Archived Transcript for 16 November 2001: Pages 151 to 166

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1 MR SHELDON: Do you know if you did say it where you would

2 have got that understanding from?

3 DR ALEXANDER: I cannot but I think if I remember right the

4 mother was seen to inform her that a referral has been

5 made to social services.

6 MR SHELDON: Absolutely. If you did give that information

7 that would seem to be correct.

8 DR ALEXANDER: That is right, I would have got that

9 information either you know -- I do not know if you know

10 the structure of North Middlesex but John Gilpin Ward

11 which is a day assessment unit and Rainbow are directly

12 opposite, and after the ward rounds sometimes the two

13 registrars or the junior doctors meet together and we

14 might have shared that information then and the call

15 must have come through to me because I was probably the

16 doctor on-call that day, the registrar on-call, and any

17 calls through the switchboard asking for a paediatrician

18 would come through to me.

19 MR SHELDON: Absolutely, and, sir it is 265 for your note,

20 exactly what Karen Johns says you said was going to

21 happen did happen so it is not unlikely that you said it

22 but I did want to confirm that that is your best guess

23 as well, that you did have a conversation and that is

24 what you said.

25 DR ALEXANDER: It is difficult for me to make a record of

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1 that because I do not know where I was when I got this

2 phone call.

3 MR SHELDON: I am not suggesting you necessarily should have

4 made a record, just that is likely to have been what

5 happened. Have a look down 253, please:

6 "Telephone call to Rainbow Ward. I spoke to Sue,

7 nurse in charge, updated her on referral to Haringey.

8 Also asked if she could remind the doctors to either

9 complete a new child protection form in respect of the

10 old marks on Anna or write their comments that they

11 suspect NAI on the existing form."

12 So it would seem that the next day as well

13 Karen Johns is still trying to get confirmation from

14 some doctor at the hospital that this is a suspicion of

15 NAI, which would reinforce the point, would it not, that

16 I made earlier that the golden opportunity, your ward

17 round with Dr Meates, was missed and that after that it

18 becomes increasingly difficult for Karen Johns to be

19 aware of the true position?

20 DR ALEXANDER: That is right.

21 MR SHELDON: Do you accept that in view of the

22 responsibilities placed on registrars in the Child

23 Protection Guidelines, in view of the fact that nobody

24 had done a proper examination of Victoria's injuries so

25 as to form an opinion as to their cause, by the 27th,

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1 you should first of all have done that examination, you

2 or Dr Meates?

3 DR ALEXANDER: All I can say is that if we were aware that

4 such an examination was not carried out or if there was

5 a specific request as detailed here was being made, that

6 should have been done on that day and we did not.

7 MR SHELDON: If you were aware -- you should have been

8 aware, should you not?

9 DR ALEXANDER: Probably.

10 MR SHELDON: The situation as you appear on the ward would

11 seem to be no examination has been done, social worker

12 asking more than once for information as to whether

13 doctors think it is NAI. That is the background. So as

14 you arrive on the ward you should have done the

15 examination.

16 DR ALEXANDER: Well, this is dated the 28th. The ward round

17 was on the 27th.

18 MR SHELDON: Absolutely. The only reason I took you to that

19 is to show after you left the ward the same problem

20 still exists.

21 DR ALEXANDER: That is right.

22 MR SHELDON: So should you have done that examination?

23 Should you have made Karen Johns aware that there were

24 suspicions of non-accidental injury?

25 DR ALEXANDER: That would have been the ideal situation,

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1 yes. We should have done it.

2 MR SHELDON: Does it represent good practice let alone

3 utopia?

4 DR ALEXANDER: I would say that that would represent good

5 practice.

6 MR SHELDON: 3rd August 1999, on that occasion you did the

7 ward round on your own, did you not?

8 DR ALEXANDER: That is right.

9 MR SHELDON: A note of it is at page 270 of volume 37, which

10 I think is on its way over to you now. You appear to

11 note that Victoria is better and that a proper history

12 from Anna and mum re what exactly happened with

13 Lucienne -- I believe that is Lucienne Taub, is that

14 right -- she is coming in today. First of all I take it

15 no examination on this day either.

16 DR ALEXANDER: No.

17 MR SHELDON: How do you know as you record in your statement

18 then that Victoria was medically fit for discharge at

19 this point?

