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Archived Transcript for 13 November 2001: Pages
1 to 50
1
1 Tuesday 13th November 2001
2 (10.00 am)
3 MR GARNHAM: Good morning sir. I said yesterday that
4 I would indicate first thing this morning our proposals
5 with regard to the timetabling of witnesses for the rest
6 of this week. Sir, we plan today to take Dr Rossiter to
7 the conclusion of her evidence. Then Lori Hobbs, then
8 Rachel Crowe, Launa Brown and, if we have time,
9 Bridget Inal. Then on Thursday we will finish Miss Inal
10 if we have not finished her today, then Karen Johns
11 Cynthia Lipworth and Liz Fletcher. We also hope to be
12 able to call on Thursday Dr Richardson, although since
13 we have now moved him at least twice we are waiting for
14 confirmation that he is available from those who employ
15 him. On Friday it is our plan to call Dr Alexander and
16 Dr Meates, again both of those are subject to
17 confirmation. Mr Mason is being very helpful in trying
18 to secure their attendance but we have not yet had that
19 confirmed.
20 That I think makes for a reasonably sensible
21 programme for the rest of the week. It will have
22 a knock-on effect into next week in that our timetable
23 is now significantly behind our original schedule. We
24 will tomorrow, in the day when we are not sitting,
25 recast that timetable from now to the end of the Inquiry
2
1 and I will let the interested parties and you have the
2 details on Thursday morning.
3 THE CHAIRMAN: I am grateful to you Mr Garnham and clearly
4 the recasting of the timetable will reflect the
5 experience so far, if I can put it that way.
6 MR GARNHAM: It will, sir, and the experience has been that
7 over the last week or so there has been a change in the
8 pace and the degree of involvement of the interested
9 parties, and we welcome that sir, but it is rather more
10 difficult for us precisely to estimate how long
11 a witness takes in the present circumstances. That is
12 no bad thing but it just means we need to be flexible.
13 THE CHAIRMAN: I agree and my comment was not intended at
14 all to be critical. The Inquiry needs to be as thorough
15 as you and others wish it to be, certainly I wish it to
16 be.
17 MR GARNHAM: Thank you. Can I recall Dr Rossiter.
18 DR MARY ROSSITER (continued)
19 MR GARNHAM: Good morning Dr Rossiter.
20 DR ROSSITER: Good morning.
21 MR GARNHAM: Thank you for coming back again. You will
22 remember that you are still on oath.
23 DR ROSSITER: Yes.
24 MR GARNHAM: At the end of yesterday afternoon the Chairman
25 asked you to give some further thought to the name of
3
1 the social worker who you had described in your evidence
2 yesterday. Has a name appeared?
3 DR ROSSITER: A name has appeared. I hope I have got it
4 right, I would feel dreadful if I had not.
5 MR GARNHAM: Before I ask you to give it to us, that being
6 your concern, I wonder if you can have a look at the
7 document we looked at yesterday in case that is of any
8 assistance to you.
9 DR ROSSITER: That would be very helpful.
10 MR GARNHAM: It is the minutes of the meeting of paediatric
11 social work team paediatric consultants on
12 11th February 1998 and you will find it in volume 26B,
13 page 237. Do you have the minutes of the meeting there
14 in front of you now?
15 DR ROSSITER: I do.
16 MR GARNHAM: It is 11th February I am interested in.
17 DR ROSSITER: And the person that I would name was present
18 at that meeting.
19 MR GARNHAM: And does that help you firm up your views?
20 DR ROSSITER: It does help me firm up my views. If I may,
21 I would like to comment that I am really not criticising
22 this person. She was an excellent social worker. We
23 had concerns about her health. Obviously this was as
24 colleagues, not as doctors, but we truly believed that
25 she had problems that her manager should have been aware
4
1 of and we tried to explain that to her managers.
2 MR GARNHAM: Who was the person concerned?
3 DR ROSSITER: Shirley Braithwaite.
4 MR GARNHAM: I want next to return to the matters we were
5 discussing towards the conclusion of your evidence
6 yesterday afternoon and I apologise that we may need to
7 go over again some of the ground we covered in the last
8 few minutes. I am interested in particular in the
9 conversation that you had with Lisa Arthurworrey in that
10 week in August.
11 DR ROSSITER: Yes.
12 MR GARNHAM: And I want to make sure by tracing it through
13 what the extent of your recollection of that
14 conversation has been at various points. You tell us in
15 paragraph 33 of your statement, and do you still have a
16 copy of your statement in front of you? It is coming to
17 you.
18 DR ROSSITER: Thank you.
19 MR GARNHAM: Turn up 33 if you will. Paragraph 33, you tell
20 us that during the week beginning 3rd August you
21 received a telephone call from Lisa Arthurworrey.
22 DR ROSSITER: Yes.
23 MR GARNHAM: That much you do recollect or you did recollect
24 at the time you made that statement?
25 DR ROSSITER: By the time I made the statement I recollected
5
1 it but I know that I had not recollected it at the time
2 of the court appearance because I was about to go in and
3 give evidence and that is why I thought that as there
4 was a witness there that I could ask, I confirmed with
5 Lisa Arthurworrey that I had spoken to her, and as far
6 as I recall all I said was, "You did telephone me or we
7 did speak, did we not?" and she said yes and then I went
8 in.
9 MR GARNHAM: The statement you made to the CPS, which again
10 I think you should see, volume 46/180, there is no
11 reference to this conversation in that brief statement,
12 is there?
13 DR ROSSITER: I doubt it but let me read it please.
14 MR GARNHAM: Have a look.
15 DR ROSSITER: It is just an introduction to the other
16 documents that are available.
17 MR GARNHAM: It does not refer to that telephone
18 conversation.
19 DR ROSSITER: No.
20 MR GARNHAM: Then can we see, please, the transcript of your
21 evidence at the Old Bailey, volume 49. Your evidence
22 starts at page 306. That I think is where your evidence
23 starts.
24 DR ROSSITER: Yes.
25 MR GARNHAM: If you flick through to page 322, we see the
6
1 start of your cross-examination by Mr Rumfitt and at the
2 top of 333 --
3 DR ROSSITER: It does not fit, does it? Humph.
4 MR GARNHAM: One moment. Go to 323, I am sorry. Top of
5 that page:
6 "Question: Do we deduce from that, first of all,
7 the social worker responsible for letting the child go
8 home never spoke to you?
9 "Answer: I believe she telephoned me on Tuesday
10 3rd August, not on the ward. I do not have a record but
11 she may have."
12 You are there reflecting on what you had learned in
13 the witness waiting room a few minutes earlier, are you?
14 DR ROSSITER: Well I appear to be but then in the next
15 paragraph I have contradicted myself.
16 MR GARNHAM: Quite.
17 "Question: That would be the conversation that is
18 referred to on the previous page in the discharge
19 summary: 'Social worker spoke to Dr Rossiter on the
20 phone who expressed her very clear views as above'?
21 "Answer: Yes.
22 DR ROSSITER: It was a social worker. I have no record
23 which one it was, but we must conclude that it was
24 Lisa Arthurworrey.
25 MR GARNHAM: Reading on:
7
1 "Question: So in the telephone conversation of
2 3rd August you say, 'I think this child may well have
3 been the victim of abuse'?
4 "Answer: Yes.
