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Archived Transcript for 22 November 2001:
Pages 151 to 213
151
1 said that there were a number of marks on Victoria's
2 body but she was not sure whether these marks were
3 caused by scratching, scabies or an infection.
4 MR GARNHAM: Look at paragraph 98 of your statement, please.
5 This is your overview of the information from the NMH,
6 immediately before your first home visit, was being
7 discussed:
8 "As a result of the information I received from NMH
9 I knew that Victoria had apparently poured hot water
10 over her head ... and that this was not seen as ...
11 non-accidental. A number of marks had been observed on
12 Victoria's body but the hospital was unsure what these
13 were from. Dr Rossiter had suggested that the marks may
14 have been from scabies or from an infection from
15 Victoria scratching the scabies. Without a clear
16 diagnosis of non-accidental injury from NMH I could only
17 note the hospital's ambivalence ..."
18 So after your conversation with Rossiter your
19 conclusion is still that the hospital are ambivalent?
20 MISS ARTHURWORREY: About the old markings.
21 MR GARNHAM: So what do you do to decide what those marks
22 represent to resolve that ambivalence?
23 MISS ARTHURWORREY: As I said, I spoke to Kouao and when
24 I received the information from the Central Middlesex
25 Hospital I was -- I tried to test the information that
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1 she gave me with the information that I had received
2 from the Central Middlesex Hospital.
3 MR GARNHAM: But up until you got that information from the
4 CMH on 12th August the ambivalence remains unresolved.
5 MISS ARTHURWORREY: It does, although Kouao had quite
6 clearly stated that the marks on Victoria's body were
7 due to scabies.
8 MR GARNHAM: Of course she would if she were the abuser.
9 MISS ARTHURWORREY: Well, the way I put it to Kouao is that,
10 "The hospital have noted a number of marks on Victoria's
11 body. Can you tell me what they are?"
12 MR GARNHAM: She was hardly likely to say, "Well, that is
13 where I have been beating her with a belt", was she?
14 MISS ARTHURWORREY: But I did say to Kouao two other marks
15 have been observed on Victoria's body.
16 MR GARNHAM: She was unlikely to say, "That is where I grip
17 her so hard that I bruise her", was she?
18 MISS ARTHURWORREY: No.
19 MR GARNHAM: So the position is that you are conducting this
20 early part of the assessment, knowing that the hospital
21 are unsure what these marks represent, without testing
22 it, without going to the doctor and saying, "There seems
23 to be ambivalence here in the hospital notes. You seem
24 to be unsure what is it that I am to conclude".
25 MISS ARTHURWORREY: I did not have that discussion with the
153
1 hospital.
2 MR GARNHAM: Can I ask you now to consider the totality of
3 the information that was available to you about the
4 concerns expressed about Victoria? It is convenient to
5 do that by looking at the Monaghan report again,
6 volume 45A, please, page 150.568. Mr Monaghan may have
7 got this wrong so I want to ask you whether or not this
8 is correct. By 4th August 1998 he suggests that the
9 following information was available to you:
10 "... five and a half hour delay in taking the child
11 to hospital after a scalding incident".
12 Do you agree that was available?
13 MISS ARTHURWORREY: Yes, that was available.
14 MR GARNHAM: "... old marks, shaped like a belt buckle, on
15 her body ".
16 You knew that?
17 MISS ARTHURWORREY: That had not been confirmed by the
18 North Middlesex.
19 MR GARNHAM: I agree you only had a suggestion that may be
20 non-accidental, nothing more than that.
21 MISS ARTHURWORREY: Although there was no specific
22 suggestion to the belt buckle mark in the information
23 I received from Nurse Quinn.
24 MR GARNHAM: Not in the medical information you received
25 from Nurse Quinn, no, but there was in the earlier
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1 medical information and Nurse Quinn was only dealing as
2 you have told us with emotional matters.
3 MISS ARTHURWORREY: When you say earlier medical
4 information?
5 MR GARNHAM: You had seen reference to it in the referral
6 note from Caroline Rogers and she had got it from the
7 NMH.
8 MISS ARTHURWORREY: Yes.
9 MR GARNHAM: "... dirty clothes, no underwear, and unkempt
10 appearance of the child compared to the smart appearance
11 of MTK."
12 MISS ARTHURWORREY: Yes.
13 MR GARNHAM: "... nervousness exhibited by VC in the
14 presence of MTK and the master/servant relationship."
15 MISS ARTHURWORREY: I would like to -- the example that
16 Dr Rossiter gave me with regards to the master/servant
17 relationship was Victoria running to her mother's side
18 as if being called to attention.
19 MR GARNHAM: All right. We will qualify that to that
20 extent.
21 "VC wets herself when MTK visited and no effort made
22 was made by MTK to deal with this."
23 MISS ARTHURWORREY: I had that information.
24 MR GARNHAM: "... no treats or clothes were brought in".
25 MISS ARTHURWORREY: Yes.
155
1 MR GARNHAM: "... frightened of being undressed ... "
2 MISS ARTHURWORREY: Yes.
3 MR GARNHAM: "... frightened of Manning".
4 MISS ARTHURWORREY: Yes.
5 MR GARNHAM: "... crying without tears when MTK left the
6 ward".
7 MISS ARTHURWORREY: Yes.
8 MR GARNHAM: "Victoria appears to love MTK but not sure if
9 this is reciprocated".
10 MISS ARTHURWORREY: Yes.
11 MR GARNHAM: "... presents as a bright child who can speak
12 three languages".
13 MISS ARTHURWORREY: Yes.
14 MR GARNHAM: "... seeks attention and praise ... "
15 MISS ARTHURWORREY: Yes.
16 MR GARNHAM: "... overtreated the scabies condition ... "
17 MISS ARTHURWORREY: Yes.
18 MR GARNHAM: "... treated the scald with a cleaning agent".
19 MISS ARTHURWORREY: Yes.
20 MR GARNHAM: "... two thumb prints on VC's body".
21 MISS ARTHURWORREY: Yes.
22 MR GARNHAM: "... eating large amounts of food".
23 MISS ARTHURWORREY: Yes.
24 MR GARNHAM: "... anxious attachment".
25 MISS ARTHURWORREY: Yes.
156
1 MR GARNHAM: "Queries about emotional neglect".
2 MISS ARTHURWORREY: Yes.
3 MR GARNHAM: " ... been in the UK since March 1999 but VC
4 had not attended school".
5 MISS ARTHURWORREY: Yes.
6 MR GARNHAM: "Photographs and a skeletal survey had been
7 ordered" but not yet obtained.
8 MISS ARTHURWORREY: Yes.
9 MR GARNHAM: "... hospital was satisfied about the
10 description given of the scalding incident", you tell
11 us.
12 MISS ARTHURWORREY: Yes.
13 MR GARNHAM: "Differences in the account of the scalding".
14 MISS ARTHURWORREY: Yes.
15 MR GARNHAM: One from hot water from a bathroom tap, the
16 other water from a hot kettle.
17 MISS ARTHURWORREY: Yes.
18 MR GARNHAM: Looking at the totality of that information, do
19 you say you assessed the risk to Victoria properly?
20 MISS ARTHURWORREY: I tried to address each of those points
21 in turn and Kouao gave explanations, for example the
22 dirty clothes, no underwear and unkempt appearance of
23 the child.
24 MR GARNHAM: At the moment that information was available to
25 you on 4th August. Did you, as a matter of interest,
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1 list it in that sort of way?
2 MISS ARTHURWORREY: No, I did not.
3 MR GARNHAM: Did you attempt to evaluate it -- did you
4 attempt to evaluate how it stacked up?
5 MISS ARTHURWORREY: No, I did not.
6 MR GARNHAM: Sir, I have been passed a note from
7 Miss Arthurworrey's counsel asking if I could suggest to
8 you a break. I am perfectly content with that if you
9 are, sir?
10 THE CHAIRMAN: Yes indeed. Is this a convenient moment for
11 you?
12 MR GARNHAM: Yes, sir.
13 THE CHAIRMAN: Do you want to put the question again, or
14 not?
15 MR GARNHAM: No, sir, that is fine.
16 THE CHAIRMAN: Well fine. We will take a break. The same
17 rules, Miss Arthurworrey and if we could be back here --
18 let us try and get this clock right this time. If we
19 get back here, and be really precise, at about 3.18.
