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Archived Transcript for 11th October 2001: Pages
101 to 150
101
1 requesting information, yes, and that happened
2 regularly, on a daily basis, and it would take some
3 time, yes.
4 THE CHAIRMAN: Quite a problem?
5 MR SMITH: Yes.
6 THE CHAIRMAN: You mentioned in answer earlier on that SSID,
7 you said, is problematic.
8 MR SMITH: It is time consuming. It is not the easiest
9 system to understand. The Filemaker database, the
10 referrals database that we have looked at, is, it seems
11 to me, fairly easy to understand. The information is
12 there. If you were looking at that information in SSID,
13 you would probably have to go through about 10 to 15
14 different pages, different screens, to access that
15 information.
16 THE CHAIRMAN: Time consuming?
17 MR SMITH: Very.
18 THE CHAIRMAN: And you need a certain amount of skill to do
19 it?
20 MR SMITH: With IT knowledge, you tend to be using unusual
21 keys. If you are at a certain level on IT, then systems
22 tend to come easily to you, and SSID does not.
23 THE CHAIRMAN: SSID does not come easy?
24 MR SMITH: No.
25 THE CHAIRMAN: And could you explain to those of us who are
102
1 not at that level -- Mr Turner asked you about the
2 current arrangements, the current position. For those
3 of us who may not be at quite your level, could you just
4 say where the gaps are at the present time, and what the
5 problem is?
6 MR SMITH: With SSID?
7 THE CHAIRMAN: Yes.
8 MR SMITH: It still has not taken away the fact that we have
9 to do checks on Filemaker; obviously it is easily
10 accessible now to the rest of the social services
11 departments and the One Stop Shops. To input the
12 information is very time consuming. I believe, if I am
13 correct in saying, that it is not necessarily a child
14 based database. I think it is more for adults, so it
15 has been amended to try and fit the needs of children's
16 services, and as I said, not all of our information is
17 currently on SSID, so we cannot guarantee that the
18 checks we are doing on SSID is correct. We cannot
19 extract information off of it, as we did with Filemaker,
20 i.e. the number of child protection cases, the number of
21 child in need cases. It is not easy to use, but
22 everyone in the unit has access to SSID.
23 THE CHAIRMAN: But a child potentially at risk, you would
24 not be able to be sure that the necessary connections
25 were made?
103
1 MR SMITH: No.
2 THE CHAIRMAN: You could try?
3 MR SMITH: You could try, yes.
4 THE CHAIRMAN: But it is a matter of chance?
5 MR SMITH: That is correct.
6 THE CHAIRMAN: You mentioned that files would go missing
7 because there was no simple recording arrangement of who
8 had taken the file.
9 MR SMITH: That is correct.
10 THE CHAIRMAN: Whose job was it to make sure that there was
11 such a system?
12 MR SMITH: I am not totally clear on that. I do not know.
13 It could be that my expectation would be that it would
14 be down to the managers, the duty or child protection
15 manager; depending on that, they might expect that it
16 might be for the administration staff to arrange.
17 Certainly it was -- that practice was only not happening
18 downstairs on our -- I would say that the child
19 protection filing system was a lot better than the duty
20 system at the time. A card index procedure was being
21 used in the long-term teams throughout the building, so
22 if someone took a file out, a card was put in, saying
23 where the file was and who had it, and that system was
24 not being used downstairs.
25 THE CHAIRMAN: And you mentioned that there was no one
104
1 person responsible for collecting the faxes and making
2 sure that they got to the right places.
3 MR SMITH: That is correct.
4 THE CHAIRMAN: Whose job would it have been to make sure
5 that that was corrected?
6 MR SMITH: Again, I do not know. It sounds an easy answer,
7 but the administration staff are now closer to the fax
8 machine, so currently, it is probably their
9 responsibility. They are at the other end of the office
10 at the time -- during this period.
11 THE CHAIRMAN: What I am getting to, Mr Smith, is you were
12 the Group Admin Officer.
13 MR SMITH: I was, yes.
14 THE CHAIRMAN: Would it not have been your responsibility to
15 make sure that there was a tracking system and somebody
16 was responsible for managing the faxes?
17 MR SMITH: It could have been, but I am not sure that on all
18 the other floors it is the administrators' problem to
19 pick up all the faxes. It does not -- as far as
20 I understand it, it does not work like that on all the
21 other floors. If someone is walking past the fax
22 machine, they will pick up the information and pass it
23 to the necessary person.
24 THE CHAIRMAN: Without wishing in any way to reduce this,
25 would you agree that actually setting up a system
105
1 whereby if somebody removes a file, it is recorded who
2 has removed the file, or making sure that faxes are
3 properly distributed is not actually a difficult admin
4 task?
5 MR SMITH: No, I agree.
6 THE CHAIRMAN: So why was it not done?
7 MR SMITH: I do not know, to be quite honest. I do not
8 know.
9 THE CHAIRMAN: Dealing with the young people who may have
10 been potentially at risk, and you were not to know
11 whether they were or they were not, would it not have
12 been one of the duties of the group administrative
13 officer to make sure that the simple things operated
14 effectively?
15 MR SMITH: Yes, I would agree with that, although I would
16 say that certainly the duty manager or the child
17 protection manager did not bring the issue of a problem
18 with the faxes to my attention. It has not been --
19 I was not aware of any problems.
20 THE CHAIRMAN: Okay, thank you very much indeed.
21 Miss Gibson?
22 MS GIBSON: Sir, I just have a few short questions.
23 Firstly, if you could just look at volume 7,
24 page 000.453? You have got a case there with a match
25 being made, and I just wanted to be clear about what
106
1 print-out the social worker would get forwarded to them
2 from Administration. Would they get a complete copy of
3 the other referral, the 1009966?
4 MR SMITH: They would not get a print-out, they should have
5 the actual papers for that referral. It should be
6 presented with the current referral. It should be
7 attached, it should be all brought together.
8 MS GIBSON: So they would have a complete account of that
9 referral, not just the partial -- the sentences lifted
10 by the administration officer?
11 MR SMITH: That is correct.
12 MS GIBSON: And if the social worker wished to do so, could
13 they interrogate that particular unique reference number
14 on the computer; would that always be an administrative
15 task?
16 MR SMITH: No, it is an administrative task. The social
17 workers did not have access to that.
18 MS GIBSON: If an administrative officer was entering
19 a referral such as the one we have been dealing with,
20 18th June, reference to cuts and bruises but not ticking
21 on the tick checklist of child protection, was there any
22 system in place to double check on what the manager was
23 doing, because you clearly have reference to the cuts
24 and bruises and it could simply be that the manager has
25 forgotten to tick the box, an easy mistake to make under
107
1 pressure. What kind of back-up system was there?
2 MR SMITH: Apart from actually speaking to the duty manager,
3 there was not.
4 MS GIBSON: So there was no instruction to administrative
5 officers to look and read the actual scope of the
6 referral, and question with a manager if a box had not
7 been ticked?
8 MR SMITH: No, that was not -- I was never told that, no.
9 MS GIBSON: Thank you, Mr Smith. Sir, I do not know if you
10 have any other questions?
