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Archived Transcript for 15 October 2001: Pages
1 to 50
1
1 Monday, 15th October 2001
2 (10.00 am)
3 THE CHAIRMAN: Mr Garnham?
4 MR GARNHAM: Sir, good morning. Can I begin by indicating
5 the planned programme for today? Sir, we propose to
6 begin by showing the video of Dr Dempster that was taken
7 on Friday morning, because that will complete the CMH
8 evidence. Then we will proceed through today's
9 witnesses in the following order: Thrift, Smit, Green,
10 Anderson and Bamford and either finish the morning or
11 the afternoon with the reads that were left over from
12 last week.
13 THE CHAIRMAN: Thank you very much, that is very helpful.
14 MR GARNHAM: So we will start the video, and I would ask
15 Jean if he would play that.
16 MS LAWSON: Sir, I wonder before that if I could just raise
17 one matter which arose on Friday? You will remember
18 when Ms Hines was giving evidence, you asked her about
19 the legislative basis for the proposition that a child
20 could not be asked questions about abuse without the
21 parents' permission. You are, of course, quite right in
22 saying there is no legislative provision but I thought
23 I ought to draw to your attention paragraph 6.24 of the
24 Department of Health and SSI Guidance for the Challenge
25 of Partnership, which establishes best practice, and
2
1 says in terms that it should only be on rare occasions
2 that children are interviewed without the permission of
3 their parents. So I knew you would not want to take an
4 unfair point and I do not know whether it arises in
5 relation to any of today's witnesses.
6 THE CHAIRMAN: Thank you very much, Ms Lawson. You are
7 quite right, I would not want to take an unfair point,
8 but I think that on these occasions, it requires the
9 exercise of professional judgment.
10 MR GARNHAM: Can we have the video?
11 (Videotape played)
12
13 DR CHARLOTTE DEMPSTER (affirmed)
14 MR GARNHAM: Dr Dempster, good evening. Would you give the
15 Inquiry please your full name?
16 DR DEMPSTER: Charlotte Mary Dempster.
17 MR GARNHAM: And your present professional address?
18 DR DEMPSTER: I am currently a general practitioner in
19 Paraparaumu, New Zealand.
20 MR GARNHAM: You have made one statement for the Inquiry,
21 and for you, sir, and for the record it is at volume 5,
22 page 91.501 in our bundle. Do you have a copy of that
23 statement, Dr Dempster?
24 DR DEMPSTER: I do.
25 MR GARNHAM: I think it is right that you originally
3
1 qualified as a doctor in New Zealand, and completed your
2 junior and senior house officer posts in New Zealand?
3 DR DEMPSTER: No, I was a senior house officer in England.
4 MR GARNHAM: Thank you. You worked in UK hospitals between
5 April 1996 and September 1999?
6 DR DEMPSTER: That is right.
7 MR GARNHAM: That period, I think, included two years
8 working in paediatrics?
9 DR DEMPSTER: That is right.
10 MR GARNHAM: Between February 1997 and February 1998?
11 DR DEMPSTER: That is right.
12 MR GARNHAM: And then again between October 1998 and
13 September 1999, when you returned to New Zealand?
14 DR DEMPSTER: Yes, that is right.
15 MR GARNHAM: Can you tell us what training you received in
16 child protection issues while you were in England?
17 DR DEMPSTER: From my memory, the training I received was at
18 the two hospitals at which I was working as a senior
19 house officer. The first hospital was at Greenwich, and
20 I remember attending, I think, two seminars on child
21 protection when I was in the community paediatric post
22 there. The second hospital that I worked at was
23 Hillingdon, and I attended another seminar at
24 Hillingdon.
25 MR GARNHAM: How much training in child protection issues
4
1 had you received during the course of your training in
2 New Zealand?
3 DR DEMPSTER: I think it is very similar to the training in
4 the UK. During the paediatric runs, that is part of the
5 curriculum that you are actually taught, child
6 protection issues and child protection concerns at that
7 stage, so it would have been part of our teaching.
8 MR GARNHAM: Thank you. On 15th July 1999, you worked,
9 I think, a single shift at the Central Middlesex
10 Hospital.
11 DR DEMPSTER: That is right.
12 MR GARNHAM: You were working as a locum paediatric SHO?
13 DR DEMPSTER: Yes, that is correct.
14 MR GARNHAM: Presumably having been supplied to CMH by an
15 agency?
16 DR DEMPSTER: Yes, that is right.
17 MR GARNHAM: You tell us in your statement that you first
18 met Victoria Climbie on the morning of 15th July.
19 DR DEMPSTER: Yes.
20 MR GARNHAM: During the course of a ward round that you
21 conducted.
22 DR DEMPSTER: Yes, that is right.
23 MR GARNHAM: Did you conduct that ward round alone, or were
24 you working with someone else?
25 DR DEMPSTER: No, my memory is that that ward round was
5
1 alone.
