Archived Transcript for 26 November 2001: Pages 201 to 215

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1 could see the evidence that would support that

2 conclusion.

3 Therefore, I feel strongly that however this

4 document may have got into the public domain inasmuch as

5 it has got into the public domain, it seems to me

6 absolutely essential that it is presented to the

7 Inquiry.

8 With regard to the first application, I think

9 I would like to retire and give some thought to it.

10 MR GARNHAM: Sir, before you do I am conscious of the fact

11 that Ms Boye indicated that she wanted to take

12 instructions on it so that you had the benefit of her

13 clients' views on this. It does occur to me that one

14 way around this may be for us to complete the business

15 we have for this afternoon which will not occupy you for

16 more than I should think 20-minutes, and for you then to

17 adjourn proceedings overnight which will give you

18 a chance to reflect on what you have heard so far. Then

19 if Ms Boye has anything to add or Ms Lawson anything to

20 say in reply, they could do that first thing tomorrow

21 morning, by which time you would have formed at least

22 a preliminary view which you can consider in light of

23 what you hear tomorrow before making your final

24 decision.

25 THE CHAIRMAN: Thank you, Mr Garnham. That sounds a very

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1 helpful way to proceed. I do want to make it plain that

2 I am taking this application very seriously and

3 therefore if it would assist for Ms Boye or indeed

4 anyone else to make any comment tomorrow morning.

5 Ms Boye, would that be of assistance to you?

6 MS BOYE: I will just ask, sir, if you could give me

7 a moment.

8 Mr and Mrs Climbie would like an opportunity to talk

9 to me about it, if that is all right with you, sir.

10 THE CHAIRMAN: Thank you very much indeed. Ms Lawson, are

11 you content that I will consider it when I have heard

12 any other --

13 MS LAWSON: Yes, certainly. I was also delighted to think

14 I might get an opportunity to reply.

15 THE CHAIRMAN: Yes. Well, Ms Lawson, when have I not given

16 such opportunities? I am grateful for the spirit in

17 which these matters are handled and I will certainly

18 follow that suggestion. Mr Garnham?

19 MR GARNHAM: Sir, that means we finish our live witness and

20 the video evidence for today but since we have

21 20 minutes of the afternoon left, we are well behind

22 with the read statements we need to put before you, can

23 I invite Ms Gibson to read some of the statements we

24 need you to consider.

25 THE CHAIRMAN: That is very helpful. Thank you.

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1 MR GARNHAM: Sorry, Mr Sheldon first.

2 MR SHELDON: Sir, I propose to start with three Haringey

3 Housing statements principally because they are most

4 topical. The first is from Yvonne White whose statement

5 appears in volume 3 of the witness bundle starting at

6 page 78. She states that she had no concerns with

7 support, supervision or management resources within the

8 department and that Bambos Kakouratos was an experienced

9 manager. Her only involvement with Victoria's case was

10 to take a telephone call from Social Services, which

11 from reading the file she dates as being after

12 30th November because she told the social worker that

13 the case had been deferred.

14 She recalls that the social worker making the call

15 asked for a copy of the file but as Bambos Kakouratos

16 was not in the office she told the social worker to

17 request a copy of the file from him directly. She left

18 a message to this effect for Bambos Kakouratos.

19 Secondly, Jeanette Laudat. At the relevant time

20 Ms Laudat was a Senior Assessment Officer in the General

21 section of Haringey Social Services. Her statement is

22 in volume 2 of the witness bundle starting at

23 page 202.506. She summarises her function as being

24 responsible for a team of housing assessment officers

25 whose job it was to carry out homelessness assessments.

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1 She was of equivalent seniority to Bambos Kakouratos,

2 from whom you heard earlier.

3 On 30th May 1999, due to a reorganisation, she

4 became Karen McGregor's line manager. She is able to

5 speak to the structure of the department, the resources

6 available to it and supervision and management

7 arrangements within it but she had no dealings with

8 either Victoria, Kouao or Manning.

9 THE CHAIRMAN: Thank you. Ms Gibson.

10 MS GIBSON: Thank you, sir. If I could begin with

11 a statement that relates to the evidence of Brent Child

12 Protection Team. That is a statement of Police Sergeant

13 Brandon which appears at volume 4/37.501. On 15th July

14 he was employed as a controller at Kilburn Police

15 Station. At 10.50 am he spoke to Police Constable Dewar

16 and as a result made entries on the CAD message to

17 record that Victoria's injuries had been found to be

18 self-inflicted and that the police protection had ended

19 at 10.40 am. At 10.54 am he contacted Barnaby Bear Ward

20 and informed the senior staff nurse that police

21 protection had ended.