11 THE CHAIRMAN: Just one more, if I may. Are you familiar
12 with "Quality Protects"?
13 MR SMITH: Probably not currently. I do know "Quality
14 Protects," but not in great detail.
15 THE CHAIRMAN: You do not have any responsibilities for
16 helping the organisation to put their returns together?
17 MR SMITH: I do not, no.
18 THE CHAIRMAN: I will not ask the question. Thank you very
19 much indeed, Mr Smith. Miss Gibson?
20 MS GIBSON: Yes, thank you, sir. Mr Smith may go.
21 (The witness withdrew)
22 MR GARNHAM: Sir, we are in your hands. We will not get the
23 next witness finished by 1.00. We could break now and
24 resume witnesses after lunch. It is a matter for you,
25 sir.
108
1 THE CHAIRMAN: Well, I suspect that certainly the
2 stenographer would welcome that, so why do we not, if
3 everybody is comfortable with this, break now at 12.40,
4 and could we re-assemble at 1.30? We will adjourn until
5 1.30. Thank you very much.
6 (12.40 pm)
7 (Adjourned until 1.30 pm)
8 (1.30 pm)
9 MR GARNHAM: Sir, before we commence this afternoon, I think
10 my friend has something to say.
11 MR TURNER: Sir --
12 THE CHAIRMAN: Of course, Mr Turner.
13 MR TURNER: A practical matter, if I may. I apologise for
14 delaying matters, but it has come to my attention during
15 lunchtime that there was a report on the BBC at
16 lunchtime to the effect, I believe, that you had stopped
17 the Inquiry, and I put that in inverted commas, because
18 of concern that children in Brent may be in some sort of
19 danger. Now I know sir because, of course, I heard the
20 way you put it, that that was absolutely not what was in
21 your mind.
22 I have revisited the transcript of your remarks.
23 You pointed out the obvious, if I may respectfully say
24 so, that Mr Armstrong made a number of assertions. He
25 is a man who we are disciplining, and who is suspended,
109
1 as you know, for serious dereliction of duty, in our
2 view. Secondly, you had no reason to know whether he
3 was giving an account of practices which were or still
4 are current; and thirdly, if those practices were
5 current, they may potentially -- and you used that
6 word -- expose some young people to undue risk, and you
7 called my attention to three passages, most of which
8 involved the possible handling of young refugee or
9 unaccompanied children, and their dispersal between
10 foster placements and bed and breakfast arrangements.
11 I indicated that we too were concerned by the
12 matters which had been raised; I said that I was fairly
13 confident we could deal with them, which I am. We have
14 put in hand enquiries, but as you can imagine, sir, in
15 the literally scores of young people in these
16 situations, tracing and identifying the very broad
17 allegations which have been made will take a little
18 time, but I am anxious that there should be no
19 impression given on any sort of wider platform that you
20 are in a state of as it were professional anxiety
21 broadly about children in Brent.
22 I have not heard the broadcast myself, so I am not
23 really in a position to offer detailed comment, but
24 I did feel it right to call it to your attention,
25 because it does seem as if, if I may respectfully say
110
1 so, your balanced approach to a concern which you
2 recognised was immediately beyond the immediate purview
3 of the Inquiry was that it was something which we ought
4 to try and help with. We gladly will, but at the moment
5 a rather misleading account appears to have been given.
6 THE CHAIRMAN: Well, Mr Turner, I am grateful to you.
7 I have not heard the broadcast either. As you can
8 imagine, for the reasons that you have just outlined at
9 the end of your helpful comments, I did try to choose my
10 words very carefully, and I would hope that they would
11 be reported, if they are reported, faithfully and not
12 misrepresented. Thank you.
13 MR GARNHAM: Sir, I will ask Mr Sheldon to call the next
14 witness.
15 THE CHAIRMAN: Mr Sheldon, please?
16 MR SHELDON: Thank you, sir. Could I ask Mr Bob Gobin to
17 come forward, please?
18 MR ROBERT GOBIN (sworn)
19 MR SHELDON: Please have a seat, Mr Gobin. Good afternoon.
20 Could you confirm your full name and professional
21 qualifications, please?
22 MR GOBIN: Bob Gobin, and I am Part 15 of the Child Branch,
23 nursing qualification.
24 MR SHELDON: I did not catch the first bit of that, I am
25 afraid.
111
1 MR GOBIN: I am Part 15 of the Nursing Register which is
2 paediatric qualification.
3 MR SHELDON: I see, thank you. I think it is right, is it
4 not, that you qualified as a nurse in 1996?
5 MR GOBIN: Yes.
6 MR SHELDON: And are you currently still nursing at the
7 Central Middlesex Hospital?
8 MR GOBIN: Yes.
9 MR SHELDON: On the Barnaby Bear Ward?
10 MR GOBIN: That is right.
11 MR SHELDON: Is that where you have spent your whole nursing
12 career so far?
13 MR GOBIN: Yes.
14 MR SHELDON: You have made a statement for use by this
15 Inquiry; do you recall doing that?
16 MR GOBIN: Yes.
17 MR SHELDON: I wonder if a copy of that statement could be
18 put in front of you; sir, it is found in witness bundle
19 number 5, starting at page 99. Mr Gobin also made
20 a short statement to the Crown Prosecution Service, that
21 is in bundle 46, starting at page 93.
22 Mr Gobin, is that the statement that you made for
23 us?
24 MR GOBIN: Yes.
25 MR SHELDON: Could you have a look at the last page, please?
112
1 Is that your signature at the bottom?
2 MR GOBIN: Yes.
3 MR SHELDON: And are you happy that the matters within that
4 statement are true?
5 MR GOBIN: Yes.
6 MR SHELDON: Before we come on to your dealings with the
7 little girl we now know as Victoria, I would like to
8 deal firstly with your training in matters of child
9 protection and child abuse. You say in your statement
10 that you received some training during your
11 prequalification period; what exactly did that training
12 consist of?
13 MR GOBIN: Right, it is -- child protection is part and
14 parcel of the nurse training programme. We are just
15 made aware of certain sort of problems, I mean, just
16 a broad definition of it, the likelihood of it happening
17 when I do the course, like when we start practising, but
18 not much in detail. We were being told that as we just
19 practise, we are going to learn it day by day.
20 MR SHELDON: I see, so during your prequalification
21 training, you are given a broad outline, and you will
22 fill in the details with on the job training as you go,
23 is that right?
24 MR GOBIN: That is right.
25 MR SHELDON: You say that you received some training about
113
1 how to diagnose non-accidental injuries, is that right?
2 MR GOBIN: Not to diagnose, but just probably to recognise,
3 because we do not make diagnoses, we leave those to the
4 doctor.
5 MR SHELDON: I see. And is it right to say that since you
6 started nursing at Central Middlesex, you have received
7 no formal training in child protection or child abuse
8 matters?
9 MR GOBIN: No.
10 MR SHELDON: But you do say in your statement that you have
11 received some on the job training, is that right?