20 DR ALEXANDER: Her burns were healing well and there was no

21 particular medical concerns with her. All observations

22 have been stable and there was no reason to believe that

23 she had a medical condition or a medical reason to stay.

24 MR SHELDON: You had got that all from where, from the

25 notes?

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1 DR ALEXANDER: I would have got it from the daily

2 observations being charted on the bedside charts and

3 from the fact that you know her burns -- I think by then

4 the burns were nearly healing.

5 MR SHELDON: What I am wondering is you say in paragraph 10

6 of your statement she was medically fit for discharge.

7 You do not say that in your note. I am wondering

8 firstly whether you can be sure that was your view at

9 the time, and secondly where that view came from.

10 DR ALEXANDER: It is just a reflective statement because the

11 statement for the Public Inquiry has been made in

12 response to specific questions: "What was your view?

13 What was your comments? What did you think should have

14 happened?" In that sense she was medically fit to go

15 home because her burns had healed well, she had no

16 outstanding medical problem and there was no reason why

17 she should say in for treatment.

18 MR SHELDON: So I am clear, are you saying that your view at

19 the time standing at the end of her bed on 3rd August

20 was that she was medically fit for discharge?

21 DR ALEXANDER: Yes.

22 MR SHELDON: Why not note that?

23 DR ALEXANDER: Because you know that there were significant

24 social concerns which still have not been addressed

25 fully and I believe I should have written that she is

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1 medically fit for discharge.

2 MR SHELDON: But you are clear in your mind that that is

3 what you thought at the time?

4 DR ALEXANDER: That is right.

5 MR SHELDON: You indicated in that note that you thought the

6 proper history needed to be taken.

7 DR ALEXANDER: Yes.

8 MR SHELDON: And you were aware that a proper history had

9 not yet been taken, how?

10 DR ALEXANDER: I was aware that there was a history on the

11 day of admission and looking through the notes I think

12 this is probably an offshoot from the previous day's

13 psychosocial meeting because on the previous day's

14 psychosocial meeting it was suggested that a history

15 needs to be taken again. We need to talk to Victoria

16 again.

17 MR SHELDON: You were at that meeting, were you?

18 DR ALEXANDER: I was not but I would have certainly been fed

19 that information during the ward round.

20 MR SHELDON: We were told by Dr Meates that the notes for

21 that meeting would have been 300 yards or metres away in

22 the child psychiatry department.

23 DR ALEXANDER: That is right.

24 MR SHELDON: So how would you have become aware of what was

25 said at the psychosocial meeting the day before during

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1 the course of your ward round?

2 DR ALEXANDER: There are two ways in which the information

3 gets fed back. If it is important or if it is something

4 very important that would get written up in the notes

5 after the psychosocial meeting by the SHO who comes back

6 to the ward, or it will come through the nursing staff,

7 so if I had --

8 MR SHELDON: So you were told by a nurse probably?

9 DR ALEXANDER: I would think so, because if I had

10 specifically written there it would have been prompted

11 by a nurse's suggestion.

12 MR SHELDON: Would that explain why you thought it was

13 important to get a proper history on 3rd August 1999

14 when you had not thought it was important to get

15 a proper history on the 27th July?

16 DR ALEXANDER: On 27th July I think Victoria had other

17 problems. She had burns, she had an eye which was fully

18 swollen up. She had a lot of medical needs at that

19 time. I think that was not the foremost concern at that

20 stage. She had an eye which was swollen up. We were

21 not sure if the eye was involved.

22 MR SHELDON: The taking of this history you envisaged was

23 going to involve Lucienne Taub so it was going to be

24 done through an interpreter. Did you have some sort of

25 formal arrangement in mind rather than a friendly chat?

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1 You wanted to really get to the bottom of it in a formal

2 context, did you?

3 DR ALEXANDER: The intention then would have been to talk to

4 Victoria. With a seven year old child you had to take

5 it as it comes and my intention would have been to just

6 talk to her with the view of taking a history about what

7 happened.

8 MR SHELDON: Having identified this need should you have

9 made sure that it was done?

10 DR ALEXANDER: I have thought about it 100 times but I think

11 the only thing I can think about this is that Lucienne

12 probably did not come that day. What would have ideally

13 happened is they would have either bleeped me or the SHO

14 covering the ward when Lucienne arrive on the ward to

15 talk to Anna.