22 Now turning to the evidence of Haringey Child

23 Protection Team, a statement of Chandrika Makwana is

24 found at volume 4/200.501. She is a Project Development

25 Manager employed by the Metropolitan Police and she

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1 deals with the procedure in 1999 for obtaining

2 protective clothing in order for a police officer to

3 enter a scabies infected area.

4 The first step would be to consult the Directorate

5 of Occupational Health in order to assess what type of

6 protective clothing to issue. The officer would then be

7 issued with overshoes, medical gloves and protective

8 overalls. All these items were available in police

9 stores at the time. It would be a matter for the

10 officers to decide whether to interview the child

11 dressed in such protective clothing.

12 Now turning to the statement of Dr Mann. Again,

13 this relates to the evidence from Haringey CP in

14 relation to scabies. Dr Mann is a dermatologist. He

15 saw Victoria on 28th July 1999 to review her regarding

16 her recent scabies infection. On examination, aside

17 from the burns on her face he noted older hypopigmented

18 scars on her nose and left shoulder. There were no signs

19 of active scabies and he could find no tracks or

20 burrows. He commented that frequent use of antiscabies

21 treatment such as Durbak M can itself cause skin

22 irritation.

23 He comments that scabies is easily caught from

24 contact with other people and causes excessive

25 irritation but in normal circumstances does not affect

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1 the head and skull so that itching in this area would be

2 most unusual. It is the usual practice to only apply

3 scabies treatment from the neck downwards. Usually two

4 applications of a product such as Derbak M suffice to

5 eliminate the scabies mite. The irritation caused by

6 scabies can sometimes persist for several weeks after

7 treatment is given.

8 I should say in relation to that statement that it

9 does not appear in the witness bundle but the Crown

10 Prosecution statement is to be added to the other Crown

11 Prosecution statements available to the Inquiry. So it

12 is taken from that.

13 THE CHAIRMAN: Thank you.

14 MS GIBSON: If I could now turn to outstanding evidence from

15 the North Middlesex Hospital. Dr Edgar Weithers'

16 statement appears at volume 6/288. He is the lead

17 clinician in the Accident & Emergency Department. He

18 deals with the Trust Child Protection Guidelines and the

19 procedures in place for referral to the Paediatric

20 Department in a case of suspected child abuse. He

21 states that he would not generally be asked to see

22 a child by one of his team unless, for example, an SHO

23 was unsure whether to make a referral to that

24 department. However, in practice this rarely happens as

25 there is a low threshold for referral to the Paediatric

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1 Department. He had no direct involvement in Victoria's

2 case.

3 Patricia Bell's statement is at volume 6/34 and she

4 was a staff nurse in NMH's Accident & Emergency

5 Department in July 1999. In her statement she deals

6 with the triage system. She has no memory of her

7 involvement in Victoria's case but it is apparent from

8 the casualty card that Victoria was booked into Accident

9 & Emergency on 24th July 1999 at 5.25 pm. After two

10 unsuccessful attempts, Victoria, accompanied by Kouao,

11 was called to the triage room at 6.15 pm. Ms Bell

12 checked the Child Protection Register, completed a

13 paediatric assessment form and gave Victoria a yellow

14 triage code which indicated that she needed to be seen

15 by a doctor within the next hour. Ms Bell believes

16 thereafter that she would have taken Victoria through to

17 the minor treatment area and would have informed the

18 nurse in charge of the situation.

19 The next statement is that of Comfort Boafoa whose

20 statement appears at volume 6/41.401. She is a staff

21 nurse on Rainbow Ward. She has very little recollection

22 of Victoria's case but does recall her walking happily

23 around the ward wearing a hat and carrying a handbag.

24 She remembers Victoria eating a lot. She spoke to Kouao

25 on one occasion and Kouao asked her if she might be able

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1 to get a job at the hospital. She remembers that

2 Victoria would go quiet whenever Kouao came to the ward.

3 She was in charge on the shift on the night of Sunday

4 25th July and was also on duty during the day on

5 4th August. She has no direct recollection of the

6 handover on 26th July but believes that they would have

7 discussed the burns and how they happened as part of the

8 handover in the nurses' office. As far as she can

9 recall she was not involved in any liaison with social

10 services.