12 MR GOBIN: That is right.
13 MR SHELDON: What has that consisted of?
14 MR GOBIN: Like if we have got a child that has come to
15 hospital, and we just come across the child and we are
16 suspicious of anything, just according to our own
17 professional knowledge, we just inform the doctor, could
18 it be some sort of bruises or grazes or whatever, or we
19 just see anything like -- make the child behave, sort of
20 abnormal behaviour, and we would just inform the doctor
21 straight away.
22 MR SHELDON: So it would be the doctor that you inform that
23 gives you the on the job training?
24 MR GOBIN: That is right.
25 MR SHELDON: And you would get a better understanding of
114
1 child abuse and child protection through the discussions
2 that you will have with doctors to whom you referred
3 such children?
4 MR GOBIN: That is right.
5 MR SHELDON: Were you ever given details, either by your
6 ward manager or anybody else, of ward specific protocols
7 in relation to child abuse and child protection?
8 MR GOBIN: Yes, we have a protocol on the ward, and that
9 needs to be followed.
10 MR SHELDON: Is that a written protocol?
11 MR GOBIN: No, that is -- we have got an old one, but it has
12 been updated recently.
13 MR SHELDON: It is written down though, is it?
14 MR GOBIN: Mm.
15 MR SHELDON: And where is that kept?
16 MR GOBIN: That is kept on the ward.
17 MR SHELDON: Do you know what missing family alerts are? Is
18 that a phrase that you have come across before?
19 MR GOBIN: No, I know about missing family. I have got
20 a folder called "Missing Children", but not missing
21 family.
22 MR SHELDON: Do you recall ever having been involved in
23 a post discharge discussion about a child who had been
24 admitted with suspected child abuse?
25 MR GOBIN: No.
115
1 MR SHELDON: Did you ever attend any external study days
2 about child abuse whilst you were employed at Central
3 Middlesex?
4 MR GOBIN: Not at the moment, but it is something that is
5 coming in the near future.
6 MR SHELDON: During the four or five years that you have
7 been there, have you ever been encouraged to go on such
8 a study day?
9 MR GOBIN: No, it was not available at that time.
10 MR SHELDON: And have you been to any internal child
11 protection sessions run by Dr Schwartz?
12 MR GOBIN: No.
13 MR SHELDON: Have you ever been encouraged to do so?
14 MR GOBIN: Yes.
15 MR SHELDON: You have been encouraged to do so?
16 MR GOBIN: Yes.
17 MR SHELDON: Why did you not go?
18 MR GOBIN: There was no sort of cases at that time, no sort
19 of children, at risk or whatever, in case conference,
20 anything like that.
21 MR SHELDON: Let me just put the last question again. Have
22 you ever been to any sort of seminar or course on child
23 protection run by Dr Schwartz?
24 MR GOBIN: No.
25 MR SHELDON: Have you ever been aware of such courses going
116
1 on whilst you have been at Central Middlesex?
2 MR GOBIN: No.
3 MR SHELDON: Do you feel that the training that you have
4 received at Central Middlesex, in child protection
5 matters, has been adequate?
6 MR GOBIN: We have not received so far like formal training,
7 but we have come just to pick it up as we go along with
8 the job, and that has been based much on our nursing
9 skill and nursing experience.
10 MR SHELDON: And are you satisfied that you have received
11 enough to enable you to do your job effectively?
12 MR GOBIN: Because I mean -- I would not say enough, it is
13 just like -- it is a continuing thing, an ongoing thing,
14 I mean like the more we have to learn, the more we
15 practise and certainly I will just say that probably we
16 are going on a course in the nearby future.
17 MR SHELDON: But I suppose it is fair to say, is it not,
18 that the approach is a fairly simple one; if you have
19 any concerns, you go and see a doctor?
20 MR GOBIN: Definitely.
21 MR SHELDON: Let us come on to your dealings with Victoria.
22 You said in the statement that you gave to the Crown
23 Prosecution Service that you had no direct recollection
24 of Victoria, is that right?
25 MR GOBIN: That is right.
117
1 MR SHELDON: So that what you were able to say, and
2 presumably what you said in your statement to the
3 Inquiry, has come from reading the notes, is that right?
4 MR GOBIN: That is right.
5 MR SHELDON: Is it still the case that you have no
6 independent recollection of Victoria?
7 MR GOBIN: I cannot remember much. I mean -- but I mean,
8 what I said in my statement, just like a very faint
9 area.
10 MR SHELDON: You do remember though a conversation that you
11 had with Ms Kouao, do you not?
12 MR GOBIN: Yes.
13 MR SHELDON: That is neither in the notes nor in your CPS
14 statement, so I take it that you must have remembered
15 that yourself.
16 MR GOBIN: It was so, because it was not like a proper
17 conversation, just say a few words to her, because the
18 ward was quite busy.
19 MR SHELDON: I see. You were on duty on the night shift of
20 14th and 15th July, is that right?
21 MR GOBIN: Yes.
22 MR SHELDON: Ms Johnson, your ward manager, says in her
23 statement that it was your fairly common practice to
24 arrive a bit early before your shift started, is that
25 right?
118
1 MR GOBIN: That is right.
2 MR SHELDON: Do you remember if you got on the ward early
3 that night?
4 MR GOBIN: No, I was just in the staff room.
5 MR SHELDON: And you came on duty, I think it is right to
6 say, at about 7.45, is that correct?
7 MR GOBIN: Yes.
8 MR SHELDON: And you explain in your statement that when you
9 come on to the ward, generally you are assigned two or
10 three specific patients for whom you have particular
11 responsibility.
12 MR GOBIN: That is right.
13 MR SHELDON: Do you help out with the other patients as and
14 when required?
15 MR GOBIN: That is right.
16 MR SHELDON: If we can just turn to your statement,
17 paragraph 5, you say about halfway down paragraph 5:
18 "If [she] had arrived on the ward before my shift
19 started, I would have been given details of the handover
20 and I would have read her A&E notes. If I was on duty
21 before she arrived, I would have read the notes which
22 would have come to the ward with her."
23 We know now that Victoria came on to the ward before
24 7.45 in the evening, so presumably the first of those
25 two things must have happened.
119
1 MR GOBIN: Right.
2 MR SHELDON: And by that, I mean you would have been given
3 details at a handover, and you would have read the
4 Accident & Emergency notes, is that right?
5 MR GOBIN: Yes.
6 MR SHELDON: Let us deal with those one at a time, the
7 handover first. When would the handover take place?
8 MR GOBIN: Just before the night shift starts.
9 MR SHELDON: I see, so before you come on to the ward for
10 the beginning of your shift?
11 MR GOBIN: Right.
12 MR SHELDON: Who would give you the relevant details about
13 the child during the course of that handover?
14 MR GOBIN: The nurse who was looking after her during the
15 day.
16 MR SHELDON: Can you remember who that was on that occasion?
17 MR GOBIN: No.
18 MR SHELDON: And can you remember what you were told during
19 the course of that handover?
