse
8 that everything was fine and that Victoria could go
9 home. They had been left on the ward round that day.
10 A decision was made, I do not know who by, to say that
11 if social services had phoned to say that everything was
12 all right Victoria could go home. It does not mean that
13 I agreed with that decision.
14 MR GARNHAM: It is plain, is it not, that ward staff knew
15 that Victoria was going to go home with Kouao?
16 MS NORMAN: Yes.
17 MR GARNHAM: And that was going to happen despite the fact
18 that, as you knew, the concerns you had about Victoria's
19 safety had not been properly addressed?
20 MS NORMAN: That is right.
21 MR GARNHAM: So why was it allowed to happen?
22 MS NORMAN: I think that is something that we are going to
23 regret for the rest of our lives because it should not
24 have happened.
25 MR GARNHAM: Thank you. What should have happened?
56
1 MS NORMAN: They should at least have rung Dr Rossiter
2 before that decision was made.
3 MR GARNHAM: Did you consider whether any further steps
4 should be taken to protect Victoria once you discovered
5 that she had gone home?
6 MS NORMAN: I spoke to Dr Rossiter that morning.
7 MR GARNHAM: What did you say?
8 MS NORMAN: That I was very surprised that Victoria had gone
9 home.
10 MR GARNHAM: What did she say?
11 MS NORMAN: She was very surprised.
12 MR GARNHAM: So there you are, the two of you, each
13 expressing surprise about what had happened. What did
14 you do in consequence?
15 MS NORMAN: She took the notes, did a summary and wrote
16 a letter to express her concerns.
17 MR GARNHAM: That is the letter, was it, to Petra Kitchman?
18 MS NORMAN: As far as I know.
19 MR GARNHAM: Did you have sight of that letter before
20 Dr Rossiter sent it?
21 MS NORMAN: No, I did not.
22 MR GARNHAM: By the time that Victoria left your care or the
23 care of your ward, had you satisfied yourself whether or
24 not the scalds were self-inflicted?
25 MS NORMAN: No, I had not.
57
1 MR GARNHAM: So there was still a question mark in your mind
2 about that?
3 MS NORMAN: Yes.
4 MR GARNHAM: So it was possible that Victoria had been the
5 victim of a deliberate scalding assault?
6 MS NORMAN: It is possible.
7 MR GARNHAM: Did you ensure that that concern, that
8 reservation, was properly recorded anywhere? Do we find
9 anywhere in the notes: "It is at least possible this
10 child was the victim of a deliberate scalding"?
11 MS NORMAN: I did not write in the notes.
12 MR GARNHAM: Why not? She has gone home with the woman who
13 might have done it.
14 MS NORMAN: Because I think we felt we needed to get --
15 Dr Rossiter needed the notes. I should have got the
16 notes back and put it in afterwards.
17 MR GARNHAM: The surprise that you have expressed that you
18 felt when you came back to work which I think was on the
19 9th, on the Monday?
20 MS NORMAN: On the Monday.
21 MR GARNHAM: I am not entirely sure that I understand why
22 you were so surprised. Was it not always the intention,
23 the plan, that Victoria would go home with Kouao?
24 MS NORMAN: No, I never ever expected Victoria to go home
25 with Kouao.
58
1 MR GARNHAM: Could you have volume 37 again, page 275. Last
2 entry, 3rd August, who made that entry? I think
3 Nurse Quinn, was it?
4 MS NORMAN: Yes.
5 MR GARNHAM: "Lisa Arthurworrey, she needs to make a home
6 visit with the police before Anna can go home."
7 So was it not obvious from that that the plan was
8 that Victoria would go home and that home meant go home
9 with Kouao?
10 MS NORMAN: No, because Isobel cannot make that decision.
11 MR GARNHAM: No, but that is what is envisaged as what is
12 going to happen?
13 MS NORMAN: I did not envisage that.
14 MR GARNHAM: You say in paragraph 41 that you were aware
15 that Dr Rossiter contacted various people to express her
16 concerns.
17 MS NORMAN: Yes.
18 MR GARNHAM: First of all, when did you discover that, that
19 she had do ne that?
20 MS NORMAN: I spoke to her on the Monday and discussed it
21 again that week and she said that she had contacted
22 various people.
23 MR GARNHAM: Do you know who the various people were?
24 MS NORMAN: No, I did not.
25 MR GARNHAM: Did she tell you who she had contacted?
59
1 MS NORMAN: I think she had written to social services.
2 MR GARNHAM: Letter to Petra Kitchman?
3 MS NORMAN: There was a letter to Petra Kitchman.
4 MR GARNHAM: Do you know of any other contacts Dr Rossiter
5 had made?
6 MS NORMAN: I think she sent a letter to Tottenham Social
7 Services.
8 MR GARNHAM: So you think she wrote one to Kitchman and two
9 to social services?
10 MS NORMAN: I think so.
11 MR GARNHAM: That was your understanding?
12 MS NORMAN: Yes.
13 MR GARNHAM: What did you think were the concerns that
14 Dr Rossiter was going to be expressing?
15 MS NORMAN: The child abuse of neglect, the physical
16 injuries on her body.
17 MR GARNHAM: So you thought Dr Rossiter had contacted North
18 Tottenham Social Services and Kitchman and told them
19 that the ward staff and doctors had concern that
20 Victoria had been the victim of physical abuse?
21 MS NORMAN: Physical and neglect.
22 MR GARNHAM: Physical and neglect.
23 MS NORMAN: And emotional, yes.
24 MR GARNHAM: All those three forms you thought Dr Rossiter
25 was going to be conveying information about?
60
1 MS NORMAN: Yes.
2 MR GARNHAM: Did either of you, you or Rossiter, suggest
3 that there should be a case conference in this case?
4 MS NORMAN: I did not, I do not know if Dr Rossiter did.
5 MR GARNHAM: You assumed that the case was going to be
6 followed up, did you, by the allocated social worker?
7 MS NORMAN: Yes.
8 MR GARNHAM: Did you check whether that happened?
9 MS NORMAN: No, I did not.
10 MR GARNHAM: Was there any mechanism by which ward staff
11 could check that that happens in a case where they have
12 residual concerns?
13 MS NORMAN: I think we have to trust the people we work with
14 who have passed on the case and we expect them to do
15 their job.
16 MR GARNHAM: So the answer to my question is no, there is
17 not a mechanism?
18 MS NORMAN: No, there is not.
19 MR GARNHAM: There is not a mechanism?
20 MS NORMAN: No, we can ring and find out but you cannot
21 always speak to the person you need to speak to.