20 Thank you.
21 (3.10 pm)
22 (A short break)
23 (3.20 pm)
24 MR GARNHAM: Miss Arthurworrey, as you know your counsel is
25 very solicitous for your welfare and she felt you needed
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1 a break and I am anxious to ensure if you feel you need
2 a break you indicate it to us because your evidence is
3 important and if you think the pressure is mounting and
4 you are starting to not be able to reflect on your
5 answers, you must ask for a break.
6 MISS ARTHURWORREY: Okay. Thank you.
7 MR GARNHAM: The impression I am left with is that you took
8 the view by the end of the 3rd of August that the
9 primary matters into which you had to investigate were
10 the questions of neglect and emotional abuse.
11 MISS ARTHURWORREY: That is correct, yes.
12 MR GARNHAM: Given that Victoria was at that time still in
13 hospital and had not been seen by anybody in hospital,
14 how could neglect and emotional abuse be assessed by
15 a home visit?
16 MISS ARTHURWORREY: At the time there was an understanding
17 that Victoria had contracted scabies from the Tottenham
18 address.
19 MR GARNHAM: I am not quite sure I understand that. That
20 would justify going to the home address to see whether
21 that is where the scabies were.
22 MISS ARTHURWORREY: That is right.
23 MR GARNHAM: But that point aside, how is a home visit going
24 to help you assess emotional abuse if Victoria is not
25 there?
159
1 MISS ARTHURWORREY: It would not at all.
2 MR GARNHAM: So what do you see as the purpose of the home
3 visit then; to look for scabies?
4 MISS ARTHURWORREY: To see if the home environment was
5 a safe and fit environment for Victoria to be discharged
6 back.
7 MR GARNHAM: You could only, with her not there, you could
8 only decide whether or not the physical space was
9 adequate, could you not?
10 MISS ARTHURWORREY: That is correct, yes.
11 MR GARNHAM: So that you were not going to get very far with
12 your assessment into emotional abuse and neglect by the
13 home visit.
14 MISS ARTHURWORREY: Not if Victoria was not there, no.
15 MR GARNHAM: The plan was you would visit on 4th August when
16 she would not be there, she would still be in hospital.
17 MISS ARTHURWORREY: That is right, yes.
18 MR GARNHAM: How did you see the respective roles of you and
19 Jones on that visit?
20 MISS ARTHURWORREY: This was the first time I had carried
21 out a joint investigation with the police. I understood
22 Constable Jones's role as to investigate potential
23 crimes against Victoria.
24 MR GARNHAM: And your role?
25 MISS ARTHURWORREY: To investigate the welfare of the family
160
1 but on the whole I did see it as a joint effort.
2 MR GARNHAM: Welfare of the family or welfare of Victoria?
3 MISS ARTHURWORREY: Welfare of Victoria first and foremost.
4 MR GARNHAM: What advice did you seek from your managers as
5 you contemplated this home visit? Any?
6 MISS ARTHURWORREY: No advice.
7 MR GARNHAM: Is that because you did not seek it or because
8 they did not respond to your request for assistance?
9 MISS ARTHURWORREY: I gave Carole Baptiste the information
10 that I had received from the North Middlesex Hospital.
11 Her response to me was to carry out a home visit before
12 Victoria was discharged and that was it.
13 MR GARNHAM: You do say in paragraph 97 of your statement --
14 turn it up if you will -- that you were looking in broad
15 terms as to whether Victoria had been physically abused.
16 MISS ARTHURWORREY: That is correct, yes.
17 MR GARNHAM: So the possibility that she had been physically
18 abused was still live in your mind?
19 MISS ARTHURWORREY: Absolutely, yes.
20 MR GARNHAM: How is a home visit going to assist with that?
21 MISS ARTHURWORREY: It would not have, apart --
22 MR GARNHAM: Apart --
23 MISS ARTHURWORREY: Apart from speaking with Kouao or
24 Manning but that would not have.
25 MR GARNHAM: Did you discuss how you were going to manage
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1 this meeting with PC Jones?
2 MISS ARTHURWORREY: I do not recollect having
3 a conversation, no.
4 MR GARNHAM: This home visit was planned for 4th August and
5 it was to be announced, it was an arranged visit, was
6 it?
7 MISS ARTHURWORREY: That is correct, yes.
8 MR GARNHAM: Did you contemplate an unannounced visit?
9 MISS ARTHURWORREY: I did not contemplate an unannounced
10 visit, no.
11 MR GARNHAM: Would it have assisted? Not I suppose with the
12 limited purpose you had in mind for this home visit.
13 MISS ARTHURWORREY: No.
14 MR GARNHAM: That planned visit to the home was changed to
15 an office visit to be held on 5th August.
16 MISS ARTHURWORREY: That is correct, yes.
17 MR GARNHAM: Why the change?
18 MISS ARTHURWORREY: Could I refer to my notes, please?
19 MR GARNHAM: Yes. I think it is because of the discussion
20 about scabies, is it not?
21 MISS ARTHURWORREY: That is right.
22 MR GARNHAM: I think it is right that Jones, PC Jones had
23 obtained some information?
24 MISS ARTHURWORREY: That is correct, yes.
25 MR GARNHAM: And she passed on to you the advice she had
162
1 received from the hospital?
2 MISS ARTHURWORREY: That is correct, yes.
3 MR GARNHAM: To the effect that scabies was highly
4 infectious and you should not go into the home without
5 protective clothing and the like?
6 MISS ARTHURWORREY: That is correct, yes.
7 MR GARNHAM: You knew by that time that Victoria did not
8 have scabies, did you not?
9 MISS ARTHURWORREY: I did.
10 MR GARNHAM: Did you tell PC Jones that?
11 MISS ARTHURWORREY: I do not remember telling PC Jones that.
12 MR GARNHAM: Did you take as read PC Jones' advice about
13 scabies or did you make enquiries to confirm she was
14 right?
15 MISS ARTHURWORREY: Sorry, could you repeat that question
16 again please?
17 MR GARNHAM: Did you accept PC Jones's advice about scabies
18 or did you question it?
19 MISS ARTHURWORREY: I did not question it, no. I went to
20 seek advice from my manager in the first instance who
21 was not available. I then spoke to Barry Almedia, the
22 senior practitioner.
23 MR GARNHAM: And he told you?
24 MISS ARTHURWORREY: Barry began to make some enquiries.
25 MR GARNHAM: About scabies?
163
1 MISS ARTHURWORREY: About scabies because as I said before
2 there was an understanding Victoria caught scabies from
3 the Tottenham address. I believe that Barry began by
4 phoning the North Mid Hospital, then I think he phoned
5 the Environmental Health. It was whilst he was phoning
6 the Environmental Health that Carole Baptiste turned up
7 and I put PC Jones's concerns to Carole Baptiste.
8 MR GARNHAM: And?
9 MISS ARTHURWORREY: And she advised that Kouao be invited to
10 the office.
11 MR GARNHAM: PC Jones made it sound as if the decision to
12 cancel the home visit was a joint decision of the both
13 of you, would you describe it as such?
14 MISS ARTHURWORREY: I would not describe it as such. I do
15 remember on the morning of the 4th August coming into
16 work. The home visit had been scheduled for that
17 morning and as soon as I walked into the office I was
18 informed that PC Jones had left a message and that
19 I needed to call her back.
20 MR GARNHAM: Then you phoned her back and got this
21 information?
22 MISS ARTHURWORREY: I did.
23 MR GARNHAM: As I understand your statement it was presented
24 to you as her saying, "I obtained this advice and I am
25 not going to conduct a home visit."
164
1 MISS ARTHURWORREY: Yes.
2 MR GARNHAM: In essence.
3 MISS ARTHURWORREY: In essence, yes.
4 MR GARNHAM: Before I come to the detail of the meeting that
5 did take place that day I want to explore a little why
6 there was no home visit, either then or later. During
7 the office visit that was to follow that was put in its
8 place -- I will come on to that in a moment -- but
9 during that meeting Kouao told you that the scabies had
10 not been contracted at the Tottenham address but had
11 been contracted in a bed and breakfast hostel.
12 MISS ARTHURWORREY: That is correct, yes.
13 MR GARNHAM: By then you knew that Victoria had been
14 successfully treated for scabies.
15 MISS ARTHURWORREY: Yes.
16 MR GARNHAM: So from that point onwards there was no reason
17 to fear catching scabies in the flat, was there?