20 MR GOBIN: No, I cannot.
21 MR SHELDON: If a child was on the ward about whom there
22 were child protection concerns, and if people thought
23 she or he might be abused, as the nurse taking over his
24 or her care would you expect to be told about that?
25 MR GOBIN: Yes.
120
1 MR SHELDON: Would you expect to be told if a child to whom
2 you had been assigned was under police protection?
3 MR GOBIN: Yes.
4 MR SHELDON: Would you expect to be told if a child you were
5 going to look after was awaiting a visit from a social
6 worker?
7 MR GOBIN: Yes.
8 MR SHELDON: Would you expect to be told if that child was
9 not to be visited by his or her mother without
10 supervision?
11 MR GOBIN: That is right.
12 MR SHELDON: So although you cannot remember, it is likely,
13 would you have said, that you were given all those bits
14 of information when you came on to the ward?
15 MR GOBIN: Definitely.
16 MR SHELDON: Let us have a look at the Accident & Emergency
17 notes now, which you say you would have read, and
18 I wonder if Mr Gobin could be shown volume 37. Page 16,
19 first of all, please.
20 Mr Gobin, that is the front sheet of the Accident &
21 Emergency notes. As you went through the Accident &
22 Emergency notes, presumably that is where you would have
23 started, is that right?
24 MR GOBIN: Yes.
25 MR SHELDON: So you would have seen the information on
121
1 there, that there had been a diagnosis of "abnormal
2 injuries query NAI", and that the matter had been
3 referred to the paediatricians?
4 MR GOBIN: Right.
5 MR SHELDON: Would you also have looked at the triage form
6 over the page at page 17?
7 MR GOBIN: Yes.
8 MR SHELDON: And over the page on page 18, would you have
9 looked at that general minors protocol which was filled
10 out by the Accident & Emergency doctor?
11 MR GOBIN: Yes.
12 MR SHELDON: Would you have stopped there, or would you have
13 had a look through some more of the notes?
14 MR GOBIN: Well, I would just stop here and just look what
15 the comments are that were made by the nurse or the
16 doctor.
17 MR SHELDON: I see, because if you turn over the page to
18 page 20, we have the start of a series of notes made by
19 Dr Ajayi-Obe which runs up to page 26, which set out the
20 results of her examination and her diagnosis. Would you
21 have looked at those?
22 MR GOBIN: Can you repeat your question, please?
23 MR SHELDON: Would you have looked at those notes, starting
24 at page 20, going on to page 26?
25 MR GOBIN: I think those notes were made on the ward.
122
1 I would not have come across them at that time.
2 MR SHELDON: I see. They are kept in a different place to
3 the Accident & Emergency notes?
4 MR GOBIN: No, they are kept in the same folder, but these
5 notes were just made on the wards.
6 MR SHELDON: But your common practice was, was it, to look
7 at the Accident & Emergency notes and then stop, and not
8 go through the notes that had been made subsequent to
9 admission to the ward?
10 MR GOBIN: That is right.
11 MR SHELDON: Why?
12 MR GOBIN: Because the child was just seen by the doctor on
13 the ward, and while the child was being assessed, the
14 doctor was just making the notes then and there.
15 MR SHELDON: Go to page 28, please. That is a set of notes
16 headed "Communication Sheet"; can you see that?
17 MR GOBIN: Yes.
18 MR SHELDON: You would occasionally have cause to write on
19 that communication sheet?
20 MR GOBIN: That is right.
21 MR SHELDON: So would you glance through the entries that
22 had been made on the communication sheet prior to coming
23 on duty to familiarise yourself with what had happened
24 to that child on the ward up until you took over her
25 care?
123
1 MR GOBIN: Yes, sometimes.
2 MR SHELDON: Sometimes, or all the time?
3 MR GOBIN: That depends.
4 MR SHELDON: Can you remember if you looked in Victoria's
5 case?
6 MR GOBIN: I do not think I look at notes then.
7 MR SHELDON: You said it would depend; what would it depend
8 on?
9 MR GOBIN: That depends if the notes were just with the
10 doctor, or it was just in the folder or just was
11 circulating somewhere else.
12 MR SHELDON: If you turn over to page 37/029, you can see at
13 the bottom of that page a note by P Johnson, Ward
14 Sister. There is a note there signed "P Johnson, Ward
15 Sister", and it explains that firstly a social worker
16 will be visiting, that there is a Police Protection
17 Order in place, and that there should be no visit unless
18 supervised. Can you see that?
19 MR GOBIN: Yes.
20 MR SHELDON: Do you recall seeing that before you took over
21 Victoria's care?
22 MR GOBIN: I mean, that was said to us verbally, but that
23 was not written when we started the shift.
24 MR SHELDON: You see, it is written at 17.30, we can see
25 that because that comes immediately under the date on
124
1 the left-hand side, and you came on to your shift at
2 19.45, so it must have been written, must it not, by the
3 time you came on duty?
4 MR GOBIN: Maybe I did not look at it, but I heard from the
5 sister during handover.
6 MR SHELDON: I see, so although you did not read it, this
7 information was known to you?
8 MR GOBIN: That is right.
9 MR SHELDON: You say that you were not around when
10 Dr Schwartz visited the ward and carried out her
11 examination of Victoria, is that right?
12 MR GOBIN: That is right.
13 MR SHELDON: And we can see over the page, page 30, again
14 looking at the left-hand side, that that visit took
15 place at 8.00.
16 MR GOBIN: Right.
17 MR SHELDON: That was after your shift started. Where were
18 you, can you remember?
19 MR GOBIN: Maybe I was just involved in a process somewhere
20 on the ward.
21 MR SHELDON: I see. Is it not necessarily obligatory for
22 nurses to be present when a consultant is reviewing one
23 of their patients?
24 MR GOBIN: That is right. Maybe my colleague would have
25 followed her.
125
1 MR SHELDON: Did you ever discuss Victoria's case with
2 Dr Schwartz?
3 MR GOBIN: No.
4 MR SHELDON: How did you find out that a diagnosis of
5 scabies had been made?
6 MR GOBIN: I mean, this is what we were being told by the
7 doctors.
8 MR SHELDON: Who told you?
9 MR GOBIN: I mean, we got it first -- it was told by the
10 doctors to the nurses during the day and we get it
11 during handover, when we came.
12 MR SHELDON: Let us look at each bit of that answer in turn.
13 Firstly, you say, "We would have been told by the
14 doctors and nurses during the day". Do you remember
15 being told during the day, before you came on to your
16 shift --
17 MR GOBIN: I mean the day staff will tell us when we come on
18 for handover.
19 MR SHELDON: Are you saying that you were told when you
20 received your handover of Victoria that she had been
21 diagnosed with scabies?
22 MR GOBIN: That is right.
23 MR SHELDON: The reason I query that is because we can see
24 that the diagnosis of scabies was made at 8.00 by
25 Dr Schwartz, when you were elsewhere. You came on duty
126
1 at 7.45 and would have had your handover then or
2 slightly before then, so you could not have been told
3 during the course of your handover that there had been
4 a diagnosis of scabies, could you?