22 MR GARNHAM: There is no Haringey social worker based at
23 NMH, is there?
24 MS NORMAN: Not at the moment.
25 MR GARNHAM: Nor was there in August 1999?
61
1 MS NORMAN: No, there was not.
2 MR GARNHAM: The job is covered, is it not, by the
3 Enfield -- or was in 1999 covered by the Enfield social
4 worker?
5 MS NORMAN: Yes.
6 MR GARNHAM: Did that system work satisfactorily as far as
7 you were concerned?
8 MS NORMAN: Not really, no.
9 MR GARNHAM: In what way was it not satisfactory?
10 MS NORMAN: Because you have always got to go through
11 somebody to get to Haringey Social Services.
12 MR GARNHAM: Why was that a problem?
13 MS NORMAN: It is much easier to deal with people direct.
14 MR GARNHAM: Did it cause difficulties in Victoria's case as
15 far as you were concerned?
16 MS NORMAN: Yes, I think we would have had better
17 communication if they had been in the hospital. They
18 would have been able to come and see Victoria on the
19 ward.
20 MR GARNHAM: Could Karen Johns not do that?
21 MS NORMAN: I do not know if it is her place to do that.
22 MR GARNHAM: Did she in fact come on your ward and see
23 Victoria herself?
24 MS NORMAN: I do not think she spoke to Victoria, no.
25 MR GARNHAM: Did the hospital arrange any follow-up for
62
1 Victoria after she had left?
2 MS NORMAN: Only if she needed medical care would she have
3 an outpatient's appointment.
4 MR GARNHAM: But she did not and so there was not such an
5 appointment?
6 MS NORMAN: No.
7 MR GARNHAM: Was a health visitor involved by the ward?
8 MS NORMAN: The liaison health visitor knew about it.
9 MR GARNHAM: She knew about it?
10 MS NORMAN: Yes.
11 MR GARNHAM: Who is that health visitor?
12 MS NORMAN: At the time it was Maggie Low.
13 MR GARNHAM: Maggie L-O-W-E?
14 MS NORMAN: L-O-W I think.
15 MR GARNHAM: So she knew about it?
16 MS NORMAN: Yes.
17 MR GARNHAM: Do you know what she was going to do?
18 MS NORMAN: She would contact the health visitor Victoria
19 would be under. She passes on the information to the
20 health visitor in the community.
21 MR GARNHAM: That is what you say she would do. Do you know
22 whether she did?
23 MS NORMAN: I am not sure if she did.
24 MR GARNHAM: Can we just look back at this stage and review
25 how much information available to the hospital had
63
1 reached social services by the time Victoria had left
2 the hospital. Nurse Quinn says in her statement and has
3 told us that she sent a six-page fax and we have that at
4 page 72, volume 37, if you would like to turn that up.
5 Page 72 is the cover sheet.
6 MS NORMAN: That is right.
7 MR GARNHAM: Said to be a facsimile of six pages including
8 that one, so we look for five more and we see there is
9 a letter or notes to Lisa Arthurworrey of 3rd August.
10 MS NORMAN: Yes.
11 MR GARNHAM: That refers to the incident where Victoria is
12 said to have jumped out of bed and stood to attention,
13 master and servant attitude.
14 MS NORMAN: Yes.
15 MR GARNHAM: Second entry relating to Anna wetting herself
16 and mother making no effort to assist.
17 MS NORMAN: Yes.
18 MR GARNHAM: Dr Rossiter's evidence of emotional abuse and
19 mum visiting, when leaving Anna started to cry but there
20 were no tears in her eyes and she recovered very
21 quickly.
22 MS NORMAN: Yes.
23 MR GARNHAM: And then finally Anna eating a large amount of
24 food, yes?
25 MS NORMAN: Yes.
64
1 MR GARNHAM: What else was passed from your hospital to
2 social workers?
3 MS NORMAN: The CP forms.
4 MR GARNHAM: The CP forms, which were in their 24th July
5 state apart from one addition made by Dr Rossiter
6 substantively?
7 MS NORMAN: Yes.
8 MR GARNHAM: Anything else? That would seem to account for
9 the six pages of the fax, would it not?
10 MS NORMAN: I think so, yes.
11 MR GARNHAM: Lisa Arthurworrey says in her statement that
12 she received 11 pages and that included the handwritten
13 note at page 73 in that bundle, which we have just
14 looked at, the body maps which we have at page 60, which
15 we have already looked at, the paediatric assessment
16 form which is found in volume 6 although it might be
17 elsewhere in 37. Could we have volume 6, please,
18 page 248. It may be my notes are wrong, it may be
19 volume 5. Is that the paediatric assessment form or
20 have I got the wrong volume?
21 MS NORMAN: This is the paediatric assessment form from A&E.
22 MR GARNHAM: It is?
23 MS NORMAN: Yes.
24 MR GARNHAM: So that document Arthurworrey says she received
25 and also the A&E form at page 254 in that same bundle.
65
1 MS NORMAN: Yes.
2 MR GARNHAM: Tell me if I am wrong but looking through that
3 documentation there does not seem to be anything clearly
4 indicative of a belief that Victoria was the victim of
5 physical abuse.
6 MS NORMAN: I thought the letter that Nurse Isobel Quinn had
7 sent.
8 MR GARNHAM: Well, I am sure it is me but I do not see where
9 that is so. Do you mean the note at 73 in volume 37?
10 MS NORMAN: The first one we looked at?
11 MR GARNHAM: Yes.
12 MS NORMAN: Yes.
13 MR GARNHAM: That is a note from Isobel Quinn to
14 Lisa Arthurworrey. What is there in that that shows
15 evidence of physical abuse?
16 MS NORMAN: She wrote this after the CP forms had been
17 obtained and filled in which had the injuries and the
18 burns on the face, so she just put in what the nurses
19 had observed.
20 MR GARNHAM: But from where in that material are the social
21 workers supposed to understand that you collectively
22 believed that Victoria might have been the victim of
23 physical abuse?
24 MS NORMAN: It is not very obvious here because you needed
25 to sit down and have a meeting with people and be able
66
1 to talk to --
2 MR GARNHAM: That is an enormous problem, is it not?
3 MS NORMAN: Yes.
4 MR GARNHAM: You are discharging this little girl who you
5 believe had been the victim of physical abuse back to
6 the person who might have been her abuser and you are
7 relying on social services following up but social
8 services are not being provided with the information
9 that indicates what your concerns were. That is
10 a recipe for disaster, is it not?
11 MS NORMAN: Yes, I did not expect her to be discharged.
12 MR GARNHAM: But it is hopeless. Can you sensibly run
13 a ward in those circumstances where she is allowed off
14 the ward without this information being passed to social
15 services but relying on social services to follow it up?