18 MISS ARTHURWORREY: From the 5th August, yes.
19 MR GARNHAM: That is right.
20 MISS ARTHURWORREY: Yes.
21 MR GARNHAM: So why do you not then visit the flat after you
22 discovered that from Kouao?
23 MISS ARTHURWORREY: After my interview with Kouao I reported
24 back to my manager the outcome of that interview. Her
25 directions were, "Go and visit Victoria in hospital".
165
1 MR GARNHAM: Because it would then have been perfectly
2 possible to visit the home, would it not?
3 MISS ARTHURWORREY: It would have been.
4 MR GARNHAM: You could have done that visit before Victoria
5 was discharged.
6 MISS ARTHURWORREY: We could have done, yes.
7 MR GARNHAM: So that if you were right in your original plan
8 that there should be such a home visit there was nothing
9 to stop you conducting it?
10 MISS ARTHURWORREY: There was nothing to stop us from
11 conducting it.
12 MR GARNHAM: Because as it turned out it appears as if you
13 were willing to contemplate Victoria's discharge to
14 a place that you were not prepared to visit, but by then
15 you would have been prepared to visit it, would you not?
16 MISS ARTHURWORREY: By 5th August, definitely, yes.
17 MR GARNHAM: Even prior to that, when you thought the flat
18 might be the source of the scabies, is it not the case
19 that you were prepared to allow Victoria to go to
20 somewhere that you were not prepared to go?
21 MISS ARTHURWORREY: I do not believe that is correct, no.
22 MR GARNHAM: Well, help me with why it was not. When you
23 thought the Tottenham flat could be the source of the
24 scabies, it was to the Tottenham flat that Victoria
25 would be discharged.
166
1 MISS ARTHURWORREY: But we would have had to have gone and
2 seen the Tottenham flat before that discharge.
3 MR GARNHAM: So you had in mind that she could not be
4 discharged to the Tottenham flat because of the risk of
5 scabies until you had been there?
6 MISS ARTHURWORREY: On the 4th, yes.
7 MR GARNHAM: Did you inform anybody of that, that there
8 could be no discharge to that address until you had had
9 the chance to visit it?
10 MISS ARTHURWORREY: I do not recollect, no.
11 MR GARNHAM: Because the danger is that the hospital think
12 that she is fit for discharge, able to be discharged and
13 the plan is that she will be discharged to this home
14 subject to your visit to the flat?
15 MISS ARTHURWORREY: Yes.
16 MR GARNHAM: Whereas in fact at that stage, knowing what you
17 did then, there could be no discharge until you were
18 sure there was no scabies in the flat?
19 MISS ARTHURWORREY: That is right, yes.
20 MR GARNHAM: As things turned out, the fact that there was
21 no home visit prior to discharge meant that you were not
22 able to assess Victoria's living conditions, were you?
23 MISS ARTHURWORREY: Not before she was discharged, no.
24 MR GARNHAM: You were not, for example, able, you and Jones
25 together, to test out how the scalding might have
167
1 happened?
2 MISS ARTHURWORREY: No.
3 MR GARNHAM: You were not able to test out whether she could
4 get her head under the tap or whether there was a kettle
5 kept in the bathroom, were you?
6 MISS ARTHURWORREY: Although we had been informed from Kouao
7 that Victoria had used a beaker to pour the hot water
8 that she had taken from the tap over her head.
9 MR GARNHAM: Nor were you able to assess the adequacy of the
10 flat in terms of space, of facilities?
11 MISS ARTHURWORREY: No we were not.
12 MR GARNHAM: Can I turn then to the 5th of August. You
13 telephoned Kouao and agreed a meeting at your office for
14 later that day.
15 MISS ARTHURWORREY: That is correct, yes.
16 MR GARNHAM: You met first with PC Jones before the meeting.
17 How long?
18 MISS ARTHURWORREY: I would say about half an hour. Kouao
19 was actually a little bit late for that appointment so
20 it may have been longer.
21 MR GARNHAM: At that stage you had still not met Victoria?
22 MISS ARTHURWORREY: No, I had not.
23 MR GARNHAM: Would not a meeting with her prior to meeting
24 Kouao have been the sensible way to go about it?
25 MISS ARTHURWORREY: My understanding of Haringey's child
168
1 protection procedures was we needed to interview the
2 carer and we needed to get as part of those procedures
3 to obtain permission from the carer to interview
4 Victoria, the child.
5 MR GARNHAM: Did the two of you prepare for this meeting in
6 the sense of setting out a list of questions you needed
7 to cover?
8 MISS ARTHURWORREY: We knew the areas that we needed to
9 cover because they had been outlined in the strategy
10 meeting. The interview with Kouao was to address the
11 recent injury, the old markings, and I believe the
12 neglect concerns reported by the hospital.
13 MR GARNHAM: By then I think it is right PC Jones had the
14 medical report, the memo from Quinn.
15 MISS ARTHURWORREY: Yes.
16 MR GARNHAM: Do you record her exclaiming as she read it
17 something like, "It says nothing"?
18 MISS ARTHURWORREY: I showed -- Constable Jones did see that
19 report from Nurse Quinn. I believe that that remark
20 came after she was looking at Dr Forlee's report, the
21 CP --
22 MR GARNHAM: CP1 and thereafter.
23 MISS ARTHURWORREY: And thereafter but I do remember her
24 saying, "This does not say anything".
25 MR GARNHAM: You do not think that was a reference to her
169
1 seeing Quinn's report?
2 MISS ARTHURWORREY: No.
3 MR GARNHAM: Because it was Quinn's report that you had
4 given to her, was it not?
5 MISS ARTHURWORREY: When I met with Constable Jones in the
6 office on 5th August I had Victoria's case file open and
7 I showed her all the correspondence that I had received
8 from the North Middlesex Hospital, including the faxes
9 from Karen Johns.
10 MR GARNHAM: Your record of the meeting with Kouao is at
11 volume 6/314; is that right?
12 MISS ARTHURWORREY: Yes.
13 MR GARNHAM: Can I ask you some questions about what went on
14 in that meeting? Did you ask Kouao about registering
15 Victoria with a GP?
16 MISS ARTHURWORREY: I do not believe I asked her at that
17 meeting.
18 MR GARNHAM: Did you seek to check out the information you
19 received from Kouao about the bed and breakfast? Did
20 you ask for the address and find out whether it was
21 a bed and breakfast that was known?
22 MISS ARTHURWORREY: No, I did not.
23 MR GARNHAM: Did you ask Kouao why she had not taken
24 Victoria to the health centre next door to her when the
25 scalds occurred?
170
1 MISS ARTHURWORREY: I believe Constable Jones asked why
2 Kouao had taken Victoria to the Central Middlesex
3 Hospital as opposed to the North Middlesex. Kouao's
4 response to that was that they had been out sightseeing
5 and they were not familiar with the area and they just
6 ended up at Central Mid.
7 MR GARNHAM: This is after the scalding? They were not
8 sightseeing after the scalding, were they?
9 MISS ARTHURWORREY: Sorry, could I have that question again,
10 please?
11 MR GARNHAM: Yes. After the scalding -- you discussed the
12 scalding with her. You are aware there was a delay
13 between the scalding and arrival at the hospital. You
14 discovered that there is a health centre virtually next
15 door to where they live, just round the corner. Did you
16 ask, "Why did you not take your little girl who has just
17 scalded her head to the medical centre"?
18 MISS ARTHURWORREY: I did not know at that time that there
19 was a health centre next door. I only became aware of
20 that facts during my home visit on 16th August.
21 MR GARNHAM: How did you put the questions you say you put
22 about Kouao hitting Victoria?
23 MISS ARTHURWORREY: I remember informing Kouao that the
24 North Middlesex Hospital had noted a number of concerns
25 on Victoria's body, could she tell me what these marks
171
1 were, and Kouao started to talk about scabies, that
2 Victoria had caught scabies and that she did a lot of
3 scratching, which is why she has old marks and she did
4 mention fresh marks.
5 MR GARNHAM: Did you ask her, "Have you hit Victoria"?
6 MISS ARTHURWORREY: I did ask her.
7 MR GARNHAM: How did you put it?
8 MISS ARTHURWORREY: "Do you ever hit Victoria?"
9 MR GARNHAM: And her reply?
10 MISS ARTHURWORREY: "No, no, no, no, no".
11 MR GARNHAM: Did you ask Kouao how she and Victoria would
12 spend a typical day?