5 DR ROSSITER: Yes.
6 MR GARNHAM: That was a stylishly leading question in
7 cross-examination of you. You seemed happy to have
8 adopted the point though. Did you have a recollection
9 at that time that you said to Lisa Arthurworrey,
10 "I think this child may well have been the victim of
11 abuse"?
12 DR ROSSITER: I have no recollection of the conversation.
13 This is my problem.
14 MR GARNHAM: Yes.
15 DR ROSSITER: The more I try to remember the more confused
16 I get, as is very evident here.
17 MR GARNHAM: Does it mean that we should read with some
18 caution the evidence you give at the Central Criminal
19 Court on this topic?
20 DR ROSSITER: I think the most reliable thing is my
21 discharge summary because that was done nearest to the
22 time.
23 MR GARNHAM: I will come to that in a moment. Can we finish
24 this exchange:
25 "Question: ... 'I think this child may well have
8
1 been the victim of abuse'?
2 "Answer: Yes.
3 "Question: Then without any further reference to
4 you, the social worker arranges for the child to be
5 discharged home on 6th August?
6 "Answer: I think the link with that is that we had
7 agreed that now the child had completed a medical
8 treatment she was physically fit to be discharged. What
9 we had not said was that -- what we had not said was
10 that she recommended that she went home."
11 DR ROSSITER: I think the "we" about agreeing is more likely
12 to be the ward staff. What I cannot guarantee is that
13 the "we" was myself and Lisa Arthurworrey.
14 MR GARNHAM: Who is the "she" in the sentence: "What we had
15 not said was that she recommended ..."?
16 DR ROSSITER: It does not make sense, bearing in mind this
17 is verbal evidence under stress and one comes out with
18 extremely strange things.
19 MR GARNHAM: "And I do not think that I have -- and I do
20 think that I have not been absolutely clear in my letter
21 of 13th August of that."
22 DR ROSSITER: That is also gobbledegook.
23 MR GARNHAM: One can just about discern a meaning from that
24 though Dr Rossiter. You appear to be saying you do not
25 think that you were absolutely clear in your letter of
9
1 13th August. Is that your view?
2 DR ROSSITER: No, I think there is a double negative. I am
3 sure --
4 MR GARNHAM: Where is the double negative? I only see one.
5 DR ROSSITER: "I do think that I have not been absolutely
6 clear."
7 I think when we revisit the letter that was typed on
8 13th August in retrospect it is not completely clear.
9 MR GARNHAM: We will come to that.
10 "But as I said we were expecting a social work
11 assessment with a view to referral to our child
12 psychiatrist and also we wished to discuss between us
13 where the child should go and I would have expected that
14 probably she would be accommodated or at least if she
15 went home there would be a protection plan with a case
16 conference to which I would have been invited."
17 We have dealt with much of that.
18 DR ROSSITER: Yes.
19 MR GARNHAM: Let us then go to the discharge sheet, which is
20 in volume 37, page 52. For the present I only want to
21 look at this for the purposes of understanding what went
22 on between you and Lisa Arthurworrey so can I take you
23 to the sentence four lines above the figure 1:
24 "Concerns shared with hospital social worker who
25 attended the planning meeting at North Tottenham Social
10
1 Services," that is a reference to Karen Johns?
2 DR ROSSITER: Yes.
3 MR GARNHAM: Then:
4 "Social worker spoke to Dr Rossiter on the phone who
5 expressed her very clear views as above."
6 Did you intend that to be a reference to your
7 conferring with Lisa Arthurworrey?
8 DR ROSSITER: I have no idea. It could equally have been
9 Karen Johns.
10 MR GARNHAM: Are you now confident that you expressed to
11 either of them in clear terms the same material as we
12 see set out in that letter?
13 DR ROSSITER: You mean the letter typed on the 13th?
14 MR GARNHAM: Yes.
15 DR ROSSITER: All I can say is that what was written here,
16 albeit when I was in a slightly distressed state of
17 mind, is the nearest we can get to my memory. Anything
18 that has happened since is clouded by rethinking.
19 MR GARNHAM: So that we have to make the best we can of this
20 letter?
21 DR ROSSITER: I regret so.
22 MR GARNHAM: You are not able to confirm one way or the
23 other its accuracy?
24 DR ROSSITER: I really cannot in all honesty.
25 MR GARNHAM: Thank you. Can we then go back to
11
1 Lisa Arthurworrey's record of the conversation and you
2 will recall that late yesterday afternoon I was finding
3 the order of the pages somewhat confusing. I hope
4 I have now understood it. It is in volume 6., page 64.
5 The ordering is actually very simple, it is just reverse
6 order, so we start at 64, get to the bottom of that page
7 and then 63, and then the bottom of that page go to 62.
8 DR ROSSITER: I am grateful to you.
9 MR GARNHAM: It is said on 64 that the purpose of the
10 telephone conversation was to clarify the concerns in
11 her medical report. You had not written a report by
12 that stage.
13 DR ROSSITER: No, I had not been asked.
14 MR GARNHAM: It appears from Miss Arthurworrey's witness
15 statement, so it is volume 2, page 71, that she is
16 referring to Nurse Quinn's statement that we have in
17 volume 37 at page 73. Although this means some juggling
18 I would like you to see that as well, please; volume 37,
19 page 73.
20 DR ROSSITER: Yes. That is very important, bearing in mind
21 that when the telephone conversation came I would not
22 have had what Nurse Quinn had said in front of me.
23 MR GARNHAM: Absolutely. In fact you did not have any of
24 the notes in front of you.
25 DR ROSSITER: No.
12
1 MR GARNHAM: Do you have that?
2 DR ROSSITER: I have page 073.
3 MR GARNHAM: That is a letter or memo to Lisa Arthurworrey.
4 DR ROSSITER: Yes, from Isobel Quinn.
5 MR GARNHAM: We cannot be certain but that at least is what
6 we are told by Miss Arthurworrey she was referring to.
7 Glance through that if you would. You were going to say
8 something.
9 DR ROSSITER: I am waiting to be asked.
10 MR GARNHAM: That letter was not in front of you?
11 DR ROSSITER: No.
12 MR GARNHAM: And was there any indication as to what
13 Miss Arthurworrey had in mind when she began the
14 conversation? Answer, you cannot remember?
15 DR ROSSITER: I could imagine her being confused though. In
16 other words, if I had seen this letter I might have best
17 guessed why she was not understanding it.
18 MR GARNHAM: But you say you had not seen the letter?
19 DR ROSSITER: No.
20 MR GARNHAM: The conversation that follows is then set out
21 on the next two pages.
22 DR ROSSITER: Yes.
23 MR GARNHAM: I am going to ask you whether you are in
24 a position to disagree with anything that
25 Lisa Arthurworrey records about that conversation and
13
1 I understand that you may recollect little of it but
2 I would like to look through those two pages first
3 please.
4 DR ROSSITER: Right. The top of 64 is really repeating the
5 facts that were given in the fax.
6 MR GARNHAM: I really want you to read from --
7 DR ROSSITER: What strikes me is about perception:
8 "Dr Rossiter feels Anna may be subject to emotional
9 abuse ... believes she is displaying evidence of anxious
10 attachment," when we were feeling very clearly that she
11 was likely to be subject to, well, emotional abuse and
12 we had observed her displaying evidence of anxious
13 attachment.