16 MS NORMAN: Yes, it was not good enough.
17 MR GARNHAM: Because you are leaving social workers to
18 discern this information from the air, are you not?
19 MS NORMAN: Yes.
20 MR GARNHAM: The problem is, Nurse Norman, that the evidence
21 that we are now getting in this Inquiry about your
22 staff's fears about Victoria are far more serious than
23 appear in the notes.
24 MS NORMAN: They are very serious.
25 MR GARNHAM: And they are more serious than appear in the
67
1 notes.
2 MS NORMAN: I think it was very difficult to put it in
3 words. I think people did find that difficult to put in
4 words.
5 MR GARNHAM: But you can see the potential consequences if
6 you do not make an effort to put it in words, can you
7 not?
8 MS NORMAN: Yes.
9 MR GARNHAM: You see, there are two possibilities, are there
10 not, Nurse Norman? Either you and your nursing staff
11 had these fears and these concerns and you failed to
12 ensure that that information reached social services, or
13 you did not really have fears to that degree, which is
14 why it does not appear in the notes. Those are the two
15 possibilities, are they not?
16 MS NORMAN: Yes.
17 MR GARNHAM: Either you had them and did not record them or
18 you did not have them at all?
19 MS NORMAN: We definitely had the fears.
20 MR GARNHAM: What I am wondering is whether the truth is it
21 is only now you know what a ghastly fate Victoria met
22 that you are starting to look back on what happened and
23 think about things that you ought to have felt.
24 MS NORMAN: No.
25 MR GARNHAM: Because it would be quite understandable if you
68
1 did that. This is an appalling case and nobody would
2 criticise you if in the light of that you thought about
3 things that you wished you had seen and believed at the
4 time.
5 MS NORMAN: I wished she did not go home when I came to work
6 on that Monday morning.
7 MR GARNHAM: And these fears were fears and concerns that
8 you honestly had at the time?
9 MS NORMAN: Yes.
10 MR GARNHAM: This is not the result of a conversation that
11 you have had with Dr Reynders afterwards?
12 MS NORMAN: I have not seen him.
13 MR GARNHAM: Was there no discussion amongst nursing staff
14 since this all happened about what occurred on the ward?
15 MS NORMAN: I think everybody was very shocked obviously
16 when it happened.
17 MR GARNHAM: I am sure they were. So you will have talked
18 about it?
19 MS NORMAN: Yes.
20 MR GARNHAM: Do you think that it might be that it is in
21 those conversations that these fears started to surface
22 rather than at the time?
23 MS NORMAN: No, I can categorically say no, the fears were
24 there all along.
25 MR GARNHAM: If that is right then your failure to ensure
69
1 that social services knew of those fears is a serious
2 one, is it not?
3 MS NORMAN: Yes.
4 MR GARNHAM: Just a couple of minor points to finish with,
5 please. Could you go to page 264 in volume 37. Do you
6 have that, 264?
7 MS NORMAN: I am getting there.
8 MR GARNHAM: Top right-hand corner, there is a note beside
9 the date 27th June. There is then what looks like an R
10 and a squiggle and then what could be RA or NA and then
11 "VA not done -?! cannot read ?? says does not know".
12 Could you translate that? Do you have any idea who
13 wrote it or what it says? First of all do you know who
14 wrote it?
15 MS NORMAN: No, I do not.
16 MR GARNHAM: Not a handwriting you recognise?
17 MS NORMAN: No it is not.
18 MR GARNHAM: Do you have any idea what it means?
19 MS NORMAN: In the beginning I thought they were talking
20 about treatment with R, and then the cross, but I am not
21 sure what VA is referring to, "VA not done". That might
22 be -- no, I am not going to speculate.
23 MR GARNHAM: What about the date, 27th of the 6th? Does
24 that look like an error? Should it be 27th of the 7th,
25 given its place in the file?
70
1 MS NORMAN: Yes 27th, I think that is an error.
2 MR GARNHAM: Next of these additional little questions. Is
3 it correct that Victoria wet herself every night or
4 virtually every night she was in the hospital?
5 MS NORMAN: Quite a few of the nights she was in hospital,
6 yes.
7 MR GARNHAM: Did she ever soil herself?
8 MS NORMAN: Never.
9 MR GARNHAM: Third point, when did Victoria treat herself
10 with Hibiscrub? We have a reference to that at page 269
11 in this bundle. Halfway down the page: "Evidence of
12 emotional abuse, anxious attachment", and a word I have
13 tried several times to pronounce and failed but I think
14 it means "? short", and then third, "self-treatment with
15 Hibitane ..." which I think is another word for
16 Hibiscrub, is it not?
17 MS NORMAN: Yes, it is similar.
18 MR GARNHAM: That is a sort of antiseptic wash or soap?
19 MS NORMAN: Yes, we have it in the sink.
20 MR GARNHAM: "Self-treatment with Hibitane for itching
21 scalp, is this evidence of emotional neglect?"
22 Then again at page 69 in that volume, about halfway
23 down the page onward:
24 "Anna poured Hibiscrub over herself. She finds it
25 difficult to ask for help."
71
1 My question is whether it was thought by you nurses
2 that this self-medication with Hibiscrub or Hibitane was
3 indicative of an inability to ask for help and whether
4 you were equating that with the self treatment by
5 tipping water over her head?
6 MS NORMAN: It is difficult to know exactly what she was
7 trying to do, really.
8 MR GARNHAM: The fourth of these supplementary questions,
9 can you confirm that Karen Johns came on to the ward on
10 28th July in order to collect copies of the medical
11 notes?
12 MS NORMAN: That is what I was told, that she came to the
13 ward.
14 MR GARNHAM: Sir, could I have one moment? I have just been
15 handed some more questions and I am trying to read as
16 I go.
17 I think the easiest thing is if I put these
18 questions to you as I have been asked to do and you can
19 deal with them. It is right, is it not, that there were
20 no entries on the critical incident log after
21 3rd August?
22 MS NORMAN: I do not know, I would have to see.
23 MR GARNHAM: 37/275. It appears as if the entries end on
24 3rd August at 4.30.
25 MS NORMAN: It is difficult for me to say that because I am
72
1 sure there would have been another for the 4th, 5th and
2 6th until she went home.
3 MR GARNHAM: You think this is wrong?
4 MS NORMAN: It might be.
5 MR GARNHAM: I would be surprised given Mr Mason's
6 carefulness at providing us with documents, but it is
7 being suggested that there were pages that continue
8 after 37/275.