13 MISS ARTHURWORREY: No, I did not.
14 MR GARNHAM: Is that not the sort of question you would ask
15 if you are conducting an assessment into an emotional
16 abuse and neglect case?
17 MISS ARTHURWORREY: It would have been a very good question
18 to ask.
19 MR GARNHAM: Did you ask what Victoria's interests were?
20 MISS ARTHURWORREY: I knew at the home visit on 16th August
21 that Victoria liked reading but it was not asked at the
22 meeting of the 5th of August.
23 MR GARNHAM: Did you talk about the accommodation that Kouao
24 was trying to secure?
25 MISS ARTHURWORREY: Kouao wanted to discuss the
172
1 accommodation during that office visit and she made
2 a point of wanting to discuss it but our focus of that
3 particular meeting was on obtaining an explanation for
4 the scalding injury and for looking at the old marks.
5 MR GARNHAM: Well, was it? I thought you said that by then
6 the possibility of physical abuse was slipping down the
7 agenda and you were most interested in neglect and
8 emotional abuse.
9 MISS ARTHURWORREY: But because there had been a mention of
10 a belt buckle mark in particular, and two old thumb
11 marks, that still needed to be looked at.
12 MR GARNHAM: Although you regarded Kouao as being able to
13 give you evidence that could satisfy you about that?
14 MISS ARTHURWORREY: At that time, yes.
15 MR GARNHAM: Looking back on that decision, that was
16 a mistake, was it not? You should not have regarded
17 Kouao as being someone capable of satisfying you with
18 relation to those marks?
19 MISS ARTHURWORREY: I had no reason not to.
20 MR GARNHAM: Well, she might have been the abuser.
21 MISS ARTHURWORREY: She might have been the abuser. As
22 a social worker I work with the facts as they are
23 presented to me at the time. Had North Middlesex
24 Hospital given a clear diagnosis of non-accidental
25 injury I would have had to have sought guidance around
173
1 how to address this part of the interview with Kouao.
2 MR GARNHAM: But the trouble is Miss Arthurworrey it does
3 not always come to you on a plate, does it? Sometimes
4 you have to press and you have to enquire and here you
5 were conducting a home visit, amongst other reasons
6 because you had concerns about marks which could have
7 been caused by assaults by this woman, and you were
8 willing to accept her answers about them.
9 MISS ARTHURWORREY: Because North Middlesex Hospital had not
10 made specific reference to non-accidental injury.
11 Dr Rossiter had clearly informed me that she thought
12 that the marks were due to scabies or an infection from
13 the -- infection from scratching the scabies.
14 MR GARNHAM: It appears that Kouao well understood the
15 majority of your questions when they were put in
16 English.
17 MISS ARTHURWORREY: That is correct, yes.
18 MR GARNHAM: But that her English suddenly failed her when
19 you started to talking about your child protection
20 concerns.
21 MISS ARTHURWORREY: Yes I do remember that.
22 MR GARNHAM: Did that make you suspicious?
23 MISS ARTHURWORREY: Avoidance of child protection concerns
24 was a concern of mine, yes, which is why I noted it.
25 MR GARNHAM: And you raised it with Carole Baptiste?
174
1 MISS ARTHURWORREY: I raised it with Constable Jones after
2 the meeting, that was the first thing I discussed, then
3 I raised it with Carole Baptiste immediately after that.
4 MR GARNHAM: And Carole Baptiste told you to visit Victoria?
5 MISS ARTHURWORREY: That is what Baptiste told me.
6 MR GARNHAM: How was that going to assist, resolve the
7 question in your mind why Kouao suddenly retreated into
8 ignorance of English when asked about this?
9 MISS ARTHURWORREY: It did not assist me at all.
10 MR GARNHAM: Would you have done anything different if
11 Baptiste had not intervened at that point, if she had
12 not said what she did? If you had not had that steer
13 from your manager at that point would you have acted any
14 differently?
15 MISS ARTHURWORREY: I do not believe I would, apart from
16 having a discussion about the possibility of why she
17 might have been avoiding child protection concerns,
18 looking at hypotheses as to why she might be avoiding.
19 But the Haringey procedures were that once the interview
20 with mother had taken place we needed to seek permission
21 to go and interview Victoria.
22 MR GARNHAM: Could you take volume 26A, please. Page 31,
23 this is part of the Duty Investigation and Assessment
24 Team procedures which I think you told us was devised by
25 Angella Mairs.
175
1 MISS ARTHURWORREY: That is correct.
2 MR GARNHAM: Page 31 deals with interviewing children and
3 the first paragraph confirms what you told us you had
4 been told, namely:
5 "1. Always seek parental permission".
6 Look at the rest:
7 "2. Always be child focused ...
8 "3. What is the child's account of injury?
9 "4. Make a note of injuries seen.
10 "5. Observe child's interaction with parent/carer.
11 "6. Find out child's wishes and feelings.
12 "7. Check whether environment is safe for child to
13 remain at home.
14 "8. Use interpreter, when appropriate."
15 MISS ARTHURWORREY: Yes.
16 MR GARNHAM: This presumably would have been in your mind as
17 you contemplated the meeting you were going to have on
18 6th August the following day with Victoria.
19 MISS ARTHURWORREY: That is correct, yes.
20 MR GARNHAM: Again, what preparation did you make for that
21 meeting?
22 MISS ARTHURWORREY: Very little. I do remember on the
23 morning of 6th August being on Duty until about
24 12 o'clock so I knew --
25 MR GARNHAM: Not much.
176
1 MISS ARTHURWORREY: Not much.
2 MR GARNHAM: You had not seen photographs of Victoria's
3 body?
4 MISS ARTHURWORREY: I had not.
5 MR GARNHAM: And you had not seen a full report of the sort
6 you wanted describing each of the marks?
7 MISS ARTHURWORREY: I was not sure how that report should
8 look because this was the first case.
9 MR GARNHAM: But you did not have a report you regarded as
10 comprehensive and satisfactory dealing with the marks
11 that were on Victoria's body?
12 MISS ARTHURWORREY: ... in accidental injury.
13 MR GARNHAM: So you were proceeding in a state of some
14 ignorance, really, about Victoria's condition?
15 MISS ARTHURWORREY: Absolutely, yes.
16 MR GARNHAM: There was no interpreter?
17 MISS ARTHURWORREY: There was no interpreter.
18 MR GARNHAM: Was that because of Kouao's assertion that
19 Victoria spoke good English?
20 MISS ARTHURWORREY: Not only that, it was also the assertion
21 from the North Middlesex Hospital.
22 MR GARNHAM: About speaking three languages?
23 MISS ARTHURWORREY: After Kouao had told me that Victoria
24 had a good command of the English language and would
25 speak to us I phoned the hospital to check that point
177
1 out and I was told that we would not need an interpreter
2 because Victoria had been chatting in English most of
3 the time, all of the time. I did consider taking an
4 interpreter even after that but I thought that Victoria
5 may have felt three adults intimidating as opposed to
6 two.
7 MR GARNHAM: Although as you point out in your statement
8 there were actually three because the nurse was there as
9 well.
10 MISS ARTHURWORREY: That is correct, yes.
11 MR GARNHAM: Victoria is an eight-year old child, been in
12 this country for four months having come from the Ivory
13 Coast. When you interview her carer you provide an
14 interpreter. It seems odd that you do not automatically
15 provide one for Victoria especially in the light of
16 observations we have seen in the guidelines, but you
17 worked on what you had been told.
18 MISS ARTHURWORREY: I did consider taking an interpreter but
19 I decided against it.
20 MR GARNHAM: Did you not think there might be a danger that
21 even if Victoria could make herself understood in
22 English, that using that language which was not her
23 mother tongue she might not have been able to get across
24 the subtleties of what she wanted to tell you?
25 MISS ARTHURWORREY: That thought did not cross my mind at
178
1 the time.
2 MR GARNHAM: That she might not be able to explain what is
3 for many children a difficult concept that they are
4 being hurt by the people who are supposed to be caring
5 for them?
6 MISS ARTHURWORREY: I can see that now but at the time I was
7 informed that Victoria had a good command of the English
8 language. This was confirmed by the North Middlesex
9 Hospital who told me an interpreter would not be needed.
10 I did consider, because it is good practice to take an
11 interpreter, but I thought three adults may be
12 intimidating, Victoria may find three adults, three
13 strangers intimidating, so I decided on that basis,
14 because I had been informed that she could speak
15 English, that I would not take an interpreter.
16 MR GARNHAM: And what language was the interviewed conducted
17 in?