14 I am coming back to what I said yesterday about the
15 difficulties of communicating with people in other
16 disciplines, let alone when you have never met them, and
17 if I may take the medical analogy further, when I am
18 setting up a therapeutic relationship with a family
19 I spend quite a bit of time getting to know them,
20 finding out their previous experience, what their
21 perception of the illness is et cetera, so that I can
22 then explain what I wish from them.
23 Even when I think people have understood me and they
24 smile and say, "Thank you Doctor" and I say, "Fine,
25 I will send you a copy of the letter and I do not need
14
1 to see you again," almost by reflex the nurse comes back
2 and say "Mrs So and So does not know when the next
3 appointment is," so I am extremely aware of the problems
4 of communicating with people and even when you think you
5 have explained things, there is the person who says and
6 the person who receives.
7 MR GARNHAM: That is helpful but if you would just glance
8 through those two pages.
9 DR ROSSITER: Indeed. That is how I would comment at the
10 bottom of the page from that.
11 MR GARNHAM: 63.
12 DR ROSSITER: "... appears to seek attention and praise," it
13 is documented that she did, "but when mother arrives
14 rushes to her side as if she is being called to
15 attention (master and servant relationship)."
16 "As if." Well, that is fair enough.
17 "It appears that the circumstances of the incident
18 was the child was suffering from scabies and mother
19 treated this condition with medication from her GP."
20 It does not seem to relate to anything that is in
21 the fax from Nurse Pereira.
22 MR GARNHAM: Nurse Quinn.
23 DR ROSSITER: Nurse Quinn I do apologise.
24 MR GARNHAM: And you do not recollect that?
25 DR ROSSITER: I do not recollect it.
15
1 MR GARNHAM: Carry on if you would.
2 DR ROSSITER: "However, it appears that mother may have
3 over-treated this condition and Anna's skin reacted in
4 the over-treatment. Mother apparently did not receive
5 medical advice to Anna's latest skin reaction and that
6 is when the child poured hot water over her skin to
7 relieve the itching."
8 Again, it is a matter of emphasis. "It appears
9 mother did not receive advice." What we were saying was
10 that she did not seek advice.
11 "Anna was frightened of being undressed. Appeared
12 to be frightened of mother's partner." So she knew
13 there was a partner. "Dr Rossiter said there were
14 a number of marks on Anna's body. Dr Rossiter is
15 unclear whether they were caused by Anna's scratching
16 herself or infection from the scratching" and then this
17 curious remark.
18 MR GARNHAM: Before we get there, that is quite important.
19 Did you say -- would you have said if you cannot
20 remember, Dr Rossiter, that you are unclear as to
21 whether the marks on the body were caused by Anna
22 scratching herself or infection from scratches?
23 DR ROSSITER: I think the way I would have phrased it would
24 be that she probably was scratching, however that did
25 not account for the large number of marks that we had
16
1 seen.
2 MR GARNHAM: You have no recollection of saying that but
3 that is what you think you would have said?
4 DR ROSSITER: Yes.
5 MR GARNHAM: Thank you. Carry on. Two thumb marks, you
6 mentioned that yesterday.
7 DR ROSSITER: Yes, I mean thumb marks have never crossed my
8 mind and I do not know where that would have come from.
9 MR GARNHAM: "Dr Rossiter feels ..."
10 DR ROSSITER: "... Anna loves her mother very much but is
11 not sure such love is reciprocated."
12 I would have got that from the nurse's record so
13 that is likely to have been something I said.
14 MR GARNHAM: I do not recollect seeing it in the nurses'
15 records but you think that might have come from the
16 nurses?
17 DR ROSSITER: It is something to do with the fact that --
18 no, it cannot be because that was when she went home.
19 I must have got it from somewhere.
20 MR GARNHAM: You do not dispute this version of events by
21 Lisa Arthurworrey though?
22 DR ROSSITER: I think it is likely I did say that, yes.
23 MR GARNHAM: Carry on.
24 DR ROSSITER: "Discussion with Karen Johns."
25 MR GARNHAM: You have missed out a sentence:
17
1 "Agreed to update Dr Rossiter following home visit
2 to mother."
3 DR ROSSITER: Yes, so I was expecting to hear from her.
4 MR GARNHAM: Yes.
5 DR ROSSITER: "Discussion with Karen Johns."
6 MR GARNHAM: I think that is the end of your phone call.
7 DR ROSSITER: So it looks as if I must have taken something
8 from it because when I called in on the wards each day,
9 when we did our chart round, it would have been waiting
10 for social worker to feed back and the next day waiting
11 for social worker to feed back.
12 MR GARNHAM: Are you able to say from your limited
13 recollection of this conversation with Lisa Arthurworrey
14 whether you said anything to her which should have led
15 her to believe that it was your view then, never mind
16 what she might have gathered from other sources, your
17 view then that there was a risk of Victoria being
18 subjected to deliberate physical assault?
19 DR ROSSITER: I do not recall at all.
20 MR GARNHAM: Because there were options open to you, if you
21 had feared that Victoria was at risk of physical
22 assault, were there not? You did not have to wait
23 simply on the social worker's actions?
24 DR ROSSITER: No, again I think using my usual thought,
25 I assumed if one had three types of abuse (check answer)
18
1 then the child is at risk of any of them and that was
2 a false assumption. It is because I know it that
3 foolishly I thought that other people knew it.
4 MR GARNHAM: For the present purposes I am interested in
5 what you knew and what you did. Given that you feared
6 those were three options that might occur, you could
7 have called a predischarge meeting, could you not?
8 DR ROSSITER: I could have if I had not thought that I would
9 be getting some sort of feedback. I mean, we really in
10 my mind had not got to the stage of discharge. What
11 I thought we were doing was getting feedback from the
12 social worker, regrouping on the Monday psychosocial
13 meeting, discussing with the ward team where we were,
14 whether the psychiatrist would now accept a referral,
15 and then after that start thinking about her going home.
16 MR GARNHAM: But it is right to say that a predischarge
17 meeting was something in your gift?
18 DR ROSSITER: It was in my gift.
19 MR GARNHAM: And you could have called it?
20 DR ROSSITER: Had she still been there and had we not had
21 a meeting called by social services then I feel
22 confident, moderately confident that that is what
23 I would have done, even with the benefit of hindsight.
24 MR GARNHAM: You could, I suppose, have asked the police to
25 take Victoria into police protection.
19
1 DR ROSSITER: I cannot see why it would have been necessary
2 at this stage.
3 MR GARNHAM: If you had feared that matters were moving on
4 and she was going to have to be discharged on medical
5 grounds if there was not something to stop it.
6 DR ROSSITER: The only person that I had expected to try to
7 remove her was her mother, as she appeared to be. I was
8 not expecting unilateral action from another agency.
9 MR GARNHAM: So absent a decision by the hospital to release
10 her she was safe and she could stay where she was?
11 DR ROSSITER: That was what I believed. We knew that had
12 Kouao tried to remove her or had attempted to we would
13 just call the police.
14 MR GARNHAM: There was no problem, was there, with you
15 thinking, "I have got no medical justification for
16 keeping her"? If you had felt that she was at risk of
17 physical harm she could have gone on occupying the bed.
18 DR ROSSITER: Yes, even if it put her at risk of getting
19 intercurrent infections, but yes of course she could.