9 MS NORMAN: It could have been. I am trying to remember
10 what the 3rd was. It might have been -- she went home
11 on the 6th. I really cannot say.
12 MR GARNHAM: One would have expected further entries after
13 the 3rd in the next three days?
14 MS NORMAN: Yes, if anything had happened.
15 MR GARNHAM: So either we do not have them or nothing
16 happened?
17 MS NORMAN: If nothing happened then nothing would be
18 entered.
19 MR GARNHAM: If there were the continuing concerns that you
20 say you had, would you not expect them to be recorded on
21 the critical incident log?
22 MS NORMAN: There might have been days when there was
23 nothing to report.
24 MR GARNHAM: Even the days immediately preceding her
25 discharge?
73
1 MS NORMAN: I think those days we were just waiting to see
2 what was going to happen from social services.
3 MR GARNHAM: Again this is a question I am asked to put to
4 you. Go to 37/053 please. We have looked at these
5 before, these are the CP forms, but if you want time to
6 look at them again before you answer this question,
7 please do. What impression do you think would be left
8 with a social worker reading the notes?
9 MS NORMAN: Which notes?
10 MR GARNHAM: All the notes from 53 through to 55. I mean
11 look in particular at 55 under "Emotional State":
12 "Child relaxed, smiling, scratching hands plus and
13 arms plus plus plus. Very -- "
14 That is the end of the quote. I think the point
15 that is being made is that reading these notes one would
16 have gained the impression that this was a child who was
17 not in significant distress. Would that be fair?
18 MS NORMAN: Yes, if you are reading these notes, yes.
19 MR GARNHAM: Last question. Where does it say "suspect
20 non-accidental injury" anywhere on the critical
21 incident? It does not, does it?
22 MS NORMAN: No, not on the critical incident log but that is
23 not up to the nurses to decide whether it is
24 non-accidental or not.
25 MR GARNHAM: Thank you very much.
74
1 MR MASON: Good morning Mrs Norman.
2 MS NORMAN: Good morning Mr Mason.
3 MR MASON: Can I ask you a question about something that
4 arose on Friday? I do not have LiveNote, it may be my
5 inadequate notetaking. I think you were asked about
6 interagency mechanisms, meetings, communicating, and
7 I believe you said it was like a social meeting where
8 you could meet social workers, and the social workers
9 were not attending. Was it no social workers attending
10 the psychosocial meetings in 1999 or was Karen Johns
11 attending at least some of the meetings?
12 MS NORMAN: No social workers.
13 MR MASON: No social workers at all?
14 MS NORMAN: No.
15 MR MASON: In 1999 were there non-accidental injury formal
16 meetings on Tuesdays?
17 MS NORMAN: Yes.
18 MR MASON: Were social workers invited to those?
19 MS NORMAN: They were all invited.
20 MR MASON: Did they come?
21 MS NORMAN: No, they did not.
22 MR MASON: Were the other mechanisms strategy meetings and
23 case conferences?
24 MS NORMAN: Yes.
25 MR MASON: The critical incident log, was that a document
75
1 that was available at psychosocial meetings?
2 MS NORMAN: Yes.
3 MR MASON: Was it available at non-accidental injury forum
4 meetings?
5 MS NORMAN: Yes, it could be made available.
6 MR MASON: Would they be available at strategy meetings and
7 case conferences if NHS staff were able to attend?
8 MS NORMAN: Yes, they would be.
9 MR MASON: Can I ask you something about the diagrams, body
10 maps, volume 37, page 60, but I do not think I need to
11 take you to them. You were asked about occasions when
12 they were taken for non-child abuse instances, road
13 traffic accidents and so on.
14 MS NORMAN: Yes.
15 MR MASON: If the body maps were taken for reasons other
16 than child protection matters, would they be kept in
17 child protection notes?
18 MS NORMAN: No, they would not.
19 MR MASON: Where would they be kept?
20 MS NORMAN: They would be in the notes.
21 MR MASON: The patient's ordinary notes?
22 MS NORMAN: Yes.
23 MR MASON: And you said the body maps were kept in child
24 protection, with the child protection notes; is that
25 correct?
76
1 MS NORMAN: That is right.
2 MR MASON: Also you were asked about what they record on
3 body maps. Would the body maps record all marks when
4 they are made or just marks that were suspicious of NAI?
5 MS NORMAN: Marks that were suspicious of NAI.
6 MR MASON: And not old existing marks?
7 MS NORMAN: No, because some of them you cannot, only what
8 you can see and suspect it is NAI.
9 MR MASON: But if there are marks on the body, old scars
10 that may or may not be suspicious, would they go on the
11 body map?
12 MS NORMAN: They might put old marks on as well because they
13 might be relevant.
14 MR MASON: And these body maps, would they be as available
15 at meetings as a critical incident log?
16 MS NORMAN: Yes.
17 MR MASON: So they would be available at psychosocial
18 meetings, NAI forum meetings, strategy meetings and case
19 conferences?
20 MS NORMAN: Yes.
21 MR MASON: Photographs, you were asked if they were normally
22 shown to the police or social services. First of all,
23 is that something that is normally produced to those
24 organisations automatically or in response to a request?
25 Do you know, is that something you deal with?
77
1 MS NORMAN: The photographs are in response to a request.
2 MR MASON: And whose decision is it to release them?
3 MS NORMAN: The consultant.
4 MR MASON: You have been asked about the note-keeping and
5 the recording of suspicions and I think you said that
6 was possibly something that wasn't really done very much
7 in 1999.
8 MS NORMAN: Yes.
9 MR MASON: Has the practice changed now?
10 MS NORMAN: The practice has changed. CP6 has been changed.
11 It is more user friendly, we have plenty of room to
12 write down everything concerning the child, the parent
13 or the carer.
14 MR MASON: Do nursing staff now record their suspicions as
15 well as their facts?
16 MS NORMAN: Yes.
17 MR MASON: Turning to the strategy meeting that was held on
18 the 28th, volume 5, page 254. That is a note of the
19 meeting. Can I ask you please to turn back one page.
20 Karen Johns halfway down the page refers to a telephone
21 call from Shanti Jacobs. Is she a Haringey social
22 worker?
23 MS NORMAN: She must be.
24 MR MASON: She refers there to being told by Shanti Jacobs
25 of the strategy meeting. There is nothing on the page
78
1 of 253 or 4 that I can find to say that Karen Johns
2 passed this information on to you or any of your
3 colleagues. Am I correct in that?
4 MS NORMAN: Yes.
5 MR MASON: In fairness to Karen Johns would it be her job to
6 pass that on or would it be up to Haringey to organise
7 your attendance?