5 MR GOBIN: No, because what we are saying, I mean, because
6 even before Dr Schwartz came, there was just a registrar
7 and the other doctors on the ward so just enquiring you
8 would say scabies. This is what we got, and then
9 finally, when Dr Schwartz came, and this is what she
10 said.
11 MR SHELDON: So you are saying, are you, that there was
12 discussion on the ward prior to Dr Schwartz's visit, to
13 the effect that this little girl was suffering scabies?
14 MR GOBIN: Yes.
15 MR SHELDON: Can you remember who was involved in those
16 discussions?
17 MR GOBIN: No, I cannot.
18 MR SHELDON: But you are clear in your recollection that
19 they took place, are you? I am asking you if you are
20 sure, Mr Gobin, because it had been our understanding up
21 until now that it was not until Dr Schwartz made her
22 ward round at 8.00 on 14th July that the diagnosis of
23 scabies had been made. You are suggesting that it had
24 at least been considered before then, and I am wondering
25 if you are absolutely sure about that.
127
1 MR GOBIN: No, the diagnosis was not made until Dr Schwartz
2 came, that is right, that is correct.
3 MR SHELDON: It was or was not made?
4 MR GOBIN: Was not.
5 MR SHELDON: So would you have got the diagnosis of scabies
6 from the notes that we can see on page 30, in Dr Modi's
7 handwriting?
8 MR GOBIN: I do not think so, no.
9 MR SHELDON: So how would you have found out? Someone would
10 have told you, would they?
11 MR GOBIN: That is right.
12 MR SHELDON: Can you remember who told you, because you say
13 it was not Dr Schwartz, because you did not speak to
14 her.
15 MR GOBIN: It should be like one of the doctors, but
16 I cannot remember.
17 MR SHELDON: Right. But certainly by that point, you were
18 clear in your mind that it was a diagnosis of scabies,
19 and that is what this child was suffering.
20 MR GOBIN: That is right.
21 MR SHELDON: Were you aware of any debate or doubt about
22 that, or was it clear as far as you were concerned?
23 MR GOBIN: It was clear.
24 MR SHELDON: Could you turn over the page to page 32,
25 please, which is a page with the words "Ongoing
128
1 Investigations" at the top. Can you see that, and can
2 you see halfway down a heading "Communication Sheet for
3 Care Givers"?
4 MR GOBIN: Mm.
5 MR SHELDON: Is that your handwriting?
6 MR GOBIN: That is right.
7 MR SHELDON: What is the purpose of this document?
8 MR GOBIN: That helps us to describe or define the care that
9 we gave on a continuous basis, if there have been any
10 changes or any update, just for the next -- for the
11 staff, just to run down it every time.
12 MR SHELDON: And that is a document for the nurses, is it?
13 MR GOBIN: That is right.
14 MR SHELDON: At what stage should the nurses fill that in?
15 MR GOBIN: Once the child is on the ward, and if anything
16 happens, they just document it here.
17 MR SHELDON: I see, so that is only for recording things
18 that happen whilst the child is on the ward, it does not
19 necessarily have to be completed on the child's arrival?
20 MR GOBIN: No.
21 MR SHELDON: There is nothing in your note there about
22 anything other than scabies, is that right?
23 MR GOBIN: That is right.
24 MR SHELDON: Because I think as you have already said, as
25 far as you were concerned, after Dr Schwartz's visit,
129
1 there was no doubt about the diagnosis at all.
2 MR GOBIN: No.
3 MR SHELDON: You say there in the first line of your note:
4 "Admitted via A&E for scabies."
5 That is not right, is it? Victoria was not admitted
6 for scabies, she was admitted because of suspicions of
7 non-accidental injury.
8 MR GOBIN: Probably. I mean, this was a query.
9 MR SHELDON: Well, you had read the Accident & Emergency
10 notes, starting at page 16 and going on to page 18, and
11 you had read Dr Beynon's history that we see at page 18,
12 and you will have seen from that that the initial
13 suspicion was non-accidental injury, would you not?
14 MR GOBIN: Yes.
15 MR SHELDON: And then here was Victoria on the ward, and
16 then subsequently, the diagnosis of scabies had been
17 made. So the initial admission was not for scabies, was
18 it?
19 MR GOBIN: No.
20 MR SHELDON: So why did you write "admitted for scabies" on
21 your communication sheet?
22 MR GOBIN: This is what I was told by the doctors.
23 MR SHELDON: Have you come across many cases of scabies
24 before?
25 MR GOBIN: Probably a couple, but not that many.
130
1 MR SHELDON: Would it be usual in your experience of
2 paediatric nursing for a child, seven or eight years
3 old, suffering only from scabies, to be admitted as an
4 in-patient?
5 MR GOBIN: Yes.
6 MR SHELDON: Because the treatment is fairly simple, is it
7 not; you just apply some lotion?
8 MR GOBIN: That is right.
9 MR SHELDON: Presumably that could be done equally as well
10 at home as it could be on a hospital ward?
11 MR GOBIN: That is right.
12 MR SHELDON: So is there any particular reason why a child
13 suffering from scabies would have to be admitted to
14 hospital?
15 MR GOBIN: If the lesion is infected, then they might need
16 treatment.
17 MR SHELDON: Can you turn over to page 37/033, please? This
18 is a nursing care plan; do you have that?
19 MR GOBIN: Not yet.
20 MR SHELDON: I wonder if Mr Gobin could be given some help.
21 MR GOBIN: I have it.
22 MR SHELDON: Nursing care plan; did you fill that in?
23 MR GOBIN: Yes.
24 MR SHELDON: For whose benefit is this written?
25 MR GOBIN: For the child.
131
1 MR SHELDON: Who reads the nursing care plan?
2 MR GOBIN: The nursing staff.
3 MR SHELDON: Can you remember at what stage of your care of
4 Victoria you filled this out?
5 MR GOBIN: The night she came to the ward.
6 MR SHELDON: Sorry?
7 MR GOBIN: The night I was on the ward and then I come
8 across her.
9 MR SHELDON: Would it have been one of the first things you
10 would have done after you came onto the ward and been
11 assigned a particular child, or would it have taken some
12 time for you to have got round to filling a document
13 like this out?
14 MR GOBIN: Some time.
15 MR SHELDON: That is the only nursing care plan I can find
16 in the notes. Was it, as far as you were aware, the
17 first time a nursing care plan had been filled out for
18 this particular child?
19 MR GOBIN: Yes.
20 MR SHELDON: Is that usual? By that, I mean, we know that
21 Victoria came on the ward by 5.30 at least, possibly
22 earlier, and the nursing care plan cannot have been
23 completed by you until at least 8.00. Is it usual for
24 a child to wait two and a half hours or so until
25 a nursing care plan is completed for them?
132
1 MR GOBIN: That depends. If a child is going to stay and if
2 nurses are busy, then they cannot do it right away, but
3 during the course of the shift, they will have to do it.
4 MR SHELDON: I see. And again we see in the top box,
5 "Patient problem, Anna has been admitted with scabies",
6 so again we know this must have been after Dr Schwartz's
7 diagnosis.