18 MISS ARTHURWORREY: The interview was conducted in English.
19 MR GARNHAM: Could you be given volume 46, please. Page 11
20 is the start of the document and it is the statement you
21 have produced for the CPS. I would like you to turn on
22 to page 16, please. In the light of the answers you
23 have just given, help me with what you meant by this:
24 "The following day, 6th August, myself and Karen
25 attended the Rainbow Ward at North Middlesex. An
179
1 interpreter was not taken. When we spoke to Anna she
2 only spoke in French."
3 MISS ARTHURWORREY: At the time I made this statement I was
4 in a state of shock about Victoria's death. I had not
5 had time to really reflect on the case and I made this
6 statement based on the facts that were recorded in the
7 case file.
8 MR GARNHAM: Let us look at those. I think that is
9 volume 6, page 183. This is the note of the interview
10 with Victoria, page 183, about by the second punch hole:
11 "Although mother had informed Anna has a good
12 command of the English language, spoke to myself and
13 Karen in French."
14 So that is plainly where you got that from to put in
15 the CPS statement.
16 MISS ARTHURWORREY: I did.
17 MR GARNHAM: I still do not understand, and help me with
18 this, how when you made those notes you thought Victoria
19 was speaking in French when you have just told us your
20 recollection is she spoke in English.
21 MISS ARTHURWORREY: When I arrived at North Middlesex
22 Hospital Victoria presented shy and withdrawn and she
23 was reluctant to answer any of the questions that we
24 were asking her. Constable Jones then said a few words
25 to Victoria in French and this seemed to relax and make
180
1 her more comfortable. At the time I was quite impressed
2 with Constable Jones's language skills and
3 I overemphasised the point when I made my notes. It was
4 a mistake.
5 MR GARNHAM: Just a bit. I mean, she said one sentence in
6 French, did she not, and then after that it was all in
7 English?
8 MISS ARTHURWORREY: That is right.
9 MR GARNHAM: And you record it as a conversation that was in
10 French?
11 MISS ARTHURWORREY: I was very busy when I wrote up these
12 notes. It just was a mistake.
13 MR GARNHAM: And not one you thought to correct when you did
14 the CPS statement?
15 MISS ARTHURWORREY: Like I said, I was in a state of shock
16 when I completed the CPS statement.
17 MR GARNHAM: You say that Victoria initially seemed
18 reluctant to talk but she warmed up, so to speak, after
19 the introduction in French by Karen Jones. She
20 continued to remain reluctant to talk about her home
21 life, did she not?
22 MISS ARTHURWORREY: She did.
23 MR GARNHAM: Did you form a conclusion as to why that might
24 be?
25 MISS ARTHURWORREY: At the time I was concerned but I had
181
1 regard to the fact that Victoria was a young child who
2 I thought had been recently bereaved, who had just lost
3 her father. She was in a foreign country in a strange
4 environment and also talking to two strangers, so
5 I thought that may have accounted for her quiet manner.
6 MR GARNHAM: Did that make you think again about getting an
7 interpreter in?
8 MISS ARTHURWORREY: After that hospital visit I came back
9 and spoke to Carole Baptiste. I specifically told
10 Carole Baptiste that Victoria had been unwilling to
11 answer questions about her home life. Carol asked me
12 what I thought about the situation. I gave her that
13 analysis about her being in a strange country and
14 Carole Baptiste's advice to me was, "Okay, phone mother.
15 Victoria can go home".
16 MR GARNHAM: You say in your statement that you interpreted
17 that reluctance to talk about home life as an indication
18 that she wanted to go home.
19 MISS ARTHURWORREY: Victoria actually asked me, I think it
20 was at the end of that interview, Victoria asked me,
21 "When can I go home?"
22 MR GARNHAM: What did you think she meant by "home"?
23 MISS ARTHURWORREY: I thought she meant home being
24 267 Somerset Gardens.
25 MR GARNHAM: Could it be that she meant the Ivory Coast?
182
1 MISS ARTHURWORREY: That did not cross my mind at the time.
2 MR GARNHAM: And now?
3 MISS ARTHURWORREY: It could have been. I do remember when
4 I said to Victoria -- when Victoria said to me, "When
5 can I go home?", and this is something that I have
6 recollected since reading Nurse Graham's statement.
7 When Victoria asked me, "When can I go home?" I would
8 have said to her, "Would you like to go home?" Victoria
9 said "Yes". I then must have said, "Well, we will see
10 if we can arrange that as soon as possible but we have
11 a few more people to talk to".
12 MR GARNHAM: Still not clear from that which home you had in
13 mind.
14 MISS ARTHURWORREY: I thought it was the 267 Somerset
15 Gardens home.
16 MR GARNHAM: Did you ask Victoria about the marks on her
17 body?
18 MISS ARTHURWORREY: At that point I did not think it was
19 appropriate to ask Victoria about the marks on her body.
20 MR GARNHAM: Why not?
21 MISS ARTHURWORREY: Because Dr Rossiter had suggested the
22 marks were from scabies, or from an infection from
23 Victoria scratching her scabies and Kouao had given what
24 I thought was credible explanations and it did appear
25 Victoria had caught scabies.
183
1 MR GARNHAM: Is it not pretty elementary to ask the child if
2 you have any child protection concerns about how she
3 came by the injuries?
4 MISS ARTHURWORREY: The injury that we were talking about
5 was the scalding injury.
6 MR GARNHAM: No. Were you not concerned about all the
7 marks?
8 MISS ARTHURWORREY: We were concerned about the marks.
9 I would like to say that at the time that I interviewed
10 Victoria, in all of the information I did have the one
11 consistent piece of medical advice was the scabies
12 issue.
13 MR GARNHAM: Yes. But that might be right but it does not
14 necessarily explain all the marks, does it? The fact
15 that she has scabies does not mean she might not also
16 have been abused.
17 MISS ARTHURWORREY: My training has taught me that the first
18 interview with a child should be about gaining
19 a rapport, establishing trust and allowing the child to
20 give a non-direct explanation as to the injuries.
21 MR GARNHAM: But it sounds from the way you describe this
22 conversation as if the question of these marks on
23 Victoria's body never even came up.
24 MISS ARTHURWORREY: Not in that interview with Victoria.
25 MR GARNHAM: Should you not have engineered it so as to have
184
1 provided you with something with which to test Kouao's
2 explanation for them?
3 MISS ARTHURWORREY: That would have been a good idea, yes.
4 MR GARNHAM: Whilst you were at the hospital that day did
5 you attempt to see Rossiter?
6 MISS ARTHURWORREY: I did ask to see Dr Rossiter at the end
7 of the interview with Victoria.
8 MR GARNHAM: So you thought it was something that would be
9 useful?
10 MISS ARTHURWORREY: Absolutely, yes.
11 MR GARNHAM: Why did you not do it later when you could not
12 see her that day?
13 MISS ARTHURWORREY: Because I overlooked doing this when
14 I updated my manager.
15 MR GARNHAM: Did you tackle the issues of neglect and
16 emotional abuse with Victoria? Did you address those?
17 MISS ARTHURWORREY: Not with Victoria.
18 MR GARNHAM: Again, why not? Why not ask her about her
19 standing to attention when her mother came to see her at
20 the hospital?
21 MISS ARTHURWORREY: I did not think to ask Victoria about
22 that. I did not know how to raise the issue of the
23 master/servant relationship without sounding offensive.
24 MR GARNHAM: Was it because you had had an explanation from
25 Kouao that you thought was credible?
185
1 MISS ARTHURWORREY: That is right, yes.
2 MR GARNHAM: But the danger from that is you are getting an
3 explanation from the person who is one of the obvious
4 candidates for the emotional abuser?
5 MISS ARTHURWORREY: Yes, that is correct.
6 MR GARNHAM: So that is a mistake, is it not?
7 MISS ARTHURWORREY: It is a mistake.
8 MR GARNHAM: If you were going to reach a sensible view on
9 whether there was emotional abuse or neglect of this
10 little girl, you needed to have a pretty full
11 understanding of the way the home life worked, did you
12 not?
13 MISS ARTHURWORREY: Yes, we did.
14 MR GARNHAM: You simply note Victoria was reluctant to
15 answer questions about her home life.