8 MS NORMAN: She would normally tell us and that there would
9 be a meeting if she had been told by social services, or
10 they would ring themselves.
11 MR MASON: Then she has written fairly full descriptions of
12 conversations she has had and is informing you on.
13 MS NORMAN: Yes.
14 MR MASON: You also referred to a conversation that --
15 Karen Johns has made a note about a conversation with
16 you on the 29th and that is page 255, it is the first
17 entry:
18 "Went to Rainbow Ward. Spoke briefly to
19 Sister Beat."
20 How can you be sure that you did not speak to her,
21 or are you not sure?
22 MS NORMAN: I would have expressed my concerns that we were
23 not invited to the child protection meeting.
24 MR MASON: As I understand it -- that is not quite the
25 question, sorry. It may be I the way I put it. I think
79
1 you said in evidence that you did not speak to
2 Karen Johns.
3 MS NORMAN: I do not remember speaking to Karen Johns about
4 Victoria.
5 MR MASON: Are you sure that you never spoke to her or is it
6 something that you cannot remember?
7 MS NORMAN: I do not remember having that conversation.
8 MR MASON: But not remembering having a conversation does
9 not necessarily mean that you have -- it took place and
10 you have forgotten. I want to be clear. Are you saying
11 is it possible that the conversation took place and you
12 have forgotten about it?
13 MS NORMAN: I think I would have remembered it.
14 MR MASON: But you might not have done?
15 MS NORMAN: Yes.
16 MR MASON: Now to move on to communication with social
17 services. I will ask you please to look at
18 Lisa Arthurworrey's statement in the witness volume 2,
19 page 69/70. This is where she summarises what she says
20 she was told by Isobel Quinn, that Victoria is a bright
21 7-year-old, spoke three languages, presented to hospital
22 in dirty clothing without underwear in contrast to
23 Kouao, elegantly dressed. Concerns about the fact that
24 Victoria appeared to stand straight to attention when
25 Kouao was around and wet herself in Kouao's presence.
80
1 Does that all accurately reflect some of the hospital's
2 concerns?
3 MS NORMAN: Yes.
4 MR MASON: Paragraph 84 she goes on:
5 "I was told that the hospital accepted the
6 explanation that Victoria had sustained burns by pouring
7 hot water over her head to relieve the scabies."
8 Is that a correct interpretation of the hospital's
9 concerns?
10 MS NORMAN: I cannot see how we could have accepted it.
11 MR MASON: "There were concerns about Kouao's response to
12 Victoria's accident as a discrepancy between the timing
13 of the incident and Victoria's presentation" had been
14 noted. Is that accurate?
15 MS NORMAN: Yes.
16 MR MASON: "Nurse Quinn also told me that Dr Forlee had
17 noticed odd marks which appeared to be non-accidental
18 and which caused the hospital concern."
19 Leaving aside which doctor it may or may not have
20 been, who first noticed them, are the concerns about
21 marks accurate?
22 MS NORMAN: Yes.
23 MR MASON: On the next page, paragraph 83, Mr Garnham has
24 already taken you through the document that Arthurworrey
25 said she was faxed, the two-page handwritten letter from
81
1 Nurse Quinn, head sketch, body sketches, paediatric
2 assessment forms, child protection record, A&E form.
3 Taking all that together is that complete information
4 about the hospital's concern, the nursing staff's
5 concerns about Victoria?
6 MS NORMAN: At that particular time.
7 MR MASON: Is that complete, is that everything?
8 MS NORMAN: Yes, at that particular time.
9 MR MASON: If it is considered by some not to be complete,
10 is that enough in your view for a child protection
11 investigation to take place under Section 47?
12 MS NORMAN: Yes.
13 MR MASON: Calling case conferences, you were asked if you
14 could have called a case conference. Have you ever
15 personally called a case conference?
16 MS NORMAN: No.
17 MR MASON: What do you think Dr Rossiter's response might be
18 if you called a case conference on your own?
19 MS NORMAN: I think she would be horrified.
20 MR MASON: What would you do then if you had concerns about
21 a child and you thought that some multidisciplinary
22 meeting or something of that sort should take place?
23 MS NORMAN: I would discuss it with Dr Rossiter.
24 MR MASON: Discharge arrangements. Dr Rossiter's letter,
25 I do not need to take you back to it, 37/80. Is there
82
1 a difference between implicit consent of a doctor for
2 discharge, as it were a conditional consent: "If so and
3 so happens the child can go home", and explicit consent:
4 "The child can go home at this instant"?
5 MS NORMAN: Yes, there is.
6 MR MASON: Do you think that there was either implicit or
7 explicit consent in Victoria's case when she was
8 discharged and, if so, which?
9 MS NORMAN: It was implicit.
10 MR MASON: Now in 2001 is implicit consent enough?
11 MS NORMAN: No, it is not.
12 MR MASON: What is required?
13 MS NORMAN: The consultant to discharge the child.
14 MR MASON: Explicit consent?
15 MS NORMAN: Explicit.
16 MR MASON: If I may -- last question -- take you briefly to
17 one of Mr Garnham's short points, volume 37, page 264,
18 the mysterious note, the first two lines. Can you
19 please go back one page where there is an ophthalmology
20 referral by Dr Jackson. Do you think there might be
21 a connection between what you see on page 264 and the
22 referral on the previous page or do you not --
23 MS NORMAN: Yes, there could be, yes.
24 MR MASON: No more questions.
25 THE CHAIRMAN: Thank you. Nurse Norman, just a few
83
1 questions, please. First of all, you say at the
2 beginning of your statement that at the time Victoria
3 was admitted to hospital you were the lead nurse in
4 paediatrics.
5 MS NORMAN: That is right.
6 THE CHAIRMAN: I am not familiar with such titles. Can
7 I take it that you were the nurse manager?
8 MS NORMAN: Yes.
9 THE CHAIRMAN: You were responsible for the nurses on the
10 paediatric wards?
11 MS NORMAN: Yes, I was.
12 THE CHAIRMAN: And you have since moved to another job,
13 I understand.
14 MS NORMAN: Yes.
15 THE CHAIRMAN: A different job now. What are your
16 responsibilities now?
17 MS NORMAN: Still the paediatric unit but with A&E added on,
18 A&E paediatrics.
19 THE CHAIRMAN: So you have wider managerial
20 responsibilities?
21 MS NORMAN: Yes.
22 THE CHAIRMAN: You say in your statement at paragraph 5,
23 I think just in front of you there, you were on the
24 Rainbow Ward from 7.30 in the morning until 7.30 or
25 8 o'clock in the evening.