8 MR GOBIN: Yes.
9 MR SHELDON: There is nothing on this sheet, as far as I can
10 see, about any concerns of non-accidental injury; is
11 that because as far as you were aware, those concerns no
12 longer existed?
13 MR GOBIN: Yes.
14 MR SHELDON: But we do know at that point, do we not, that
15 the police protection that had been taken out in respect
16 of Victoria was still in force; were you aware of that?
17 MR GOBIN: No.
18 MR SHELDON: Well, you were told at handover, at 7.45 or
19 thereabouts, that Victoria was under police protection.
20 MR GOBIN: Yes.
21 MR SHELDON: You were told that a social worker was coming
22 to visit, and you were told that her mother was not to
23 visit unsupervised. You were told all that, is that
24 right?
25 MR GOBIN: Yes.
133
1 MR SHELDON: Were you ever told that the Police Protection
2 Order had been lifted?
3 MR GOBIN: I cannot remember.
4 MR SHELDON: Were you ever told that it was now all right
5 for the mother to visit unsupervised?
6 MR GOBIN: I cannot remember.
7 MR SHELDON: Because let us look what you have written on
8 page 33; the last bullet point in the box "nursing care
9 required", you say:
10 "Involve mum in Anna's care at all times."
11 You were told when you handed over, at the beginning
12 of your shift, that Anna's mother was not to visit
13 unsupervised. You have written in the nursing care
14 plan, "Involve mum in Anna's care at all times", and
15 nothing about unsupervised visits. Who told you that
16 you could disregard the earlier instruction that the
17 mother was not to visit unsupervised?
18 MR GOBIN: When I say "involve mum at all times," that means
19 under the nurse's supervision. It is not on her own.
20 MR SHELDON: Is it usual for parents who come on the ward
21 when they are visiting their children to do so under the
22 constant supervision of nursing staff?
23 MR GOBIN: Most of the time, yes.
24 MR SHELDON: You will stand over them the whole time --
25 MR GOBIN: Not the whole time, but we will just observe what
134
1 they are doing.
2 MR SHELDON: It is a specific instruction in the note
3 written by Paula Johnson, on page 29, is it not? If you
4 turn to that, the bottom of the page:
5 "They are attempting to inform mum and friend, Child
6 Protection Team would prefer mum not to visit this
7 evening. Must be supervised if she visits."
8 That accords with what you were told in the
9 handover.
10 MR GOBIN: That is right.
11 MR SHELDON: So you were told there were concerns about the
12 mother coming, you were told that the child was under
13 police protection. When we come to your nursing care
14 plan, we see nothing of either police protection or
15 concerns about mother visiting. What I am trying to
16 understand is, who told you that those concerns no
17 longer existed, and that the police protection and
18 restriction on the mother visiting no longer applied?
19 MR GOBIN: Because I mean, when it just comes to this
20 decision we do not write it on the care plan because we
21 do not want it -- we take it as being very confidential,
22 and if we just leave it in the care plan, then everybody
23 can read it, so that is why it probably does not apply,
24 or does not appear on the care plan that was written.
25 MR SHELDON: All right. Back to page 33, the second to last
135
1 bullet point:
2 "Refer to dermatologist and other multidisciplinary
3 team."
4 You say this document was produced for the benefit
5 of nurses, for nurses to read. Do I take it from that
6 that it was your intention that it should be a nurse,
7 either you or somebody else, who referred to
8 dermatologist and other multidisciplinary team?
9 MR GOBIN: Right. It would be through the nurses, through
10 the doctors and then to the dermatologist.
11 MR SHELDON: Did you do it?
12 MR GOBIN: No. I mean, I passed the message on, handover
13 time, morning time, and I expected my colleague to pass
14 on the message to the doctors.
15 MR SHELDON: So when you came off shift the next morning,
16 you would have told the incoming nurse that it was his
17 or her job to refer to the dermatologist?
18 MR GOBIN: No, to tell the doctors, because we cannot refer,
19 it has to come from the doctors.
20 MR SHELDON: Could you look at page 36, please, of
21 bundle 37? We can see from that that something called
22 "Derbac" was administered at 9.00, 21.00 hours. You
23 have spelt it wrongly, it is actually Derpac, I do not
24 suppose that particularly matters, but did you apply
25 that lotion?
136
1 MR GOBIN: No, that was applied by the lady who was supposed
2 to be mum standing there, or the lady who we thought
3 actually was mum. She was the one to apply it, under
4 supervision.
5 MR SHELDON: So the mother was on the ward at 9.00, was she?
6 MR GOBIN: Yes, some time like that.
7 MR SHELDON: And she applied the lotion. Given that we have
8 a note made at 5.30, the one we have already read, from
9 Paula Johnson, that the Child Protection Team would
10 prefer the mum not to visit this evening, must be
11 supervised if she does, do you think it should have been
12 noted in the communication sheet that the mother had
13 come on to the ward and was treating the child?
14 MR GOBIN: Yes.
15 MR SHELDON: Do you think you should have noted it?
16 MR GOBIN: Yes.
17 MR SHELDON: Did you notice Victoria scratching herself
18 during the course of the night while she was under your
19 care?
20 MR GOBIN: Yes.
21 MR SHELDON: How much was she scratching herself?
22 MR GOBIN: She was scratching all her hand basically, and
23 part of her body.
24 MR SHELDON: A lot or a little?
25 MR GOBIN: Intermittently.
137
1 MR SHELDON: Given that there was a possible diagnosis of
2 scabies, and that she was being treated for that, do you
3 think you should have noted that she was scratching in
4 the notes?
5 MR GOBIN: Say that again.
6 MR SHELDON: Given that there had been a possible diagnosis
7 of scabies, and given that she was being treated for
8 that condition, do you think the fact that she was
9 scratching intermittently is significant?
10 MR GOBIN: Yes.
11 MR SHELDON: Do you think it is significant enough to go in
12 the notes?
13 MR GOBIN: Yes.
14 MR SHELDON: Do you think you should have put it in the
15 notes?
16 MR GOBIN: Yes.
17 MR SHELDON: You say scabies is very infectious; do you know
18 how it is spread?
19 MR GOBIN: Body contact.
20 MR SHELDON: Did you take any precautions whilst you were
21 looking after Victoria?
22 MR GOBIN: Yes.
23 MR SHELDON: What precautions did you take?
24 MR GOBIN: I had an apron and gloves.
25 MR SHELDON: You spoke to Mrs Kouao at some stage, is that
138
1 right?
2 MR GOBIN: Yes.
3 MR SHELDON: Was that around about the time that she was
4 putting the lotion on Victoria, or was that later?
5 MR GOBIN: Probably later.
6 MR SHELDON: Okay. Can you remember what you talked about?
7 MR GOBIN: Just telling her about facilities parents get
8 while being on the ward, about telephone services,
9 accommodation, where they can make tea and coffee and
10 things like that.
11 MR SHELDON: I see. Did you see her interacting with the
12 little girl you thought was her daughter? Did you watch
13 them together?
14 MR GOBIN: Yes.
15 MR SHELDON: Was there anything that caused you any concern
16 as you watched them together?