16 MISS ARTHURWORREY: On 6th August, yes.
17 MR GARNHAM: But you could not, could you, come to any
18 conclusion about neglect and emotional abuse until you
19 had taken that forward?
20 MISS ARTHURWORREY: That is correct, yes.
21 MR GARNHAM: So when was it taken forward?
22 MISS ARTHURWORREY: It was taken forward when I visited
23 267 Somerset Gardens on 17th August.
24 MR GARNHAM: By which time Victoria had been at home in
25 Kouao's care for ten days?
186
1 MISS ARTHURWORREY: That is correct.
2 MR GARNHAM: Which means that if there was anything in the
3 emotional abuse and neglect possibilities, she had been
4 exposed to another ten days' worth of that?
5 MISS ARTHURWORREY: My manager made the decision that
6 Victoria be discharged. I had noted that the hospital
7 had wanted to discharge Victoria and had wanted that to
8 happen as soon as possible.
9 MR GARNHAM: But you are the one who is making the social
10 worker assessments.
11 MISS ARTHURWORREY: That is correct, yes.
12 MR GARNHAM: The fact that the hospital want, if that be the
13 case, to get that bed freed up does not override your
14 obligation, does it, to make sure this little girl is
15 not being exposed to emotional abuse or being neglected?
16 MISS ARTHURWORREY: I think we need to look at definitions
17 of neglect. My definition of neglect is the persistent
18 failure to meet a child's basic needs.
19 MR GARNHAM: Let us work with that. There had been some
20 suggestion, had there not, that that had been what had
21 happened in the past, the way she was dressed, the
22 circumstances in which she came to scald herself if that
23 be the case?
24 MISS ARTHURWORREY: But Kouao had given credible
25 explanations for that, also --
187
1 MR GARNHAM: I think before you concluded you were wrong to
2 rely on that.
3 MISS ARTHURWORREY: Okay. But also I had regard for their
4 social circumstances. This was a foreign family who
5 appeared to have no fixed abode and who were living
6 temporarily with friends.
7 MR GARNHAM: Yes, so?
8 MISS ARTHURWORREY: So there were obviously difficulties.
9 MR GARNHAM: And that explained the neglect, did it?
10 MISS ARTHURWORREY: Well, the neglect, the examples of
11 neglect that I was given was the fact -- I was given
12 specific examples. Victoria -- can I refer
13 to Ms Quinn's fax?
14 MR GARNHAM: Yes, please do. Are you thinking about the
15 strange way she was dressed when you arrived at the
16 hospital?
17 MISS ARTHURWORREY: I am.
18 MR GARNHAM: Let us test that for a minute. She turns up at
19 the hospital dressed in a dress with no underwear.
20 MISS ARTHURWORREY: Yes.
21 MR GARNHAM: The explanation you get from Kouao about that
22 is that there was a pile of dirty washing available and
23 they were in a hurry to get her to the hospital and she
24 grabbed the first thing that came to hand.
25 MISS ARTHURWORREY: That is what she told us.
188
1 MR GARNHAM: And the same reason for putting on no knickers.
2 She was anxious to get her to the hospital.
3 MISS ARTHURWORREY: That is what they told us.
4 MR GARNHAM: The problem with that is this does not stack up
5 with the time she got to the hospital, does it?
6 MISS ARTHURWORREY: Kouao said there were difficulties with
7 the journey. She had tried to call a taxi, the taxi was
8 delayed and then they had had to walk to the hospital
9 which caused the delay.
10 MR GARNHAM: Did you think it adequately explained what must
11 have been at least two hours and probably five or six
12 hours in getting Victoria to the hospital?
13 MISS ARTHURWORREY: The discrepancy was put to Kouao and she
14 emphasised to Constable Jones and myself that she had
15 tried to get Victoria to the hospital as soon as she
16 could.
17 MR GARNHAM: But I am suggesting to you you should not have
18 believed her because it just was nonsense. First of all
19 why not ring 999? Did you ask that?
20 MISS ARTHURWORREY: No, I did not.
21 MR GARNHAM: Second, did you work out how far it was from
22 the flat to the hospital to assess whether the time
23 estimate she gave was reasonable?
24 MISS ARTHURWORREY: That was not done, no.
25 MR GARNHAM: You see, I have difficulty in understanding how
189
1 in those circumstances you could regard the explanation
2 about rushing to grab the first piece of clothing that
3 came to hand as adequate.
4 MISS ARTHURWORREY: It seemed plausible at the time.
5 MR GARNHAM: But not if you set it against the timings.
6 MISS ARTHURWORREY: Constable Jones had noted -- well it had
7 been noted at the strategy meeting about the discrepancy
8 which was put to Kouao and she emphasised that she tried
9 to get Victoria to the hospital as soon as possible but
10 there had been reasons for the delay.
11 MR GARNHAM: You see at this stage I am not suggesting that
12 you were failing to note the material factors, I am
13 suggesting that you failed to analyse them and think
14 through what they meant.
15 MISS ARTHURWORREY: Absolutely and I think that that was
16 a general problem when a social worker does not get
17 supervision, regular, consistent supervision.
18 MR GARNHAM: That may be right but it is also a failing on
19 your part, is it not?
20 MISS ARTHURWORREY: Oh it is, yes.
21 MR GARNHAM: In truth, at the end of the interview with
22 Victoria you had gained very little information about
23 her life, had you?
24 MISS ARTHURWORREY: Very little information.
25 MR GARNHAM: You knew nothing about the old injuries?
190
1 MISS ARTHURWORREY: That is correct.
2 MR GARNHAM: You had not asked her how she was disciplined
3 at home?
4 MISS ARTHURWORREY: No we did not.
5 MR GARNHAM: Beyond the question, "Do you hit her?"
6 MISS ARTHURWORREY: To Kouao, yes.
7 MR GARNHAM: You did not know how she was ordinarily fed and
8 clothed and looked after, did you? What arrangements
9 were made if Manning and Kouao went out? You did not
10 know about that?
11 MISS ARTHURWORREY: I did not know about that.
12 MR GARNHAM: You had not addressed the two different
13 accounts of the scalding?
14 MISS ARTHURWORREY: The two different accounts?
15 MR GARNHAM: The kettle or hot water from the tap.
16 MISS ARTHURWORREY: Well those discrepancies had appeared
17 all the way through Victoria's case.
18 MR GARNHAM: Yes.
19 MISS ARTHURWORREY: In the initial referral it made
20 reference to hot water from the tap. I believe in my
21 conversation with Nurse Quinn she made reference to
22 a kettle. Therefore, in order to clarify those
23 discrepancies I spoke to Kouao which, again, was
24 a mistake.
25 MR GARNHAM: But I am looking at what you learned from the
191
1 interview with Victoria and really it is precious
2 little.
3 MISS ARTHURWORREY: Precious little except that she did
4 confirm the scalding explanation and she did also
5 display the actions of pouring hot water over her head.
6 MR GARNHAM: It might be said that that should have given
7 you a clue as to how you might have asked her about the
8 other injuries. Because she acted out that one, she
9 could have acted out others if you had asked her.
10 MISS ARTHURWORREY: My understanding at that time was that
11 Victoria had suffered from scabies and had not been the
12 victim of physical abuse.
13 MR GARNHAM: I have to suggest to you that you were really
14 in little position to form a judgment about Victoria's
15 safety by the end of that meeting.
16 MISS ARTHURWORREY: I now know that, yes.
17 MR GARNHAM: I have taken you to one piece of guidance you
18 said about how to conduct an interview with a child.
19 Let me get you to look at another in volume 24, please,
20 page 35. Part of Haringey's child protection
21 guidelines. This is the Good Practice Guidelines in
22 relation to seeing a child. Page 35, do you have that:
23 "Introduce yourself to the child explaining your
24 role ..." and so on. "Find out the wishes and feelings
25 of the child."
192
1 Did you do that?
2 MISS ARTHURWORREY: Yes.
3 MR GARNHAM: "Get their agreement for a medical
4 examination..."; did you do that?
5 MISS ARTHURWORREY: Where are we looking, sorry?
6 MR GARNHAM: Page 35. Sorry, you have the wrong page, have
7 you? Do you have it now?
8 MISS ARTHURWORREY: I have.
9 MR GARNHAM: Paragraph 4.1 and onwards.
10 MISS ARTHURWORREY: Yes.
11 MR GARNHAM: "Get their agreement for a medical
12 examination..."