84
1 MS NORMAN: I actually meant to correct that when we first
2 started. I start at 7.30 because I like to have the
3 report with the rest of the nurses and I usually would
4 finish about 5, unless it is very busy I will cover, but
5 I do get my time back by taking a day off in the middle
6 of the week.
7 THE CHAIRMAN: I am happy to accept that correction. In any
8 event, what it means is that not much happens on the
9 Rainbow Ward that you do not know about?
10 MS NORMAN: Not really.
11 THE CHAIRMAN: In fact, I suppose in another way it is your
12 job to know about everything that happens on the Rainbow
13 Ward?
14 MS NORMAN: That is right.
15 THE CHAIRMAN: These psychosocial meetings on a Monday, what
16 time on a Monday do they take place?
17 MS NORMAN: 2 pm.
18 THE CHAIRMAN: You said in answer to Mr Garnham that
19 Victoria had a bath at 11.30 in the evening on the day
20 that she was admitted.
21 MS NORMAN: I am not sure. She was admitted 11.30 that
22 night. She came in Saturday night and I am not sure if
23 she was given a bath when she arrived on the ward that
24 night. I definitely know that she had a bath on the
25 Monday and Nurse Grace Pereira said that she gave her
85
1 a bath on the Sunday.
2 THE CHAIRMAN: So what do you definitely know?
3 MS NORMAN: She had a bath on the Sunday and she had a bath
4 on Monday.
5 THE CHAIRMAN: And each time she had a bath it was different
6 staff that bathed her?
7 MS NORMAN: Different staff, yes.
8 THE CHAIRMAN: And each time the marks on her body were
9 observed and reported?
10 MS NORMAN: Yes.
11 THE CHAIRMAN: You are sure about that?
12 MS NORMAN: Yes.
13 THE CHAIRMAN: Why did you not see the photographs that were
14 taken of Victoria?
15 MS NORMAN: I do not know why we did not get the
16 photographs.
17 THE CHAIRMAN: Would it be normal practice that you would
18 see the photographs?
19 MS NORMAN: Not always.
20 THE CHAIRMAN: Why sometimes and not other times?
21 MS NORMAN: Usually the photographs are taken and sent
22 straight to the consultant. If they feel it is
23 necessary for us to see them they would show them to us.
24 THE CHAIRMAN: Included in the record on the ward that the
25 nurses have access to or not?
86
1 MS NORMAN: The consultant would then get them and send them
2 to the various people that need to see them and then
3 they would be kept in a legal file.
4 THE CHAIRMAN: Accessible to the nurse manager or not?
5 MS NORMAN: If I needed to see them, yes.
6 THE CHAIRMAN: So you could have seen the photographs?
7 MS NORMAN: I could have seen the photographs.
8 THE CHAIRMAN: You were aware that the photographs were
9 requested?
10 MS NORMAN: Yes.
11 THE CHAIRMAN: So you could have seen the photographs but
12 you did not see the photographs?
13 MS NORMAN: No, I did not until 2nd November.
14 THE CHAIRMAN: 2nd November just passed?
15 MS NORMAN: Yes.
16 THE CHAIRMAN: This is quite an interesting issue in that it
17 was the nurses that observed and reported the marks on
18 Victoria's body.
19 MS NORMAN: Yes.
20 THE CHAIRMAN: Why is it that if the nurses had observed and
21 reported the marks on the body, you did not think it
22 very important that you saw the photographs that were
23 taken?
24 MS NORMAN: Because I think we had seen Victoria in real
25 life. We had seen the burns on her face, we had seen
87
1 the horrible marks on her body. We did not need to see
2 the photographs to be convinced that she was abused.
3 THE CHAIRMAN: No, I accept that, you did not need to be
4 convinced. I think that my question was not about
5 whether you needed to be convinced, it was about whether
6 other people needed to be convinced that what you and
7 your staff had reported was correct.
8 MS NORMAN: Yes, I will agree with that.
9 THE CHAIRMAN: So if you had real concerns, which you say
10 that you have, you could have actually reinforced those
11 concerns by saying, "What my staff have reported are
12 confirmed in the photographs"?
13 MS NORMAN: Yes.
14 THE CHAIRMAN: So it would have actually given you, if I can
15 put it this way, greater authority had you seen the
16 photographs and been able to say, "They simply confirm
17 what my staff report"?
18 MS NORMAN: Yes.
19 THE CHAIRMAN: So it would have been better had you seen the
20 photographs?
21 MS NORMAN: Yes.
22 THE CHAIRMAN: What in your view is the purpose of the
23 CP forms?
24 MS NORMAN: The child protection forms are to tell you the
25 problems, the child abuse problems that the child has,
88
1 the initial clerking that the doctor first sees, and it
2 is really just a beginning of what should be a full
3 investigation following the Child Protection Guidelines.
4 CP forms alone would not be enough. You would need to
5 get all the information together.
6 THE CHAIRMAN: Right, and do you recognise, if you could, if
7 you could tell me, a distinction between recording
8 suspicions and recording observations?
9 MS NORMAN: Yes.
10 THE CHAIRMAN: Tell me where you would draw the line between
11 a suspicion and an observation.
12 MS NORMAN: I think it is very difficult to draw the line.
13 We did wonder about for example Kouao not being the
14 mother and the nurses expressed that. It was very
15 difficult simply because the reason was they did not
16 look alike but knowing that a lot of people do adopt
17 children, it is very difficult to say to somebody, "This
18 child does not look like you", and therefore to write it
19 down you are accusing somebody of something which could
20 be quite -- turn out to be quite -- not a very nice
21 thing to say.
22 THE CHAIRMAN: So that is a suspicion that you would not
23 feel was at the time proper to record?
24 MS NORMAN: At the time.
25 THE CHAIRMAN: But an observation that there was no warmth
89
1 shown between the person who is thought to be the mother
2 of the child and the child, that the mother never
3 brought anything in for the child, that there was no
4 physical contact between the mother and child, would
5 they be suspicions or would they be observations?
6 MS NORMAN: Those would be observations.
7 THE CHAIRMAN: So you would expect, would you, your staff to
8 have recorded carefully and thoroughly matters that
9 could rightly be described as what they saw, their
10 observations?
11 MS NORMAN: Yes.
12 THE CHAIRMAN: And do you think that the standard of
13 recording that has been put before the Inquiry was
14 typical of the work of you and your staff, or not?
15 MS NORMAN: It was not good enough.
16 THE CHAIRMAN: But was it typical?
17 MS NORMAN: I would not say it is typical because we do have
18 a lot of children under child protection and they do
19 have good notes kept.
20 THE CHAIRMAN: So normally the notes would be very much
21 better than the notes that we have seen?