17 MR GOBIN: She was saying only a few words, but like in a
18 very sort of, very smiling way.
19 MR SHELDON: What I am trying to get at, Mr Gobin, is did
20 you have any concerns throughout that night that
21 Victoria was being abused?
22 MR GOBIN: No.
23 MR SHELDON: Thank you very much. That is all I have.
24 THE CHAIRMAN: Mr Mason?
25 MR MASON: Thank you, sir. Mr Gobin, very briefly you have
139
1 been asked a lot about discussions you have had and
2 notes that you may or may not have read. How much of
3 this do you actually remember about what you read and
4 what was said to you, by whom and when? How much do you
5 actually remember, and how much are you trying to think
6 now of what might have happened?
7 MR GOBIN: To be honest, I do not remember that much, but
8 I am just trying to get the sequence, or just follow the
9 events. Probably through my recollection, and I decided
10 when I go through the notes probably, that gave me
11 a faint idea.
12 MR MASON: So you are just trying to reconstruct it now from
13 what you can see in the notes?
14 MR GOBIN: That is right, from my statement.
15 MR MASON: You were asked about the protocols on the ward,
16 and you said there were protocols on the ward for child
17 protection. Have they been changed?
18 MR GOBIN: Yes, they have been recently updated and now we
19 do have sort of a referral form, which is quite new.
20 MR MASON: Okay. Do the changes include some new forms?
21 MR GOBIN: Yes.
22 MR MASON: Have you ever had to use those forms and the new
23 procedures yet?
24 MR GOBIN: No, not yet.
25 MR MASON: And have you read the procedures and looked at
140
1 the forms?
2 MR GOBIN: Yes.
3 MR MASON: Do you think they will help you in your work or
4 not?
5 MR GOBIN: Definitely they will.
6 MR MASON: They will help?
7 MR GOBIN: They will.
8 MR MASON: Thank you very much.
9 THE CHAIRMAN: Thank you very much indeed, Mr Mason.
10 Mr Gobin, just one question, please, and it goes
11 slightly over ground that you have already covered, but
12 I just want to make sure I understand your position.
13 Were you in the room this morning when Dr Ajayi-Obe
14 gave her evidence?
15 MR GOBIN: Yes.
16 THE CHAIRMAN: You not only will have seen but also heard
17 the reasons why she decided this child should be
18 admitted to your ward.
19 MR GOBIN: Yes.
20 THE CHAIRMAN: You may recall that she said that the
21 diagnosis of scabies had not entered her mind.
22 MR GOBIN: Yes.
23 THE CHAIRMAN: You came on duty, as you have said, at 7.45,
24 and you were not involved with the ward round or the
25 visit that Dr Schwartz made. What I cannot understand,
141
1 and this is my question, and I just want to be
2 absolutely clear, is why you as the assigned nurse and
3 experienced nurse said that Victoria was admitted via
4 A&E for scabies. I really cannot reconcile that, so
5 could you explain to me why that was so?
6 MR GOBIN: I mean, the decisions that we got from handover,
7 when we started the shift, and when I look at the front
8 page of the notes, it said it was a query, it was not
9 definite NAI, so we just initially went to the first
10 diagnosis, what we were being told. I mean, it was
11 a possibility, but we were not sure.
12 THE CHAIRMAN: So who put scabies in your mind?
13 MR GOBIN: I mean, that come after the child was seen by
14 Dr Schwartz.
15 THE CHAIRMAN: Thank you very much indeed. Mr Sheldon?
16 MR SHELDON: I have nothing further, sir. Thank you very
17 much, Mr Gobin.
18 (The witness withdrew)
19 MR SHELDON: Sir, the next witness is Paula Johnson. Sir,
20 I wonder if I might ask our witness manager to see if he
21 can find Ms Johnson.
22 THE CHAIRMAN: This is happening, I understand, Mr Sheldon.
23 MS PAULA JOHNSON (sworn)
24 MR SHELDON: Good afternoon, Ms Johnson.
25 MS JOHNSON: Hello.
142
1 MR SHELDON: Could you confirm your full name, please?
2 MS JOHNSON: Paula Angela Johnson.
3 MR SHELDON: And your professional qualifications?
4 MS JOHNSON: Registered General Nurse and Registered Sick
5 Children's Nurse.
6 MR SHELDON: I believe it is right that you first qualified
7 as a nurse in 1987.
8 MS JOHNSON: Yes.
9 MR SHELDON: And you have worked as a nurse at the Central
10 Middlesex Hospital since 1991, is that right?
11 MS JOHNSON: Yes.
12 MR SHELDON: Have you always been on paediatric wards --
13 MS JOHNSON: Yes, I have.
14 MR SHELDON: -- since you first qualified?
15 MS JOHNSON: Yes, 13/14 years.
16 MR SHELDON: And I believe it is also right that between
17 1997 and 2000, you were Ward Manager on the Barnaby Bear
18 Ward?
19 MS JOHNSON: Yes.
20 MR SHELDON: Is that your current post?
21 MS JOHNSON: No.
22 MR SHELDON: What is your current post?
23 MS JOHNSON: I am currently school nursing.
24 MR SHELDON: Thank you. Do you recall having made
25 a statement for use by the Inquiry?
143
1 MS JOHNSON: Yes.
2 MR SHELDON: I wonder if a copy of that could be put in
3 front of you. Sir, it is in witness bundle 5, starting
4 at page 107. Ms Johnson also made a statement to the
5 CPS, that is in bundle 46, starting at page 103.
6 I would like to deal with the Ward Manager role that
7 you were filling back in July 1999 first of all.
8 MS JOHNSON: Yes.
9 MR SHELDON: That is a part-time role, is it?
10 MS JOHNSON: No, it is a full-time role.
11 MR SHELDON: But you were working three days a week at the
12 time, were you not?
13 MS JOHNSON: I was eventually working three days a week on
14 return from maternity leave, but originally I started
15 the post five days a week.
16 MR SHELDON: I see. So you started the post in 1997, worked
17 full-time until when?
18 MS JOHNSON: Sorry, I need to think now. I would have
19 come -- I had my daughter in May 1998, so I would have
20 returned to work the summer of 1998 part-time.
21 MR SHELDON: I see, so by the time that we are most
22 concerned with --
23 MS JOHNSON: I was working three days a week then, yes.
24 (2.15 pm)
25 MR SHELDON: Thank you very much. I understand from your
144
1 statement that the ward manager's role is generally
2 an administrative and managerial one, rather than
3 a hands-on nursing one, is that right?
4 MS JOHNSON: Yes.
5 MR SHELDON: You do not wear a uniform, for example?
6 MS JOHNSON: No.
7 MR SHELDON: And you work out of an office?
8 MS JOHNSON: Yes.
9 MR SHELDON: Is that office situated on the ward?
10 MS JOHNSON: A ward-based office, yes.
11 MR SHELDON: But every now and again, if there is
12 a particular emergency or if there are not enough people
13 around, you will go out on to the ward and do some
14 practical nursing, will you?