16 MR SHELDON: Leaving aside what did or should have happened,

17 you have identified this gap. You have written a plan

18 which requires plugging. Should you have made sure that

19 that happened? Should you have taken responsibility for

20 making sure that that happened?

21 DR ALEXANDER: For that day, yes, but in the grand scheme of

22 things if you know there are certain plans which you

23 make for a day which do not happen for some reason or

24 the other, either due to Lucienne not coming or if I was

25 busy in Casualty, and in that situation somebody would

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1 have picked it up the next day. But yes, if -- it would

2 have been my kind of moral responsibility to come back

3 and show that it has been done.

4 MR SHELDON: Same question in relation to the discussion

5 with the social worker that is down in the notes.

6 Should you have made sure that that discussion took

7 place and that all that you wanted to have been covered

8 was covered?

9 DR ALEXANDER: Putting myself in 1999, I think at that stage

10 if I have written there "Tottenham social worker

11 Lisa Arthurworrey will contact us", that information

12 would have come to me either from the nurse who spoke to

13 whoever, you know, I think it was Karen Johns, and the

14 fact that the CP forms have been sent across to them,

15 I would have been satisfied that things have been set in

16 motion.

17 MR SHELDON: The purpose of that phone call is this, is it

18 not: Victoria is medically fit for discharge, the

19 question that is outstanding is whether it is safe for

20 her to be discharged and that is what you are going to

21 need the assistance of the social worker for, yes?

22 DR ALEXANDER: That is right.

23 MR SHELDON: You as the treating registrar who has

24 identified this plan at that stage and are responsible

25 for Victoria's safety.

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1 DR ALEXANDER: That is right.

2 MR SHELDON: Are you not going to want in those

3 circumstances to satisfy yourself that it is safe to

4 discharge Victoria, rather than delegating that

5 responsibility to a nurse, however competent she may be?

6 DR ALEXANDER: The practice varies from hospital to

7 hospital. In North Middlesex it was common practice for

8 social services to liaise with the nurses, purely

9 because as far as I can see, even to this day, that

10 there has been quite a safety net to make sure that

11 things get done from the child protection point of view

12 and if a referral has been made to the Tottenham social

13 worker and subsequently the social worker in question

14 phoned up the ward, asked for the CP forms, I would have

15 been satisfied with that, but looking back what I would

16 not have been satisfied with is probably they did not

17 have the information they exactly needed in the CP

18 forms.

19 MR SHELDON: You should have been the one speaking to

20 Lisa Arthurworrey, should you not, not Isobel Quinn?

21 DR ALEXANDER: As I said, the procedure varies from hospital

22 to hospital. There are certain hospitals I have worked

23 in where only the consultant talks to the social worker

24 and expresses their concerns. Some places where the

25 registrar does it. There was quite -- in North

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1 Middlesex certainly social workers spoke to the nurses,

2 rang the wards, spoke to the nurses on a regular basis

3 regarding cases. Yes, the ideal circumstance would have

4 been for myself to (inaudible)

5 MR SHELDON: If you had spoken to Lisa Arthurworrey on that

6 occasion and you had been told what she seems to have

7 told Isobel Quinn, which was there was going to be

8 a home visit, would you have been satisfied that all the

9 concerns of which you were aware that had been

10 identified in the hospital could be addressed simply by

11 a home visit?

12 DR ALEXANDER: Just by a home visit, no.

13 MR SHELDON: What else would you have said that needed to be

14 done before you were content that Victoria could be

15 discharged in safety?

16 DR ALEXANDER: I would have expected for a formal inquiry or

17 an investigation into the circumstances by the Child

18 Protection Team and a case conference or

19 a multidisciplinary meeting where specific details of

20 further care are discussed.

21 MR SHELDON: That is what you would have told

22 Lisa Arthurworrey if you had been talking to her on the

23 phone and she had said all she planned to do was a home

24 visit.

25 DR ALEXANDER: If she had said specifically, "All I am

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1 planning to do is only a home visit", yes I would have

2 said that, but if she said "I am doing a home visit,

3 I will take it as a first step towards a formal

4 investigation later on" ...

5 MR SHELDON: But you would have wanted to satisfy yourself

6 that such a formal investigation would take place before

7 discharge?

8 DR ALEXANDER: Yes.

9 MR SHELDON: It is a shame therefore that it was not you on

10 the end of the phone to Lisa Arthurworrey, is it not?