20 MR GARNHAM: What is it that you needed before you could be
21 satisfied that it was safe for Victoria to be discharged
22 home with Kouao?
23 DR ROSSITER: I wanted some facts and the facts were in the
24 gift of a large number of people, both within our team
25 and in the community.
20
1 MR GARNHAM: What facts did you want?
2 DR ROSSITER: I wanted from our point of view for all the
3 members of our team to have the opportunity to pool
4 their information. The psychosocial meeting, as you
5 know, only takes an hour and we discuss anything from
6 five to 10 children, so it is more of a triage than
7 a discussion group. So we were expecting to have the
8 opportunity to sit down and to be able to share the
9 concerns with ourselves and with others.
10 MR GARNHAM: Sorry to interrupt you but I am not sure that
11 entirely answers the question as to what facts you
12 needed before you could be satisfied it was safe to
13 discharge.
14 DR ROSSITER: We wanted to hear anything that had been
15 discovered by a Section 47 inquiry.
16 MR GARNHAM: So you needed the results of a Section 47
17 inquiry?
18 DR ROSSITER: Yes, and indeed in retrospect the results of
19 the strategy meeting might have been helpful as well.
20 MR GARNHAM: It was not enough, was it, for you to be
21 satisfied it would be safe, simply that there had been
22 a home visit?
23 DR ROSSITER: No.
24 MR GARNHAM: Nor was it enough simply that there had been
25 a discussion between Kouao and the social worker
21
1 investigating the family set-up, whether Manning lived
2 there or not, that alone was not going to be an answer
3 to the problem?
4 DR ROSSITER: I am still thinking backwards. There are
5 plenty of cases where we have concerns, where a child
6 might be at risk of emotional abuse, where there had
7 been excessive chastisement, and I do not believe that
8 chastisement is ever justified, but chastisement which
9 might have been perceived as justified. There have been
10 cases where a skilled social worker had believed that
11 the child was safe to go home and we had agreed, I had
12 agreed that the child could go home, obviously expecting
13 follow-up with visits and a case conference, what have
14 you.
15 MR GARNHAM: But your concern, your real concern was that
16 Victoria might be at risk if she was discharged back
17 into the charge of Kouao?
18 DR ROSSITER: I had sufficient concern to believe that on
19 the balance of probabilities she should not go back
20 there but I needed to make a joint decision.
21 MR GARNHAM: Absolutely, but what you needed to know before
22 you personally could be satisfied was not that the home
23 was okay, that the premises were up to scratch?
24 DR ROSSITER: No.
25 MR GARNHAM: So a home visit is not going to solve your
22
1 concerns?
2 DR ROSSITER: I do not think it is a risk assessment.
3 MR GARNHAM: I am sorry, I do not think I understand that
4 answer. A home visit is not a risk assessment. Yes,
5 I agree, I understand.
6 DR ROSSITER: Yes.
7 MR GARNHAM: Nor was a discussion with Kouao about her
8 relationship with Manning, that was not going to solve
9 your concerns because Kouao alone might be the
10 perpetrator of the abuse.
11 DR ROSSITER: Indeed.
12 MR GARNHAM: Whether or not the social workers should have
13 pursued their investigations further is a matter that
14 this Inquiry will have to consider but whatever the
15 outcome of that consideration the hospital were aware,
16 were they not, of what the social work team had in their
17 minds?
18 DR ROSSITER: I think we have heard already that there were
19 people who knew, who were perhaps in too junior
20 a position to --
21 MR GARNHAM: People who knew what?
22 DR ROSSITER: Who knew that Lisa Arthurworrey was intending
23 to advise discharge. I heard that yesterday, that there
24 had been a phone call and that she would be feeding
25 back.
23
1 MR GARNHAM: It is on the notes, is it not? Can we look at
2 it, volume 37?
3 DR ROSSITER: I never did a ward round looking at the notes,
4 this is the problem.
5 MR GARNHAM: I anticipated that that would be the answer you
6 would give but I still want to establish whether or not
7 there was on the notes evidence of social worker's
8 intention.
9 DR ROSSITER: I know there was because I read it over the
10 weekend.
11 MR GARNHAM: That will save me looking at the notes.
12 I think you ought to see it, 37/275, I think you ought
13 to see it in fairness to you. Final entry on that page,
14 11.20 on 3rd August:
15 "She [who I think is Lisa Arthurworrey] needs to
16 make a home visit with the police before Anna can go
17 home."
18 So that looks as if that is what they had in mind as
19 the one precondition.
20 Then if you go to the same volume, page 108 entry in
21 the history notes for two days later. Last entry on
22 page 108:
23 "Lisa Arthurworrey phoned today. She will be coming
24 to see Anna tomorrow at 14.30. If all is well then Anna
25 will be discharged home on 6th August to mum."
24
1 DR ROSSITER: Right.
2 MR GARNHAM: So it is apparent, is it not, from the hospital
3 records that whether or not the social workers were
4 right to do this, whether or not they should have
5 pursued things more, there was material in the hospital
6 files that indicated what their intention was?
7 DR ROSSITER: I might or might not have read on routine ward
8 round the entry of 3.8.99 because it is in a critical
9 incident log sheet and we discussed yesterday that that
10 is not usually seen routinely on ward rounds unless
11 produced by a nurse. However, the entry at 5.8.99 at
12 1500 hours was there and written and yes, that was
13 written there. And had I be on a ward round and opened
14 the file then I would surely have read it because it was
15 the last thing there.
16 MR GARNHAM: If we ally those notes, indicating that the
17 hospital knew of social workers' plans, with the
18 observation you make in your letter following discharge
19 to Kitchman, along the lines of "staff seem to think
20 social workers can discharge patients," there is quite
21 a worrying picture emerging, is there not, because there
22 we have the hospital aware of social workers' intentions
23 which on reflection you think were misplaced, the
24 hospital aware of that and the hospital permitting
25 social workers to go ahead and discharge Victoria?
25
1 DR ROSSITER: It goes back to what is the hospital.
2 MR GARNHAM: Absolutely.
3 DR ROSSITER: And the hospital is a team led by me.
4 MR GARNHAM: Absolutely.
5 DR ROSSITER: And if I was not supervising and if I had not
6 trained everybody apart from most people in what I knew
7 then that is my responsibility.
8 MR GARNHAM: It is your responsibility anyway, is it not,
9 ultimately?
10 DR ROSSITER: Yes.
11 MR GARNHAM: That we have this situation where the left hand
12 of the hospital does not appear to know what the right
13 hand is doing.
14 DR ROSSITER: Because so many people are involved, and
15 because there is a chain of command, I would have
16 expected a registrar to know. This entry is the 1500
17 hours and we are back again to yet another hole in a net
18 that is leaking with many holes. Had that information
19 been available to the ward round on the Thursday morning
20 I would have hoped and expected that the registrar would
21 have seen it. However, because it is an afternoon one,
22 and as we have heard we were very thin on the ground on
23 the Friday morning, the registrar had gone off after his
24 night on, the house officer, Dr Reynders, was being
25 helpful, and I had realised over the weekend that the
26
1 senior house officer who was then on for the ward during
2 the day on the Friday was Dr Selathori, and it was her
3 first day working for us.
4 MR GARNHAM: One can well understand how these sort of
5 things happen but the obvious remedy to this is surely
6 that no child in respect of whom there are child
7 protection concerns should ever have been discharged
8 from a hospital ward without the say-so of the
9 consultant.