15 MS JOHNSON: Yes, help cover lunch times, et cetera.
16 MR SHELDON: How often would you find yourself out on the
17 ward actually nursing?
18 MS JOHNSON: Probably once or twice a week for short
19 periods.
20 MR SHELDON: Right. You were also in July 1999 the named
21 nurse for child protection for the North-West London
22 Hospitals NHS Trust; is that right?
23 MS JOHNSON: It was not the North-West London Trust then, it
24 was Central Middlesex Hospital. We had not become
25 a joint Trust at that time.
145
1 MR SHELDON: So the Trust for which you were child
2 protection named nurse comprised solely of the Central
3 Middlesex Hospital?
4 MS JOHNSON: Yes.
5 MR SHELDON: When were you appointed into that post?
6 MS JOHNSON: At the same time as the ward manager's post.
7 It was part of the role in that job description at the
8 time. It was not a separate post.
9 MR SHELDON: I see. So it came with the ward manager's job,
10 rather than being a separate appointment?
11 MS JOHNSON: Yes.
12 MR SHELDON: Were you the only named child protection nurse
13 for the hospital at the time?
14 MS JOHNSON: As far as I am aware, yes.
15 MR SHELDON: And you kept that post even after you went part
16 time, after you came back from maternity leave?
17 MS JOHNSON: Yes.
18 MR SHELDON: I would like to ask you briefly about the
19 amount of training that you have had in child protection
20 matters, looking firstly at the position in July 1999,
21 and then we will cover what training, if any, you have
22 had since then.
23 You say in your statement that you had been on
24 a child abuse study day in 1988; is that right?
25 MS JOHNSON: Yes.
146
1 MR SHELDON: And some of the training that you had for your
2 RSCN qualification covered child abuse and child
3 protection matters?
4 MS JOHNSON: Yes.
5 MR SHELDON: And you received your RSCN qualification in
6 1991, is that right?
7 MS JOHNSON: Yes.
8 MR SHELDON: The element of your RSCN training that dealt
9 with child protection; was that an optional extra you
10 took or was it part of the course?
11 MS JOHNSON: No, part of the course.
12 MR SHELDON: So every registered sick children's nurse would
13 have received the training you had received, depending
14 on how it changed over time?
15 MS JOHNSON: Of course, and depending on where you
16 qualified, as to how much time they allocated to it.
17 MR SHELDON: In your individual experience, what did that
18 training comprise?
19 MS JOHNSON: We had sessions -- classroom type sessions
20 around categories of abuse and signs and symptoms,
21 et cetera, that type of thing. I could not be specific
22 about how much time, I really could not. I mean, it was
23 a long time ago now.
24 MR SHELDON: I understand. But it would be right to say,
25 would it, that when you got the post for named nurse for
147
1 child protection in 1997, you had not had any more child
2 protection training than any other registered sick
3 children's nurse would have had?
4 MS JOHNSON: No, apart from experience, you know, on the
5 job --
6 MR SHELDON: Experience that you had gleaned on the job
7 through 14 years or so of nursing?
8 MS JOHNSON: That is right.
9 MR SHELDON: Did you receive any particular child protection
10 training after you received this appointment as named
11 nurse?
12 MS JOHNSON: Specifically related to taking that title, that
13 role?
14 MR SHELDON: Well, specific to child protection. You have
15 suddenly been made named nurse for child protection.
16 Were you then sent away on a course to learn about the
17 elements of that role, or child protection in general?
18 MS JOHNSON: No.
19 MR SHELDON: Did you feel sufficiently qualified to carry
20 out that post?
21 MS JOHNSON: I recognised that I would require more
22 training, and had identified that with --
23 MR SHELDON: When did you identify that?
24 MS JOHNSON: I remember having some discussions with my line
25 manager around -- sorry, setting personal objectives.
148
1 MR SHELDON: And your line manager is or was?
2 MS JOHNSON: It changed numerous occasions throughout that
3 three year period. I think I had six line managers in
4 those three years, so I could not be specific about
5 which one, but I remember identifying my management
6 skills -- I did not have any formal management
7 qualification, so I spent the first two years doing
8 formal management training, and then had some discussion
9 about considering some specific clinical training around
10 child protection. We discussed the NB courses,
11 et cetera.
12 MR SHELDON: And what was the outcome of those discussions?
13 MS JOHNSON: The ACPC training was not running at that time,
14 and as soon as it did commence, I think I then attended
15 a day in October 1999.
16 MR SHELDON: Right. Who took over the post of named nurse
17 for child protection when you were on maternity leave?
18 MS JOHNSON: The acting ward manager.
19 MR SHELDON: Do we know who that is?
20 MS JOHNSON: I think it would have been Krishna Chapman.
21 MR SHELDON: I would like to deal now with the nature of
22 that child protection named nurse role. How often, as
23 a result of being in that post, would you find yourself
24 involved in child protection cases?
25 MS JOHNSON: I would have had some involvement with every
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1 case of child protection on the ward, depending on the
2 amount of involvement -- the amount of involvement would
3 depend on whether I was actually there on the day or
4 reviewing notes or attending conferences; it would just
5 depend.
6 MR SHELDON: What did you see your role as being?
7 MS JOHNSON: Supporting staff with issues related to child
8 protection, ensuring that child protection procedures
9 were in place and used; training staff, discussing with
10 staff, issues of child protection and just I suppose
11 raising awareness.
12 MR SHELDON: Would it have been part of your role to attempt
13 to ensure that child protection concerns raised in
14 relation to children on your ward were properly dealt
15 with before that child was discharged or lost to
16 follow-up?
17 MS JOHNSON: Yes, I think that would be fair.
18 MR SHELDON: Did you have a written down job description of
19 any sort in relation to that child protection role?
20 MS JOHNSON: No, it was a sentence in my general job
21 description.
22 MR SHELDON: But the functions that I have just suggested to
23 you, and the ones that you explained, did anybody sit
24 down with you and explain that was what was involved?
25 MS JOHNSON: No.
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1 MR SHELDON: So it was really a self-defining role as far as
2 you were concerned, and such responsibilities as it
3 carried were responsibilities that you took on your
4 shoulders yourself?
5 MS JOHNSON: Well, after having discussion with Dr Schwartz,
6 who was the named doctor for child protection, we had
7 discussions around our linking together and the types of
8 issues we would like to -- we needed to remain in touch
9 about.
10 MR SHELDON: I see. I think you say in your statement that
11 you used to liaise with Dr Schwartz.
12 MS JOHNSON: Yes.
13 MR SHELDON: On a fairly regular basis?
14 MS JOHNSON: Yes.
15 MR SHELDON: About what sort of things?
16 MS JOHNSON: Numerous things. We were very closely involved
17 with the risk assessment so we used to have regular, at
18 least monthly meetings for those. I would see her for
19 her ward rounds on the ward, and, you know, I would
20 contact her personally if there were other issues to be
21 discussed.
22 MR SHELDON: I see. So during the time that you were there,
23 the three days a week that you worked, you would become
24 actively involved with the management of a child
25 protection case, to the extent that seemed to you to be
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