13 Did you ask her about that?
14 MISS ARTHURWORREY: Well she had already been medically
15 examined because she was already in the hospital.
16 MR GARNHAM: All right. "What is the child's account of the
17 injuries and views about the concerns?"
18 MISS ARTHURWORREY: We did partially do that.
19 MR GARNHAM: "Make a note of the injuries as you observed
20 them and mark them on a copy of the outlined diagram
21 available in the Appendix."
22 MISS ARTHURWORREY: I did not do that.
23 MR GARNHAM: I am being unfair to you because I should have
24 asked you before starting this line of questions whether
25 you were aware of these provisions in this document?
193
1 MISS ARTHURWORREY: No, I was not.
2 MR GARNHAM: This is part of the Purple Book, is it not?
3 MISS ARTHURWORREY: It is, yes.
4 MR GARNHAM: So it would have been sitting in your drawer in
5 the office?
6 MISS ARTHURWORREY: That is right, yes.
7 MR GARNHAM: You could have used it but nobody directed your
8 attention to it?
9 MISS ARTHURWORREY: Nobody did, no.
10 MR GARNHAM: "Make arrangements to ensure that the
11 relationship between child/ren and parent/carers is
12 assessed by direct observations."
13 You were not in a position to do that?
14 MISS ARTHURWORREY: No.
15 MR GARNHAM: Consider whether to have a memorandum
16 interview. Did you do that?
17 MISS ARTHURWORREY: I believe the strategy meeting had
18 already decided that memorandum interview -- well it had
19 not been recommended by the strategy meeting.
20 MR GARNHAM: Yes. And you did not give it further
21 consideration on this occasion.
22 MISS ARTHURWORREY: I did not, no.
23 MR GARNHAM: You tell us in paragraph 126 of your statement
24 that because you felt you did not have the information
25 sufficient to warrant an emergency protection order,
194
1 that it was appropriate to agree to discharge Victoria.
2 MISS ARTHURWORREY: The only options we had at that time was
3 either to seek an emergency protection order or for
4 Victoria to remain in hospital or for Victoria to return
5 to the care of Kouao.
6 MR GARNHAM: But the second of those remains an option, that
7 she remains in hospital?
8 MISS ARTHURWORREY: But I was aware that the hospital had
9 informed me that Victoria was ready for discharge and
10 they would like that to happen as soon as possible.
11 MR GARNHAM: As soon as possible. Yes, but that third
12 option could have been pursued if the third option of
13 keeping her in hospital, if you were unhappy about her
14 going home.
15 MISS ARTHURWORREY: Oh absolutely, yes.
16 MR GARNHAM: You have told us already earlier, or this comes
17 next in the sequence, that you discussed that meeting
18 with Miss Baptiste.
19 MISS ARTHURWORREY: That is correct, yes.
20 MR GARNHAM: She told you she thought it appropriate to
21 discharge Victoria?
22 MISS ARTHURWORREY: She did, yes.
23 MR GARNHAM: Was there any conversation then about a home
24 visit?
25 MISS ARTHURWORREY: I was told that I need to carry out
195
1 a follow-up assessment.
2 MR GARNHAM: You were told that?
3 MISS ARTHURWORREY: Yes.
4 MR GARNHAM: Were you told whether the strategy meeting
5 ought to be convened?
6 MISS ARTHURWORREY: There was no discussion about the
7 strategy meeting.
8 MR GARNHAM: Was there any discussion about arranging a case
9 conference?
10 MISS ARTHURWORREY: There was no discussion about arranging
11 a case conference.
12 MR GARNHAM: You say that the NMH was keen for her
13 discharge.
14 MISS ARTHURWORREY: Yes I do.
15 MR GARNHAM: Do you know who had expressed that view? Did
16 you know who had expressed that view?
17 MISS ARTHURWORREY: No, I just got that view from
18 Karen Johns.
19 MR GARNHAM: I think you have told us already that when you
20 saw the note that the hospital took the view that she
21 was ready for discharge, you understood that to mean
22 there were no reservations about that.
23 MISS ARTHURWORREY: That is correct, yes.
24 MR GARNHAM: The hospital through its doctors and nurses
25 told us when they gave evidence to this Inquiry that
196
1 what they meant by "fit for discharge" was medically fit
2 for discharge and that they assumed you the social
3 workers would make the necessary enquiries before that
4 actually happened. So we appear to have them assuming
5 that you will do the checks and you are telling us,
6 I think, that you assumed that they would not put that
7 unless they thought all was safe?
8 MISS ARTHURWORREY: It would make sense, I think if they had
9 concerns, to have put that they had concerns.
10 MR GARNHAM: But the concerns may not have been medical
11 concerns but social work-type concerns about avoiding
12 emotional abuse and neglect.
13 MISS ARTHURWORREY: When I read the facts from Karen Johns
14 I understood the North Middlesex Hospital were happy
15 Victoria could be discharged and they would like that to
16 happen as soon as possible.
17 MR GARNHAM: I do not ask this out of a sense of criticism
18 of you but it seems -- and tell me whether this is
19 right -- there is a battle of conflicting assumptions
20 here, is there not.
21 MISS ARTHURWORREY: Absolutely, yes.
22 MR GARNHAM: They are assuming you are going to check that
23 all is right; you are assuming that they will tell you
24 if it is not all right?
25 MISS ARTHURWORREY: That is right, yes.
197
1 MR GARNHAM: And the trouble with that battle of conflicting
2 assumptions is that Victoria falls through the middle.
3 MISS ARTHURWORREY: Regrettably, yes.
4 MR GARNHAM: In truth, nobody should be making assumptions
5 about a girl for whom child protection concerns have
6 been raised, should they?
7 MISS ARTHURWORREY: That is absolutely correct.
8 MR GARNHAM: And you should not?
9 MISS ARTHURWORREY: I should not.
10 MR GARNHAM: You decide, as a result of the meeting with
11 Victoria, that the injuries were probably accidental,
12 that is what you say in your statement.
13 MISS ARTHURWORREY: I was talking about the scalding injury
14 in particular.
15 MR GARNHAM: Had you reached a decision about the other
16 marks?
17 MISS ARTHURWORREY: There was still ambivalence at that
18 time.
19 MR GARNHAM: Who then told Kouao that she could collect
20 Victoria?
21 MISS ARTHURWORREY: Carole Baptiste told me to phone the
22 mother and to phone the hospital.
23 MR GARNHAM: And you then did that?
24 MISS ARTHURWORREY: I then did that.
25 MR GARNHAM: You told Kouao that she could collect Victoria?
198
1 MISS ARTHURWORREY: I did.
2 MR GARNHAM: And as a result later that day she was
3 discharged back to Kouao's care.
4 MISS ARTHURWORREY: That is correct, yes.
5 MR GARNHAM: 12th August, six days later you tell us that
6 you received a fax from the CMH.
7 MISS ARTHURWORREY: That is correct, yes.
8 MR GARNHAM: And we have that in volume 6, if you still have
9 that in front of you, at page 289. Can you confirm
10 first of all that was the fax you received?
11 MISS ARTHURWORREY: This is the fax I received.
12 MR GARNHAM: It is date stamped at the top of that page
13 2 August 1999.
14 MISS ARTHURWORREY: That is correct, yes.
15 MR GARNHAM: You did not get it -- it is addressed to
16 Caroline Rogers.
17 MISS ARTHURWORREY: That is correct, yes.
18 MR GARNHAM: You tell us you did not get it until the 12th.
19 MISS ARTHURWORREY: That is correct.
20 MR GARNHAM: Ten days later.
21 MISS ARTHURWORREY: That is correct.
22 MR GARNHAM: Did you ask how it had come to be delayed?
23 MISS ARTHURWORREY: No, but this was not an unfamiliar
24 situation.
25 MR GARNHAM: A bit disconcerting, is it not, that a medical
199
1 report on a child about whom there are abuse concerns
2 takes ten days to get from one part of the office to the
3 other part.
4 MISS ARTHURWORREY: It is very disconcerting but it was
5 something that happened quite a lot.
6 MR GARNHAM: Why? People were not looking after the fax
7 machine?