10 DR ROSSITER: We have recognised this well in advance of
11 you, sir, and that is now written and accepted and is
12 done.
13 MR GARNHAM: And that is what ought to have happened back
14 in July/August 1999.
15 DR ROSSITER: I am just thinking about stable doors.
16 MR GARNHAM: Absolutely. Can I then go to the day of
17 discharge, 6th August?
18 DR ROSSITER: Is there a paper here?
19 MR GARNHAM: I shall take you to it in a moment. By
20 6th August are you confident that a clear history had
21 been obtained by your team from Kouao and Victoria?
22 DR ROSSITER: I think it is very unlikely. The child had
23 been listened to by staff who were capable of listening,
24 that is the play therapist and the nurses, in the
25 opportunistic way that they do for all children, but of
27
1 course there was the language barrier. As far as
2 listening to or discussing with Kouao is concerned, it
3 is on record that her visits were very few and far
4 between, so no, we had not.
5 MR GARNHAM: One of the reasons I ask is because there is
6 a note that has been pointed out to me that I simply do
7 not understand and the answer may be simply that it does
8 not relate to Victoria. Will you have a look at it
9 please, volume 37, page 71. You had better start with
10 37/069, please. That is the psychosocial notes for
11 2nd August. Over the page we have an advert for some
12 drug or other with the word "not Anna" written across
13 it.
14 DR ROSSITER: That was a sticker that I put on.
15 MR GARNHAM: Then the next page there is this note: "By
16 paediatric registrar, clear history to be gather by
17 team." Is this referring to Victoria or not?
18 DR ROSSITER: I suspect it is noticing again that the child
19 had not been clerked in properly. On the other hand --
20 MR GARNHAM: So you do think this relates to Victoria?
21 DR ROSSITER: Yes I think it must do and I think it was
22 a conclusion --
23 MR GARNHAM: Before you?
24 DR ROSSITER: -- from the psychosocial meeting.
25 MR GARNHAM: Go to the next paragraph on that page:
28
1 "Problem: (1) constipation, encopresis, (2)
2 communication difficulties, (3) hearing difficulties".
3 DR ROSSITER: No, that is not her, I am sorry.
4 MR GARNHAM: Which is why I ask my question whether you
5 think those first words do relate to Victoria.
6 DR ROSSITER: No, they do not. I think these must be out of
7 order. It is a completely different child.
8 MR GARNHAM: We ought to be disregarding that page then?
9 DR ROSSITER: Yes, that was one of the other children who
10 was particularly exercising my mind at the time.
11 MR GARNHAM: So far we have two answers to my question
12 whether this relates to Victoria, yes it does and no it
13 does not. Before we leave this there is a squiggle
14 which my learned friend Miss Lawson suggests might be
15 a name above the word "problems." I cannot tell whether
16 it is a name or not but it is conceivable then that what
17 is above those words relates to Victoria and what is
18 below does not. Perhaps you can help us.
19 DR ROSSITER: Well, if it is crossed out -- I am as sure as
20 I can be that it was crossed out at the time because
21 when I was preparing these papers for use by the courts
22 I knew I must not alter them after the child's death
23 because that is a crime and that is why I put those
24 commercial stickers over the confidential material. So
25 I have no idea what that was but it was something Mr --
29
1 MR GARNHAM: So, final view on those first two lines,
2 relating to Victoria or not relating to Victoria?
3 DR ROSSITER: Not relating to Victoria. I can positively
4 identify that as a different child whom I know to have
5 been on the ward at the time.
6 MR GARNHAM: Can you go to page 270 in this bundle.
7 DR ROSSITER: Thank you.
8 MR GARNHAM: We have there the notes of the ward round on
9 3rd August.
10 DR ROSSITER: Yes.
11 MR GARNHAM: I cannot see notes of any ward round on
12 6th August.
13 DR ROSSITER: That is 272: "6.8.99 ward round SHO".
14 MR GARNHAM: Then I need you first to look at the 3rd August
15 ward round. What does the second line read:
16 "... proper history from Anna and mum ..."?
17 DR ROSSITER: I think I am on the wrong page.
18 MR GARNHAM: 270, the 3rd August ward round. "Better"
19 I think.
20 DR ROSSITER: "... proper history from Anna and mum ..."
21 MR GARNHAM: "... re what exactly happened with Lucienne.
22 She is coming in today."
23 DR ROSSITER: That I am ashamed to say is a personal
24 shorthand which is not used by all doctors.
25 MR GARNHAM: Which is?
30
1 DR ROSSITER: Well, I do not know what it says and it is not
2 something I use so I do not know what it means.
3 MR GARNHAM: The amount I have read so far is fairly clear,
4 is it not:
5 "Better, proper history from Anna and mum re ..."?
6 DR ROSSITER: It is re, that is all it is.
7 MR GARNHAM: "... re what exactly happened with Lucienne.
8 She is coming in today."
9 DR ROSSITER: So it looks as though Dr Alexander who has not
10 yet given evidence was intending to discuss something
11 with Lucienne.
12 MR GARNHAM: It looks as if the idea was that there would be
13 some sort of interview with Victoria with the benefit of
14 Lucienne's translation, does it not?
15 DR ROSSITER: It may well be, yes.
16 MR GARNHAM: Then if we go on to the ward round of the 6th,
17 at 272:
18 "Ward round SHO, Anna is well, burns healed well,
19 plan for home visit today with police."
20 DR ROSSITER: "Query discharge ..."
21 MR GARNHAM: "... after that if it is safe".
22 DR ROSSITER: Again, it is difficult to tell from
23 Dr Reynders' query whether he is querying whether she
24 should be discharged, if she is safe, or -- I cannot
25 remember what the other half of that was but I do not
31
1 know whom he would be querying it with, whether he meant
2 he would be querying it with the social worker or
3 whether he would query it with someone senior to
4 himself.
5 MR GARNHAM: We can ask Dr Reynders about that. There does
6 not however appear to be, does there, any record of the
7 proper history having been taken by the 6th August that
8 was anticipated by the note that we have looked at for
9 the 3rd August?
10 DR ROSSITER: That goes back to continuity and handover and
11 my shame that I was not doing proper ward rounds in
12 person.
13 MR GARNHAM: And you accept responsibility, do you not, for
14 the absence of such a proper history?
15 DR ROSSITER: All I can say is that as I read through these
16 notes prior to this Inquiry I had a sense of mounting
17 horror.
18 MR GARNHAM: So I take it you agree with my suggestion?
19 DR ROSSITER: Yes.
20 MR GARNHAM: Before we leave events at the hospital can
21 I make sure that I understand what you say social
22 workers were aware of about Victoria by the time of her
23 discharge? Could you have volume 6 and volume 5 please
24 for this purpose and the other two volumes can go back
25 for the moment. Volume 6, page 40 first of all.
32
1 DR ROSSITER: Thank you.
2 MR GARNHAM: Volume 6, page 40.
3 DR ROSSITER: Yes.
4 MR GARNHAM: We have there handwritten notes -- I am sorry.
5 DR ROSSITER: That is the referral.
6 MR GARNHAM: Yes. Go on to 41 and there we have
7 a handwritten note of the referral signed by C Rogers.