11 The next statement is that of Sharon Doncaster,

12 which is at volume 6/65. On 24th July 1999 she was the

13 sister in charge. She deals with the triage system and

14 the procedures in place in the Accident & Emergency

15 Department. She believes that she was the sister in

16 charge of the minor treatment area that night but does

17 not recall having seen Victoria. She states that it

18 appears from records that the SHO in Accident &

19 Emergency contacted the Paediatric Registrar.

20 Next, the statement of Siobhan Gallagher which

21 appears at volume 6/104. She is a sister in the

22 Accident & Emergency Department. She too deals with the

23 triage system. She believes that she was the sister in

24 charge of the major treatment area on 24th July and

25 therefore would not have come into contact with

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1 Victoria.

2 Karen Garner's statement appears again in volume 6

3 at page 114. She is a bank nurse at NMH and worked at

4 Rainbow Ward in this capacity for four or five days

5 during July and August of 1999. She was Victoria's

6 designated nurse on 2nd August and remembers her as an

7 energetic and friendly little girl who often wanted to

8 sit on her knee and be cuddled. She also recalls that

9 she would often ask for more food. The only time she

10 remembers Victoria being quiet was when she saw her with

11 a man and woman who she presumed were her parents.

12 Dr Alison Jackson's statement appears at

13 volume 6/143. In July 1999 she was an SHO in the

14 Paediatric Department. In her statement she deals with

15 her role as SHO and her awareness of the hospital's

16 Child Protection Guidelines. She was on duty on

17 27th July and was present when Dr Alexander conducted

18 the ward round. She made an entry on Victoria's medical

19 records on 27th July at 10 am in relation to

20 microbiology results. She also contacted an

21 ophthalmologist that day and arranged for him to see

22 Victoria. Her next entry on the records is on

23 2nd August when she was on the ward round with

24 Dr Rossiter. This was her last day at NMH and she had

25 no further contact with Victoria.

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1 Next Dr Sonia Makar's statement at volume 6/163.

2 She was a paediatric SHO at NMH and was on call on

3 29th July and was also present on the ward round

4 conducted by Dr Richardson. She recalls that

5 photographs had been ordered previously but had not been

6 taken. She therefore contacted the Photography

7 Department and asked them to take those photographs as

8 soon as possible. On 31st July Dr Makar went on the

9 ward round with Dr Rossiter. A decision was taken to

10 weigh and measure Victoria as medical staff had concerns

11 about her development. Dr Makar had no further

12 involvement with Victoria.

13 Brendan McColl's statement appears at volume 6/169.

14 He was an agency radiographer at NMH. In his statement

15 he deals with the role of the radiographer. In

16 Victoria's case the X-ray request form asks for

17 a skeletal survey including the long bones and chest.

18 He cannot recall whether Victoria's X-rays were sent

19 back with her on to the ward or passed to the

20 radiologist for reporting.

21 Thomas Millard's statement appears at volume 6/182.

22 He too is a radiographer at NMH and he states that in

23 general requests for a skeletal survey had to be

24 authorised by a consultant paediatrician. He was part

25 of the team of three radiographers who took X-rays of

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1 Victoria on 27th July.

2 Next Catrina Watson's statement which appears at

3 volume 6/284. She too was a radiographer and was

4 involved in the skeletal survey on 27th July. Her

5 statement contains nothing additional to the statements

6 of the other two radiographers.

7 THE CHAIRMAN: Thank you.

8 MS GIBSON: Ian Abernethy has supplied two statements to the

9 Inquiry found at volume 6/6 and at page 8.401. He is

10 a senior medical photographer employed at NMH. His

11 professional duties include taking photographs for child

12 protection purposes which he says are always taken

13 before treatment, never after. He was called to take

14 photographs of Victoria on 29th July. He does not

15 recall who contacted him and there were no earlier

16 requests. He cannot explain why the Department of

17 Clinical Photography document has the date 26th July

18 written on it. He says that this is not in his

19 handwriting.

20 He recalls that Victoria was quite cheerful when he

21 took photographs of her and that she understood his

22 instructions given in English to turn around. He was

23 not told that the photographs were being taken because

24 of possible non-accidental injury. In his records, the

25 consultant requesting photographs was Dr Meates. The

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1 slides were sent to Dr Meates on 9th August 1999. He is

2 not aware of any staffing problem that would have caused

3 any delay in taking photographs in July. He was never

4 asked to send copies of the photographs to anyone else.