8 MISS ARTHURWORREY: Why it was -- because Caroline had been
9 working on Duty when she made this request and the
10 Duty -- her Duty week would have finished on the 30th.
11 Caroline would have then gone back to her normal duties
12 in the Long Term Team --
13 MR GARNHAM: The fax that is on her desk in the other place.
14 MISS ARTHURWORREY: I think the fax would have gone because
15 it is addressed to Caroline Rogers as opposed to the
16 Duty Team, it would have gone up to Caroline Rogers.
17 Caroline Rogers would have seen it, saw that it related
18 to a Duty case that she had been working on, taken it
19 back to Duty and then Duty would have looked on their
20 computer to see that this particular case had been
21 allocated to me and then it would have come to me.
22 MR GARNHAM: All at a relatively snail-like pace by the
23 sound of it.
24 MISS ARTHURWORREY: Yes.
25 MR GARNHAM: And ten days go by before you get sight of it?
200
1 MISS ARTHURWORREY: It depends. Obviously when
2 Caroline Rogers receives the fax, how quick that fax is
3 given back to Duty would depend on her availability and
4 whether she was in the office at the time the fax
5 appeared in her pigeonhole. But --
6 MR GARNHAM: Given the evidence the evidence we have heard
7 from another office I am almost reluctant to ask this
8 but I will try nonetheless. Was there a system in place
9 for dealing with faxes as they came into your office?
10 MISS ARTHURWORREY: We basically had two fax machines. One
11 fax machine was based in Duty, the other fax machine was
12 based on the first floor in the North Tottenham office,
13 where the typist sat, and basically --
14 MR GARNHAM: Who distributed the faxes to where they were
15 supposed to go?
16 MISS ARTHURWORREY: Anybody.
17 MR GARNHAM: Or nobody?
18 MISS ARTHURWORREY: Or nobody.
19 MR GARNHAM: Anyway, you got this fax on 12th August. Did
20 you read it?
21 MISS ARTHURWORREY: I read the first page.
22 MR GARNHAM: Which is the handwritten letter from I think it
23 is Dr Dempster.
24 MISS ARTHURWORREY: That is correct.
25 MR GARNHAM: Yes. What about the rest?
201
1 MISS ARTHURWORREY: I remember flicking through the rest of
2 the fax, registering that there had been a PPO that had
3 lapsed but that Victoria had been assessed by the
4 consultant Dr Schwartz who decided all her scratch marks
5 were all due to scabies.
6 MR GARNHAM: Were you able to read all of this document?
7 MISS ARTHURWORREY: I found it very difficult to read all of
8 the document.
9 MR GARNHAM: Chase it up to try and get better copies?
10 MISS ARTHURWORREY: I do not think the copy was the problem.
11 MR GARNHAM: It was the doctor's handwriting?
12 MISS ARTHURWORREY: It was the doctor's handwriting.
13 MR GARNHAM: Speak to the doctor, speak to the hospital
14 social worker at CMH?
15 MISS ARTHURWORREY: The fact that I had a clear letter which
16 I thought at the time provided an overview and summary
17 of the Central Middlesex involvement with Victoria,
18 I relied on that letter.
19 MR GARNHAM: You tell us you did not read the whole of it
20 thoroughly at the time but I imagine you have done so
21 since?
22 MISS ARTHURWORREY: Yes.
23 MR GARNHAM: Do you think if you had read the whole of it at
24 the time it would have changed your perception of this
25 case?
202
1 MISS ARTHURWORREY: I know for a fact that had I read this
2 fax I would have noted a huge discrepancy in the
3 information that Kouao had given to me on the 5th of
4 August.
5 MR GARNHAM: Namely?
6 MISS ARTHURWORREY: That she had taken Victoria to the
7 Central Middlesex Hospital.
8 MR GARNHAM: Yes.
9 MISS ARTHURWORREY: When in fact it was a child minder. So
10 as a result of missing that information a whole line of
11 investigation did not take place, regrettably.
12 MR GARNHAM: Because if you had read it and seen that, you
13 would have been alerted to the fact that you had there
14 a cast iron lie by Kouao which would have put in a whole
15 new light everything she had told you.
16 MISS ARTHURWORREY: Absolutely. That discrepancy would have
17 been put to Kouao on my home visit on the 16th. It
18 would also have led to discussions with Victoria about
19 what she did during the day. It would have also have
20 led to discussions with the child minder.
21 MR GARNHAM: All of which may have proved significant?
22 MISS ARTHURWORREY: Absolutely.
23 MR GARNHAM: Did you note that there were marks on the face
24 and hands and that the hands were swollen of this little
25 girl?
203
1 MISS ARTHURWORREY: I did not, no.
2 MR GARNHAM: That those marks had caused a child minder to
3 be concerned?
4 MISS ARTHURWORREY: I did not, no.
5 MR GARNHAM: That Victoria was said to have cut herself with
6 a razor blade in the past?
7 MISS ARTHURWORREY: I did not.
8 MR GARNHAM: That there were multiple bruises and scars on
9 her body on this occasion?
10 MISS ARTHURWORREY: No.
11 MR GARNHAM: That Kouao was desperate to leave Victoria with
12 the child minder for good?
13 MISS ARTHURWORREY: I did not know that either.
14 MR GARNHAM: That she was not attending school?
15 MISS ARTHURWORREY: I --
16 MR GARNHAM: You knew that?
17 MISS ARTHURWORREY: I knew that.
18 MR GARNHAM: That she wets her bed and sometimes on an
19 occasion wet herself standing up?
20 MISS ARTHURWORREY: I did not know that either.
21 MR GARNHAM: That Kouao was noted to speak harshly to
22 Victoria?
23 MISS ARTHURWORREY: I did not know that either.
24 MR GARNHAM: That when she arrived at the hospital Victoria
25 had a pungent smell and was unkempt?
204
1 MISS ARTHURWORREY: I was not aware of that.
2 MR GARNHAM: And that Brent Social Services had been
3 involved? You would have known that from the cover
4 sheet, would you not, the first letter?
5 MISS ARTHURWORREY: I knew that a PPO had been taken out.
6 MR GARNHAM: I think it is obvious that you would have
7 handled this very different if you had read that fax,
8 and you should have done.
9 MISS ARTHURWORREY: Absolutely.
10 MR GARNHAM: You say you showed it to Miss Baptiste.
11 MISS ARTHURWORREY: I did.
12 MR GARNHAM: She told Monaghan that you did not. She is
13 wrong, is she?
14 MISS ARTHURWORREY: She is very wrong. I remember that day
15 very clearly.
16 MR GARNHAM: Why, as a matter of interest?
17 MISS ARTHURWORREY: Because when I saw that fax, because
18 there had been ambivalence around the old markings I was
19 reassured by this letter and I was quite annoyed that
20 this information had not been provided to the first
21 strategy meeting. We should have had this information
22 at the first strategy meeting, or at least North
23 Middlesex Hospital should have had this information
24 before the strategy meeting.
25 MR GARNHAM: Somebody should have had it.
205
1 MISS ARTHURWORREY: That is right.
2 MR GARNHAM: So for that reason you are confident you showed
3 it to Baptiste?
4 MISS ARTHURWORREY: I remember running to Carole Baptiste
5 and saying, "I have just received this fax". I gave her
6 it, she read the letter, she flicked through the fax,
7 she smiled and she said, "It is obvious that we made the
8 right decision".
9 MR GARNHAM: So she again does not read the fax and does not
10 notice any of those points that I put to you about what
11 it revealed.
12 MISS ARTHURWORREY: She did not read the fax, no.
13 MR GARNHAM: And instead she confirmed that your view of the
14 case was the right one?
15 MISS ARTHURWORREY: That is what she did, yes.
16 MR GARNHAM: You say that the letter from Dr Dempster
17 confirmed that all the marks were due to scabies?
18 MISS ARTHURWORREY: That is correct, yes.
19 MR GARNHAM: Which marks? Presumably the marks that existed
20 at the time Dr Rossiter was writing.
21 MISS ARTHURWORREY: Yes, because the North Middlesex had
22 concerns regarding old markings.
23 MR GARNHAM: Was it not possible that there had been marks
24 inflicted between the admission to CMH and the admission
25 to NMH?
206
1 MISS ARTHURWORREY: I was aware that Victoria had been seen
2 by CMH ten days previous to her admission to the North
3 Middlesex Hospital and again the North Middlesex
4 Hospital were not talking about new marks, they were
5 talking about their concern was for old markings.
6 MR GARNHAM: But were you confident that you knew that old
7 markings meant more than a fortnight before? You see we
8 have been told by the doctors that old markings can
9 refer to anything from two or three days before to any
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