8 DR ROSSITER: That is Caroline Rogers, yes.
9 MR GARNHAM: Rather more conveniently we have a typed
10 version of that at page 288 in that bundle. Read
11 through that if you would. (Pause).
12 DR ROSSITER: Thank you.
13 MR GARNHAM: So we know that by 27th July social services
14 knew that much.
15 DR ROSSITER: It seems very clear and as I said yesterday
16 that certainly seems sufficient to progress to a full
17 investigation.
18 MR GARNHAM: I understand that that is the point you made.
19 Together with that we have the material set out in
20 Karen Johns' note in volume 5 at page 251. Sorry, it
21 starts at 250. These are fairly detailed notes and I do
22 not want you to read them all. If you glance at the
23 middle of 250 and then at the notes of the telephone
24 conversation with Dr Forlee and 251.
25 DR ROSSITER: Yes.
33
1 MR GARNHAM: And then at 252, medical team's additional
2 concerns.
3 DR ROSSITER: Yes.
4 MR GARNHAM: We can take from this further details of the
5 information that is available to the social services.
6 DR ROSSITER: Yes. When I read it I was very impressed.
7 MR GARNHAM: At the quality of the note making?
8 DR ROSSITER: By Karen Johns, yes.
9 MR GARNHAM: You have read those two documents. We have
10 also looked at what Lisa Arthurworrey records being told
11 by you in the telephone conversation.
12 DR ROSSITER: Yes.
13 MR GARNHAM: I want to make sure that we know what you say
14 was the information available to social services. Now,
15 we have it in those three sources. Is there anything
16 else that you say social services knew that is material
17 to Victoria's case?
18 DR ROSSITER: I do not know when they obtained the
19 information from Central Middlesex Hospital.
20 MR GARNHAM: Thank you. Anything else? The reason for the
21 question is obvious. You make observations about what
22 social services should have done and that will be
23 a matter for the Panel to consider.
24 DR ROSSITER: Yes.
25 MR GARNHAM: You also acknowledge deficiencies in the
34
1 communication of information to social services by your
2 hospital but we will need to understand how much had in
3 fact reached social services and I want to make sure
4 that I have your views on that topic. It seems as if it
5 is encompassed in those three documents primarily.
6 DR ROSSITER: Unless something comes to me I cannot think of
7 anything else.
8 MR GARNHAM: Thank you. Can we go on to 9th August, please.
9 You will not need those documents now. On 9th August
10 you discovered that Victoria had gone home.
11 DR ROSSITER: Yes.
12 MR GARNHAM: How does it come about that a consultant in
13 charge simply happens to discover something like that?
14 DR ROSSITER: There are two possible scenarios. Either one
15 of the nurses discovered it and rang me or -- which
16 I think is more likely -- or it came up at the
17 psychosocial meeting. I really do not remember the
18 timing. I can remember how I felt.
19 MR GARNHAM: Was your surprise, which is what you say you
20 felt, was your surprise at the fact that she had been
21 discharged or at the fact that she had been discharged
22 without you knowing about it, or both?
23 DR ROSSITER: I think discharged was what made me angry and
24 worried. Me not knowing about it made me feel very
25 insecure and therefore worried and angry.
35
1 MR GARNHAM: But were you surprised, because it sounds as if
2 there was in place no practice by that date of ensuring
3 that people, children were only discharged with your
4 agreement. So I do not see how you can be surprised.
5 DR ROSSITER: Well, there was implicit consent. The
6 understanding was that only a consultant or registrar
7 would discharge. And the practice is for all patients
8 and was -- I mean was then for all patients and now is
9 only for those with clinical problems that at a ward
10 round the person taking the ward round, who is either
11 the consultant or the registrar, would say, "Okay, so
12 and so can go home" and then we would do the paperwork
13 round the trolley.
14 MR GARNHAM: Sometimes an SHO does ward rounds.
15 DR ROSSITER: It is only under very rare circumstances the
16 SHO would do a ward round without a consultant or
17 registrar.
18 MR GARNHAM: As it happened, that happened on 6th August.
19 DR ROSSITER: With the -- which is what I said, because we
20 have enormous difficulty filling our middle grade cover,
21 allowing for sleep, holidays, et cetera.
22 MR GARNHAM: I understand your difficulties but is it the
23 case that as well as a consultant and a registrar, an
24 SHO conducting a ward round could in 1999 say, "It is
25 okay, this child can go home"?
36
1 DR ROSSITER: No, they should not do without checking.
2 MR GARNHAM: Given the concerns that you felt on 9th August,
3 was it not open to you to arrange follow-up of Victoria?
4 DR ROSSITER: The follow-up which I would do and therefore
5 I believe was what I attempted to do was through my
6 health networks primarily and that would be through the
7 liaison health visitor. Sometimes parents walk out or
8 we send them home rather sooner than we would wish at
9 a parent's request and the first point of call would be
10 the liaison health visitor who would liaise with the
11 community which would be primary care team.
12 MR GARNHAM: Did you contact the liaison health visitor
13 after you discovered Victoria had gone?
14 DR ROSSITER: If the liaison health visitor was at the
15 psychosocial meeting of which we have no record that
16 would be one time, but I truly believe that I did so on
17 the Tuesday because if I was in the hospital on the
18 Tuesday I would have had a meeting and a health visitor
19 would have been there, whether it was Enfield or
20 Haringey or a locum I do not know.
21 MR GARNHAM: Was it recorded, that liaison with the liaison
22 health visitor?
23 DR ROSSITER: Well, we know it was not.
24 MR GARNHAM: And it may be that you did it even though you
25 did not record it so your practice was not invariably to
37
1 record it?
2 DR ROSSITER: Well, very often if we were not -- you know,
3 everybody was not there, then it would be looking at the
4 notes. I should have written it down some time, I mean
5 it ought to have been annotated but we did not.
6 MR GARNHAM: I am interested to explore what your reaction
7 was when you discovered Victoria had gone home. You
8 used the word "surprise".
9 DR ROSSITER: That was a euphemism.
10 MR GARNHAM: That was a euphemism. That is interesting.
11 You used a different word when you gave evidence at the
12 Old Bailey, you said you were horrified.
13 DR ROSSITER: Well, I did not wish to repeat the language in
14 open court.
15 MR GARNHAM: Which is it?
16 DR ROSSITER: I actually swore.
17 MR GARNHAM: Demonstrating horror, surprise or what?
18 DR ROSSITER: I think the words were "bloody hell" so you
19 can interpret that how you feel.
20 MR GARNHAM: Why was that your reaction, given that when you
21 wrote to Petra Kitchman you said you would probably have
22 let Victoria go home yourself if you had been asked?
23 DR ROSSITER: I have been puzzling over that for the purpose
24 of the Inquiry. Either I was not as clear about my
25 concerns as I am now suggesting that I am, which is
38
1 possible because it is self-justification, or because
2 Petra was a colleague and I wanted to work in
3 partnership I was writing a sort of placatory letter
4 trying to share the blame. And maybe I was also bearing
5 in mind that we were talking a balance of probabilities,
6 she should not go home rather than she definitely should
7 not have gone home. These are questions I have asked
8 myself. I do not know the answer.
9 MR GARNHAM: Let me ask a more direct question then. Would
10 you have let Victoria go home, if you had been asked --
11 DR ROSSITER: If I had been phoned.
12 MR GARNHAM: -- on 6th August.
13 DR ROSSITER: If I had been phoned I know I would not have
14 done because this has happened on other occasions.