22 MS NORMAN: Yes.
23 THE CHAIRMAN: And yet why do you think that Victoria was
24 primarily admitted to the ward?
25 MS NORMAN: Victoria came into the ward under the child
90
1 protection umbrella.
2 THE CHAIRMAN: So the failure to keep adequate notes in the
3 way that you have just described is really quite
4 a substantial one?
5 MS NORMAN: Yes.
6 THE CHAIRMAN: Were you on duty -- I want to be clear about
7 this if I may. Were you on duty on 6th August?
8 MS NORMAN: I was there that day, yes.
9 THE CHAIRMAN: You were on duty that day?
10 MS NORMAN: Yes, not necessarily on the ward.
11 THE CHAIRMAN: Let me put it another way. Were you on the
12 ward on 6th August?
13 MS NORMAN: Not on the ward, no.
14 THE CHAIRMAN: Do you know why you were not on the ward?
15 MS NORMAN: I might have had meetings or I have a lot of
16 paperwork to deal with.
17 THE CHAIRMAN: And how do you know you were not on the ward
18 on 6th August?
19 MS NORMAN: Because I do not remember the round that took
20 place on that day.
21 THE CHAIRMAN: Do you remember every ward round you have
22 ever done?
23 MS NORMAN: I remember the days that I do the rounds now
24 because I do not do the rounds very often.
25 THE CHAIRMAN: You may not have been on the ward for the
91
1 ward round but you could have been on the ward at some
2 time?
3 MS NORMAN: I would have been there at 7.30 in the morning
4 to take report.
5 THE CHAIRMAN: All right. Could you turn then to page 108
6 in the file in front of you, volume 37. The last entry,
7 5th August, that is the day before you were on the ward
8 at 7.30 the following morning?
9 MS NORMAN: Yes.
10 THE CHAIRMAN: It reads:
11 "Lisa Arthurworrey, social worker, phoned today,"
12 that is the day before. "She will be coming in to see
13 Anna tomorrow at 14.30. If all is well then Anna will
14 be discharged home on the 6th August to mum."
15 MS NORMAN: I did not see that on that day.
16 THE CHAIRMAN: Who actually signed that?
17 MS NORMAN: Nurse Graham.
18 THE CHAIRMAN: If the nurses had any concerns about Anna
19 going home the next day and this was recorded in the
20 notes, would they not have brought that to your
21 attention as their line manager?
22 MS NORMAN: Yes.
23 THE CHAIRMAN: And did they?
24 MS NORMAN: No.
25 THE CHAIRMAN: Thank you very much.
92
1 MR GARNHAM: Sir, there is one thing you can be confident
2 about in this Inquiry and that is that those who sit out
3 there are on their toes. During the course of the
4 examination by Mr Mason and yours I have had a series of
5 further questions I have been invited to put. It seems
6 to me that some of them are quite important and with
7 your leave I will put them.
8 THE CHAIRMAN: That is fine. I hope that they are not the
9 only ones that are on their toes but I accept that.
10 MR GARNHAM: You recall I asked you whether there was
11 a continuation sheet for the critical incident log which
12 appeared to come to an end on 3rd August.
13 MS NORMAN: Yes.
14 MR GARNHAM: Can you help me with whether the document at
15 page 108 in volume 37 is that continuation sheet despite
16 its title?
17 MS NORMAN: Sorry, what page?
18 MR GARNHAM: 108.
19 MS NORMAN: No, that would not have been a continuation
20 sheet.
21 MR GARNHAM: Thank you very much. Do you know who took
22 responsibility to invite nurses to strategy meetings?
23 MS NORMAN: The social worker that organised the meeting.
24 MR GARNHAM: So Karen Johns, who was the Ealing social
25 worker covering from Haringey, would she invite nurses
93
1 to strategy meetings both in respect of Enfield patients
2 and Haringey patients, or only Enfield?
3 MS NORMAN: I think she would just be involved with Enfield.
4 MR GARNHAM: So who would --
5 MS NORMAN: She would have been the go-between between us
6 and Haringey.
7 MR GARNHAM: Who would issue the invitations to nurses to
8 attend strategy meetings in respect of Haringey
9 patients?
10 MS NORMAN: The social worker who is calling the meeting.
11 MR GARNHAM: Who would not be Johns but the allocated social
12 worker?
13 MS NORMAN: Yes.
14 MR GARNHAM: In Haringey?
15 MS NORMAN: Yes.
16 MR GARNHAM: You were asked by Mr Mason about the use of
17 CP forms following on from my questions on the same
18 subject. Do you remember that?
19 MS NORMAN: Yes.
20 MR GARNHAM: And you say that you only include body maps
21 with the CP forms if they are relevant to CP cases, if
22 they are indicative of CP injuries, is that right?
23 MS NORMAN: Yes.
24 MR GARNHAM: Whilst I can understand that, how do social
25 workers know that that is your practice?
94
1 MS NORMAN: They would not receive any other diagrams other
2 than --
3 MR GARNHAM: But how do they know, when they get CP forms
4 with diagrams attached, how do they know that their
5 inclusion in the CP forms is indicative of the fact that
6 what is recorded on the maps show CP concerns?
7 MS NORMAN: It would normally say on the CP form that
8 diagrams are included of the injuries. In this case --
9 MR GARNHAM: If it does not?
10 MS NORMAN: If it does not then communication falls down.
11 MR GARNHAM: If it does not, social workers cannot know that
12 the purpose of including the CP forms is to illustrate
13 the CP injuries.
14 MS NORMAN: Yes.
15 MR GARNHAM: Do body maps not show all marks on the body?
16 MS NORMAN: It shows the marks that a doctor can see.
17 MR GARNHAM: So they show all the marks that the doctor can
18 see?
19 MS NORMAN: Yes.
20 MR GARNHAM: Could you have volume 5, please, page 265.
21 That is a memo from Karen Johns to the sister in charge
22 of Rainbow Ward. In the light of the questions the
23 Chairman asked you, who was the sister in charge of the
24 Rainbow Ward?
25 MS NORMAN: There was not a sister in charge at that time
95
1 when I took the role.
2 MR GARNHAM: You took the role?
3 MS NORMAN: I had to manage the ward as well as my own job.
4 MR GARNHAM: So would you have received this memo?
5 MS NORMAN: I have never received a memo.
6 MR GARNHAM: You have never received this memo?
7 MS NORMAN: No.
8 MR GARNHAM: Can you help us with, and you may well not be
9 able to, but can you help us with how it comes about
10 that a memo like this does not reach you? I can well
11 see that you might say to that you do not know.