11 DR ALEXANDER: That is right, but as I said, most nurses in

12 North Middlesex were equally aware of Child Protection

13 Guidelines, were equally I would say experienced in the

14 sense that they had been in contact, it was normal

15 practice in North Middlesex for social workers to make

16 contact to the ward directly rather than through the

17 doctors.

18 MR SHELDON: Thank you very much.

19 THE CHAIRMAN: Mr Mason.

20 MR MASON: I am looking at my watch. I have only got one

21 question. Can I ask you to look please at volume 27

22 page 272, the same page as your 3rd August ward round.

23 At the top of that page there is Dr Rossiter's ward

24 round of the day before. Where it says "Impression:

25 able to discharge", would you have been aware of that

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1 ward round and of that note when you did your ward round

2 on 3rd August?

3 DR ALEXANDER: Yes I would have been.

4 MR MASON: Does that help you as to whether or not you would

5 have had in mind yourself the next day whether or not

6 Victoria was medically fit for discharge?

7 DR ALEXANDER: Certainly, yes. As I said, I have not

8 explicitly put it down in words but for all practical

9 purposes we all knew Victoria was medically ready for

10 discharge.

11 MR MASON: Is that what you thought the note of 2nd August

12 meant?

13 DR ALEXANDER: That is right.

14 THE CHAIRMAN: Mr Mason, are you sure you have covered

15 whatever you want? I do not want you to feel rushed.

16 MR MASON: Yes, sir.

17 THE CHAIRMAN: I have just one question. You said in answer

18 to Mr Sheldon that it would be inappropriate to write

19 opinions on the body map. The marks, fine, but not

20 opinions. What were you trained or how were you trained

21 about where you should express the opinions that relate

22 to the body map?

23 DR ALEXANDER: The normal practice would be to body map like

24 that, that would be part of your history examination on

25 that, and then one would make a formal report describing

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1 the injuries and giving your opinion on it, so that

2 would be -- there are two scenarios. You can either get

3 a social worker ringing you up saying, "I would like to

4 bring a child, I want an examination and an opinion in

5 an outpatient setting". You do that straightaway. If

6 it is an inpatient it gets recorded and then the report

7 may get done at any stage during the stay and usually it

8 is when the investigation is going full steam and we are

9 coming to a case conference and things like that.

10 THE CHAIRMAN: Do you have an example of how that worked in

11 this case that you could point my attention to?

12 DR ALEXANDER: The report?

13 THE CHAIRMAN: No, the body map is on one side and the other

14 side is the medical opinion of the significance of the

15 marks.

16 DR ALEXANDER: I will have to look through the forms.

17 THE CHAIRMAN: Sorry, I thought that you -- I am afraid

18 I have not got the page in front of me. Maybe you could

19 help with the body map.

20 MR SHELDON: Volume 37, pages 60 to 64.

21 DR ALEXANDER: You were saying on the back of the page.

22 THE CHAIRMAN: I thought you had explained to me that normal

23 practice would be that the body map would show the marks

24 and alongside the body map there would be a medical

25 opinion of the significance of the marks.

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1 DR ALEXANDER: No, what I meant is that when doing a body

2 map like this I would only give facts there in the sense

3 I have a swelling which is so many centimetres and the

4 opinion would be in the form of a medical report.

5 THE CHAIRMAN: What I was asking for, where is the medical

6 report?

7 DR ALEXANDER: There is no medical report.

8 THE CHAIRMAN: Thank you. The final question: having got

9 the body map in front of you, did the police ever ask

10 you to explain the significance of those marks?

11 DR ALEXANDER: No, not to me.

12 THE CHAIRMAN: Thank you.

13 MR SHELDON: I have no more questions thank you.

14 THE CHAIRMAN: Thank you. If there was a misunderstanding,

15 whoever was responsible for the misunderstanding,

16 I apologise.

17 MR GARNHAM: That completes our business for this week in

18 terms of live evidence and is all I am going to ask you

19 to deal with, sir. We have slipped this week only in

20 the sense that some of our reads have not been done. We

21 will slot them in where we can next week.

22 THE CHAIRMAN: I am grateful to you and indeed to everyone

23 else. Thank you very much. That being so we will

24 adjourn until 10 am on Monday.

25 MR GARNHAM: Thank you.

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1 (1.05 pm)

2 (Adjourned until 10.00 am on Monday, 19th November 2001)

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