15 MR GARNHAM: So why did you write what you did to
16 Petra Kitchman to say that you would have allowed her to
17 go home if you had been asked?
18 DR ROSSITER: I have looked at that letter and looked at the
19 letter and tried to understand what I meant about it.
20 It may have been because I was in a distressed state,
21 I did not phrase it as carefully as I should have done.
22 MR GARNHAM: Another possibility is that you did not feel as
23 strongly about it as you now say you recollect and that
24 in fact you did not appreciate that there were risks to
25 Victoria in quite the way you now say you did.
39
1 DR ROSSITER: I take that point in that we have discovered
2 that I knew less about the physical abuse than the
3 emotional abuse and neglect, and I also take the point
4 because I have this hangup about the difficulty of
5 confirming emotional abuse and neglect. So maybe I did
6 not assess the risk as skilfully as I should have done.
7 MR GARNHAM: What steps did you take to discover who had
8 actually allowed Victoria to go?
9 DR ROSSITER: I believe I discussed it with Beat Norman
10 because if a nurse had discharged then I would discuss
11 it with her line manager.
12 MR GARNHAM: You believe you did. Do you have any
13 recollection of that discussion or what came from it?
14 DR ROSSITER: I do not recall that but I do know that a copy
15 of the summary was sent to Angela Gallagher, which would
16 express my going one step further up the management
17 ladder.
18 MR GARNHAM: Had this ever happened before that somebody had
19 been discharged in these sort of circumstances without
20 bleeping you or contacting you? I mean was this
21 a running problem?
22 DR ROSSITER: No, I cannot remember it ever happening before
23 but it certainly happened twice subsequently. I mean
24 I stopped it happening, but -- so it is possible that it
25 has happened before but in circumstances that were not
40
1 so tragic or important.
2 MR GARNHAM: Was anybody disciplined for this action of
3 permitting Victoria to go out without the say-so of you
4 or a registrar?
5 DR ROSSITER: Not that I am aware of.
6 MR GARNHAM: Should they have been? Was it a disciplinary
7 type offence or had you not made it clear enough to
8 justify that? I want to understand whether it is your
9 fault for not making it clear to your staff that it
10 should not happen or their fault for disobeying a clear
11 instruction.
12 DR ROSSITER: It was not a clear instruction and I do not
13 think a member of staff should have been disciplined.
14 MR GARNHAM: So you accept responsibility for the way it
15 went?
16 DR ROSSITER: Yes.
17 MR GARNHAM: You wrote and signed the discharge summary
18 which I think you say was sent out or was typed up on
19 13th August.
20 DR ROSSITER: It was typed on the 13th. I have checked with
21 our secretaries quite recently saying, because we have
22 had some delays in typing, "Is it the date I dictated or
23 is it the date I typed?" and they spoke to each other
24 and were very clear it is their practice to put the date
25 that it is typed.
41
1 MR GARNHAM: Does that mean we do not know the date you
2 dictated it?
3 DR ROSSITER: I am as certain as I can be that it was the
4 date that I discovered, the 9th, which would probably
5 explain why it is not composed as well as it would have
6 been if I had been in a calmer frame of mind.
7 MR GARNHAM: I forget what days of the week we are up to.
8 DR ROSSITER: I think the 9th is the Monday. I am certainly
9 talking about the Monday.
10 MR GARNHAM: Is that normal that if you dictate on a Monday
11 it gets typed up on the Friday? It does not seem to be
12 very urgent.
13 DR ROSSITER: Nothing is normal. I believe that this letter
14 would have been done on what I call the medicolegal
15 tape. We have no budget for secretaries to type legal
16 work which is rather more time-consuming than clinical
17 work and there is a rota of secretaries who do it and we
18 pay them out of legal fees. So it was my responsibility
19 to have said to the secretary, "This one is urgent", but
20 in practice, bearing in mind that it was a busy time of
21 year because probably a lot of them are on holiday,
22 I probably just put it in the basket and waited for them
23 to pick it up on their rota.
24 MR GARNHAM: Because it was urgent. I mean a child had been
25 discharged about whom you had real concerns.
42
1 DR ROSSITER: Yes.
2 MR GARNHAM: Discharged without your say-so.
3 DR ROSSITER: Yes.
4 MR GARNHAM: Now lost somewhere in Haringey. This is your
5 response and it waits four days to get typed.
6 DR ROSSITER: Indeed. I think my primary response was to go
7 through health, which is what I normally do, and going
8 through the health visitor. If I had really thought
9 that it was urgent to speak to a social worker I am sure
10 I would have telephoned. So it must have been that my
11 mind set was to go through the health route and confirm
12 in writing with the social worker.
13 MR GARNHAM: And that it was less urgent than you
14 subsequently think of it to be?
15 DR ROSSITER: This may be.
16 MR GARNHAM: This discharge letter, who did it go to? Who
17 did you intend it to go to first of all?
18 DR ROSSITER: The letter rather than the summary?
19 MR GARNHAM: I am sorry, I have used the wrong expression.
20 The summary, 37/052.
21 DR ROSSITER: I believe my intention was that it would be
22 directed to the general practitioner who did not exist,
23 because that is how we do summaries.
24 MR GARNHAM: Because it is clear on the top part of the
25 summary "No registered GP".
43
1 DR ROSSITER: Yes.
2 MR GARNHAM: In fact there was some reference to a GP on the
3 file, was there not?
4 DR ROSSITER: Yes.
5 MR GARNHAM: You thought there was no registered GP so who
6 were you writing this to?
7 DR ROSSITER: I think that my mind had not put 2 and 2
8 together to say to the secretaries, as I very often do,
9 "There is no GP", and in those circumstances I would
10 send say to general practitioner via health visitor or
11 via liaison health visitor whose job it was to discover
12 who the GP was. I definitely intended it to go to
13 social services and I definitely intended it to go to
14 the legal file.
15 MR GARNHAM: I can see that you might send it to a file but
16 that is inside the hospital so that does not inform
17 anybody very much of anything.
18 DR ROSSITER: May I take this further?
19 MR GARNHAM: Yes, do.
20 DR ROSSITER: Another problem which I have discovered but
21 had not done things about as actively as I should is
22 that when the secretaries do copies for summaries, what
23 they are supposed to do is go cc this person and cc that
24 person. However, very often -- and I dictate that --
25 but very often they do not do that, they put the cc's on
44
1 a sticker. Now, I think it is very likely that that
2 unfortunately is what happened here because if you look
3 at the legal file and the copy of the summary in there,
4 where it says "copy legal file" it is in different
5 handwriting and it is not my handwriting. So someone --
6 MR GARNHAM: Sorry to cut in. Who did you intend this to go
7 to?
8 DR ROSSITER: I intended it to go to the social worker.
9 I may have intended it to go to the liaison health
10 visitor to go to primary care, I hope I did. And
11 I intended it to go to the legal file.
12 MR GARNHAM: It was never sent to Lisa Arthurworrey, was it?
13 DR ROSSITER: This is what she says and I now have no
14 verification, that it was not sent, I mean.