5 Next, the statement of Dr Nandita Anand Shirsalkar

6 whose statement appears al volume 6/252. She was an SHO

7 in the Ophthalmology Department. She does not recall

8 examining Victoria and makes a statement based on

9 a review of the medical records. Following examination

10 her conclusion was that Victoria had no ocular damage,

11 just some superficial swelling to her eyelid.

12 Regina Tsiagbe's statement appears at volume 6/265.

13 She is a nursery nurse on Rainbow Ward. Her tasks

14 include looking after children on the ward generally,

15 playing with them, taking their pulse and temperature

16 and administering medication under the supervision of

17 a qualified nurse. On 25th July she woke Victoria at

18 about 9.30 am. She gave Victoria a bath together with

19 Nurse Graham and while undressing Victoria noticed that

20 she had bruises all over her body.

21 Following the bath Dr Rossiter came to see Victoria

22 and examined her. Dr Rossiter asked her and

23 Nurse Graham to arrange for photographs to be taken of

24 Victoria's face. Later that morning Kouao arrived and

25 her recollection is that Victoria went over to hug her

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1 and looked happy to see her. She was present during

2 a discussion between Dr Rossiter and Kouao and recalls

3 Dr Rossiter asking Kouao details about how she came to

4 be in this country. She was present -- she recalls that

5 Kouao's visit was very short, in the order of 10 to

6 15 minutes.

7 Nurse Tsiagbe was again involved in Victoria's care

8 on the 29th July night shift. She recalls Victoria woke

9 in the night saying she was hungry. She wet the bed on

10 two occasions that night. She also recalls seeing

11 Victoria playing on the ward and a Barbie house being

12 put in her cubicle which she loved. She recalls

13 Victoria telling her that she could speak more than one

14 language and that she used to try and teach

15 Nurse Tsiagbe how to speak French.

16 Finally, in relation to North Middlesex Hospital the

17 statement of Claire Watling which appears again at

18 volume 6/275. She was a staff nurse on Rainbow Ward and

19 was present at the nursing handover on 26th July 1999.

20 She recalls that there were concerns that someone had

21 poured hot water over Victoria's head or had told her to

22 do this. She also recalls someone mentioning that

23 Victoria had eaten an unusual amount of food before

24 going to bed. She remembers Victoria as quite an active

25 child who seemed happy to have company.

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1 She remembers that Victoria was bathed at around

2 lunchtime. When she and Noelle O'Boyce were drying

3 Victoria they noticed what appeared to be old bruises on

4 her back and a belt buckle mark. She also saw marks on

5 Victoria's arms which looked like fingerprints. She

6 remembers fitting her hand around Victoria's arm and the

7 fingers fitted the marks.

8 Claire Watling then told the lead nurse

9 Beatrice Norman what she had seen and Dr Reynders was

10 also informed and he completed body maps of Victoria.

11 In her statement Claire Watling then goes on to deal

12 with her involvement on the night shifts for 4th August

13 and 5th August and also on 6th August when Victoria was

14 allocated as her patient.

15 Sir, that concludes the North Middlesex statements.

16 I do not know whether now would be a convenient moment

17 to break before going on to the outstanding statements.

18 I am in your hands.

19 THE CHAIRMAN: I wonder if it was serendipity that you had

20 noticed the time on the clock or remarkably good

21 planning. But whatever it is I think we will take the

22 opportunity to break now, if that is convenient for you

23 and Mr Garnham, and we will ...

24 MR GARNHAM: Sir, I rise only to indicate what our plans are

25 for tomorrow.

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1 THE CHAIRMAN: Thank you.

2 MR GARNHAM: If it is convenient for you, we will deal first

3 with the applications now outstanding from this

4 afternoon.

5 THE CHAIRMAN: Certainly.

6 MR GARNHAM: Then we will take the following witnesses:

7 Luciana Frederick, Caroline Rodgers, Shanthi Jacob and

8 Valerie Robinson.

9 THE CHAIRMAN: Thank you very much indeed. Ladies and

10 gentlemen, we will adjourn now until 10 o'clock tomorrow

11 morning. Thank you very much indeed.

12 (4.30 pm)

13 (Hearing adjourned until 10 o'clock the following day)

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