12 MS NORMAN: I do not know why it did not get to me.
13 MR GARNHAM: But you are confident that you never received
14 this memo?
15 MS NORMAN: I have not seen it until today.
16 MR GARNHAM: Would you just take the opportunity to glance
17 through it please. You will see why I am asking,
18 because it appears to set out the requirements of
19 Miss Johns following the strategy meeting. So that if
20 you had received this you would have known what
21 Karen Johns wanted the ward to do, would you not?
22 MS NORMAN: Yes.
23 MR GARNHAM: But you say you simply never received this?
24 MS NORMAN: No, I did not.
25 MR GARNHAM: What was the role that Sue Jennings performed
96
1 on your ward at this time?
2 MS NORMAN: She was the senior staff nurse.
3 MR GARNHAM: Would a memo such as this go to her?
4 MS NORMAN: I really cannot say. Normally it has got
5 "Sister in Charge" or the envelope would have had
6 "Sister in Charge". Somebody might have opened it.
7 MR GARNHAM: If it had been delivered by hand to
8 Sue Jennings would she have dealt with its contents or
9 would she have shown it to you?
10 MS NORMAN: She might have opened it. I cannot say.
11 MR GARNHAM: Who would have dealt with the requests which it
12 contains? Could she do that rather than referring it to
13 you?
14 MS NORMAN: Yes, she could.
15 MR GARNHAM: Thank you sir.
16 THE CHAIRMAN: Thank you very much indeed. Mr Garnham I am
17 anxious that we press on with Dr Rossiter but what
18 I suggest is that we have a ten minute break and we will
19 resume just before 12.30.
20 (11.20 am)
21 (A short break)
22 (11.30 am)
23 MR GARNHAM: The next witness is Dr Mary Rossiter.
24 Dr Rossiter, please.
25 DR MARY ROSSITER (sworn)
97
1 MR GARNHAM: Please have a seat Dr Rossiter.
2 THE CHAIRMAN: Mr Garnham, can I suggest that we sit until
3 1.30 or at some point convenient to you and then break
4 for three quarters of an hour.
5 MR GARNHAM: Thank you very much. Good afternoon,
6 Dr Rossiter.
7 DR ROSSITER: Good afternoon Mr Garnham.
8 MR GARNHAM: Would you give the Inquiry your full name.
9 DR ROSSITER: Mary Anne Rossiter.
10 MR GARNHAM: Your professional qualifications.
11 DR ROSSITER: Consultant paediatrician.
12 MR GARNHAM: Your professional address.
13 DR ROSSITER: North Middlesex Hospital.
14 MR GARNHAM: You have made I think two statements for this
15 Inquiry. They are to be found in volume 6, pages 220
16 and 247.501 and they are now in front of you.
17 DR ROSSITER: Yes.
18 MR GARNHAM: Would you glance through them and confirm that
19 you have signed them both.
20 DR ROSSITER: Yes.
21 MR GARNHAM: Can you confirm that their contents are true.
22 DR ROSSITER: Yes.
23 MR GARNHAM: I think it is also right that you gave evidence
24 at the Central Criminal Court in respect of the trial of
25 Manning and Kouao.
98
1 DR ROSSITER: Yes.
2 MR GARNHAM: Sir, for your note the CPS statement in that
3 regard is in the CPS bundle and the transcript of the
4 evidence is at 49/306.
5 THE CHAIRMAN: Thank you.
6 MR GARNHAM: I think it is right that you have been
7 a consultant paediatrician since July 1974?
8 DR ROSSITER: Yes.
9 MR GARNHAM: And that since July 1992 you have been employed
10 in that capacity at the North Middlesex Hospital?
11 DR ROSSITER: I was originally both at Chase Farm and North
12 Middlesex Hospitals, joint appointment, and now I am
13 only at North Middlesex Hospital.
14 MR GARNHAM: Thank you. We see on page 247 of the statement
15 bundle, a copy of which is in front of you, that you
16 have a special interest in paediatric haematology.
17 DR ROSSITER: Yes.
18 MR GARNHAM: And that as a result of that you are in
19 a position to claim some special expertise in working
20 with people from all races and cultures.
21 DR ROSSITER: Yes.
22 MR GARNHAM: I think it is right that you are the editor and
23 main author of your hospital's Child Protection
24 Guidelines?
25 DR ROSSITER: Yes.
99
1 MR GARNHAM: You carry out some 150 medicolegal examinations
2 of children each year?
3 DR ROSSITER: That is right.
4 MR GARNHAM: That is at both North Middlesex and in
5 Haringey?
6 DR ROSSITER: Yes.
7 MR GARNHAM: And a proportion of those are in respect of
8 abuse cases, about a third in respect of sexual abuse?
9 DR ROSSITER: I tend to see mainly, myself, the children
10 with sexual abuse, emotional abuse and neglect. The
11 cases of physical abuse are usually delegated to trainee
12 doctors, SHO or registrar or both.
13 MR GARNHAM: Thank you. Four out of your 11 NHS sessions --
14 and we have had sessions described to us in the past --
15 are informally assigned to child protection work.
16 DR ROSSITER: Informally, yes.
17 MR GARNHAM: The result of all that is that you are a doctor
18 with enormous experience of child protection work.
19 DR ROSSITER: Similar to other paediatricians in the
20 country, yes.
21 MR GARNHAM: Can I ask you this. Are you entirely content
22 with all of your own actions during the course of
23 Victoria's stay at the NMH?
24 DR ROSSITER: No.
25 MR GARNHAM: Can you indicate where you think you went wrong
100
1 then?
2 DR ROSSITER: I failed to realise the inadequacies of the
3 documentation. I failed to realise that what seemed
4 very obvious to us in the hospital as a clear cut case
5 of child abuse had not been comprehended by my
6 colleagues in social services.
7 MR GARNHAM: Those are significant admissions and we are
8 grateful for them. Is there anything else that we ought
9 to know at this stage?
10 DR ROSSITER: I am sure things will come up.
11 MR GARNHAM: Those observations you make are made not simply
12 in the light of the awful things that happened to
13 Victoria, I take it, but simply from a critical analysis
14 of your own actions in the light of what you could have
15 known and should have known?
16 DR ROSSITER: I have looked at the notes and I have thought
17 about Victoria on a daily basis and with mounting horror
18 actually and I feel very distressed that I did not keep
19 up to my own standards.
20 MR GARNHAM: Thank you. Can I ask the same question in
21 respect of the team for which you were responsible.
22 Does the same comments apply with regard to them?
23 DR ROSSITER: No, I think the team were excellent. Any
24 shortcomings were due to lack of my training or
25 supervision.
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