15 MR GARNHAM: Or that it was sent?
16 DR ROSSITER: Yes.
17 MR GARNHAM: You have no verification that it was sent?
18 DR ROSSITER: I have no verification that it was sent and we
19 are going back to trusting members of teams and not
20 checking. When I sign things I expect them to go to
21 where I expect them to go.
22 MR GARNHAM: But in fact we are having to just guess that
23 you had made clear your intention that a copy should go
24 to Miss Arthurworrey, because there is nothing to
25 document, no cc list.
45
1 DR ROSSITER: There is no cc list.
2 MR GARNHAM: Not sent to Petra Kitchman until it was
3 enclosed with your letter of September 2nd.
4 DR ROSSITER: I am sorry, she should have been on the list
5 of people that it was intended to go to because it was
6 a covering letter, yes.
7 MR GARNHAM: But it was not sent to Petra Kitchman.
8 DR ROSSITER: No. We are not alone as a hospital that this
9 happens. I get letters from people saying, "I have
10 enclosed ..." and we have to write back and say, "No you
11 have not".
12 MR GARNHAM: Yes, but I am concerned that this letter which
13 you obviously regard as important does not actually seem
14 to have gone to anybody who can do anything useful about
15 it.
16 DR ROSSITER: I share your concern.
17 MR GARNHAM: Was it sent to Angela Graham?
18 DR ROSSITER: No, Anne Graham.
19 MR GARNHAM: I am sorry, Anne Graham. Can we look at the
20 message that this letter conveyed, please?
21 DR ROSSITER: Could you remind me where it is?
22 MR GARNHAM: 37/052. Do you have it, 37/052?
23 DR ROSSITER: That is the summary?
24 MR GARNHAM: Yes, I want to look at what message this
25 conveyed, so to anybody who did read it:
46
1 "Presenting features: brought to Casualty having
2 poured boiling water on herself because of intolerable
3 itching."
4 Nothing to suggest that there was any doubt that
5 this had been an act done by Victoria herself.
6 DR ROSSITER: It is not a well-written summary.
7 MR GARNHAM: That is self-evident but it does not answer my
8 question.
9 DR ROSSITER: No, it is not there.
10 MR GARNHAM: On the face of it somebody reading this would
11 have thought these doctors are satisfied that this child
12 had tipped boiling water over her own head, yes?
13 DR ROSSITER: Yes, it is not well written.
14 MR GARNHAM: "Child had been treated daily for scabies,
15 treatment obtained from an A&E Department in another
16 hospital".
17 DR ROSSITER: Yes.
18 MR GARNHAM: No indication that that is a mistreatment
19 because it only needs to be applied once. We finds that
20 I think in the next line: "Seen by dermatologist".
21 DR ROSSITER: I think that the implication is there and
22 someone medical would have understood it but of course
23 you are telling me that this has been sent as
24 information to someone who is not medical.
25 MR GARNHAM: That was your apparent intention.
47
1 DR ROSSITER: Yes.
2 MR GARNHAM: "Noted to be a very distressed child."
3 Where did that come from? There are notes in the
4 files to the effect that she was upset but "very
5 distressed" seems to be something that you have added.
6 DR ROSSITER: It was my conclusion in that the anxious
7 attachment and the wetting and the polyphagia, I could
8 have said "showing signs of emotional abuse" but what
9 I did was give a shorthand of "distressed".
10 MR GARNHAM: "Multiple marks on her not just due to
11 scratching, thought possibly due to chastisement for
12 example with looped wire."
13 DR ROSSITER: Yes, it should have been "probable".
14 MR GARNHAM: "Child protection forms completed, photographs
15 taken belatedly, staffing problems."
16 Then you discuss the evidence of emotional abuse.
17 DR ROSSITER: Yes.
18 MR GARNHAM: You say "clinging desperately to mother."
19 Again I have to ask you, it is not obvious to me where
20 in the file that expression comes from. "Clingy" was
21 the only similar expression I have seen. "Clinging
22 desperately to mother."
23 DR ROSSITER: Again we are back to having information that
24 I would have heard on the many occasions she was
25 discussed, but it was not -- it was not documented as of
48
1 full minutes.
2 MR GARNHAM: Next sentence, can you explain what this means
3 please:
4 "Considered likely to be abused. Probable neglect
5 and emotional abuse. Less difficult to prove physical".
6 DR ROSSITER: It is nonsense, it is a clerical error. It
7 should be "more difficult".
8 MR GARNHAM: Should be the opposite, "more difficult".
9 DR ROSSITER: Yes.
10 MR GARNHAM: If we looked at the next two sentences:
11 "Home visit for risk assessment made by social
12 services."
13 Was that what a home visit was for?
14 DR ROSSITER: It is another misconception.
15 MR GARNHAM: "On their advice child discharged home by ward
16 staff."
17 DR ROSSITER: Yes.
18 MR GARNHAM: Very worrying case.
19 DR ROSSITER: Yes.
20 MR GARNHAM: This is hopeless, is it not, Doctor? I mean it
21 does not get across the gist of what you wanted to say.
22 It is a rushed letter.
23 DR ROSSITER: Had I the luxury to proofread every letter
24 I did, yes, it was a rushed letter and it was done in
25 a state of heat, I absolutely agree.
49
1 MR GARNHAM: Last of the three bullet points:
2 "No GP, not school time, difficult to follow up the
3 child further."
4 DR ROSSITER: Yes.
5 MR GARNHAM: No indication there that you were putting into
6 place follow-up through the liaison health visitor. If
7 that is what you had done, why did it not appear there?
8 DR ROSSITER: I have put a question mark. It looks like to
9 be planned.
10 MR GARNHAM: Question mark beside the word "follow up?
11 DR ROSSITER: Yes.
12 MR GARNHAM: In the sentence in English where you deal with
13 that, you say:
14 "No GP, not school time, difficult to follow up the
15 child further."
16 Why not say, if it were true, "but I have liaised
17 with the liaison health visitor who is going to do
18 a follow up"?
19 DR ROSSITER: Because the summary is inadequate.
20 MR GARNHAM: Yes, I think we are agreed about its
21 inadequacy. I wonder whether in that respect the
22 absence of any reference to the liaison health visitor
23 suggests that in fact you did not liaise with the health
24 visitor.
25 DR ROSSITER: It suggests to me that I had not yet
50
1 formulated in my mind what was going to happen. It
2 certainly tells me that I have not made plans but what
3 it does not tell us is what my intentions were.
4 MR GARNHAM: The observation about pouring boiling water
5 over her head, do you know where that came from?
6 DR ROSSITER: I must have been leafing through and would
7 have picked that up as something that caught my eye, so
8 it was not a well judged comment, I just took the first
9 thing.
10 MR GARNHAM: Because the observation in the notes appears to
11 be hot water.
12 DR ROSSITER: It was again sloppy thinking.
13 MR GARNHAM: Nurse Norman told us that she had understood
14 that the water had been poured from a kettle.
15 DR ROSSITER: Yes.
16 MR GARNHAM: Might that have been the origin of your
17 assumption that the water she tipped over her head was
18 boiling?
19 DR ROSSITER: I am sure it was and very stupid it was too.
20 MR GARNHAM: You have said that Victoria obtained treatment
21 from an A&E Department.
22 DR ROSSITER: Yes.
23 MR GARNHAM: Not just treated, admitted to the CMH. Another
24 defect in the summary.
25 DR ROSSITER: The admission is specified I believe. It must
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