2 MR GARNHAM: Is that normal for an SHO, doing that job?
3 DR DEMPSTER: No, it is not. Usually when you are a locum,
4 you would expect to have the registrar or the
5 consultant, if the consultant is there.
6 MR GARNHAM: Yes. How did it come about that you were doing
7 it alone?
8 DR DEMPSTER: I do not actually remember how it came about.
9 I think, from what I know, I turned up on the ward and
10 that is what happened.
11 MR GARNHAM: Do you remember what time you turned up?
12 DR DEMPSTER: I think it would have been at 9.00.
13 MR GARNHAM: And what is the purpose --
14 DR DEMPSTER: I cannot clearly remember. I am speculating
15 there.
16 MR GARNHAM: Thank you. What is the purpose of your ward
17 round?
18 DR DEMPSTER: It is to make sure that the children on the
19 ward have everything that they require at this stage, to
20 make sure that no one is becoming unwell while they are
21 on the ward, or they have not been attended to
22 satisfactorily, and it is to make sure that things that
23 have been identified are carried out.
24 MR GARNHAM: How many children -- can you give us any
25 idea -- would you have seen that morning?
6
1 DR DEMPSTER: I am afraid I really cannot remember. I think
2 the ward was full, but being there for only eight hours,
3 I cannot actually remember how big the ward is.
4 MR GARNHAM: I am trying to get some picture of whether you
5 are looking after two or three, eight or 25.
6 DR DEMPSTER: 15, 20, maybe up to 30, depending on how big
7 the ward is.
8 MR GARNHAM: Thank you. Would you ordinarily read the notes
9 of all the children who you were going to see on that
10 ward round?
11 DR DEMPSTER: Well, I like to think that you do read the
12 notes before you see the children. The problem is that
13 if you have a child who has been there for a long time,
14 of course you cannot, in the time that you are there,
15 read several weeks' worth of notes, so it would depend
16 on the situation and the child that is there.
17 MR GARNHAM: Where are the notes kept?
18 DR DEMPSTER: I think they are kept in -- well, on most
19 wards they are kept on a trolley.
20 MR GARNHAM: And does the trolley follow you round as you
21 make your ward round?
22 DR DEMPSTER: That is right, a trolley comes round with us.
23 MR GARNHAM: And when you get to each bed, you pick off the
24 relevant file, look at it, and then talk to the child?
25 DR DEMPSTER: That is right, and the parents.
7
1 MR GARNHAM: So in respect of each of these children, you
2 are having to make your read of the notes in the few
3 minutes while you stand by the bed?
4 DR DEMPSTER: That is right, but some of the information
5 that I would get, in that situation, would also be from
6 the nursing staff who were on the ward.
7 MR GARNHAM: Would they be with you on the ward round?
8 DR DEMPSTER: Generally, yes, there should be a nurse going
9 round.
10 MR GARNHAM: How long do you spend making that ward round?
11 DR DEMPSTER: Well, it is not common to spend less than
12 a couple of hours if you are doing it on your own.
13 MR GARNHAM: Even if that is right, and you are doing 25
14 children, you have got rather less than five minutes per
15 child.
16 DR DEMPSTER: Yes, if that is how many there are. You would
17 of course spend longer, depending on how many children
18 are on the ward.
19 MR GARNHAM: You remember, I think, seeing Victoria?
20 DR DEMPSTER: Yes, I do remember seeing Victoria.
21 MR GARNHAM: When you arrived, was her mother, Ms Kouao,
22 there?
23 DR DEMPSTER: I think she was there. I remember seeing the
24 two of them together.
25 MR GARNHAM: Do you remember who you spoke to first?
8
1 DR DEMPSTER: With respect to who, sorry?
2 MR GARNHAM: Kouao or her daughter, Victoria, as you were
3 led to believe she was.
4 DR DEMPSTER: No, I do not remember who I spoke to first.
5 MR GARNHAM: Did you speak to Kouao? Did you speak to
6 Ms Kouao?
7 DR DEMPSTER: Yes, I did.
8 MR GARNHAM: Do you remember what she said to you?
9 DR DEMPSTER: From my memory, she was mostly concerned about
10 housing issues, and she was trying to get help with
11 housing. I note that I have actually documented that
12 she was itching as well, but I cannot remember much more
13 of the conversation than that.
14 MR GARNHAM: Did she speak to you in English?
15 DR DEMPSTER: Yes, she did. My French was very minimal.
16 MR GARNHAM: Did you ask her anything about Victoria?
17 DR DEMPSTER: Not that -- I do not remember the
18 conversation, so I do not remember exactly what we
19 talked about, other than housing.
20 MR GARNHAM: You then presumably turned to talk to Victoria?
21 DR DEMPSTER: Yes, I would have talked to Victoria.
22 MR GARNHAM: Before I ask you about what passed between you
23 two, can I ask whether there was any handover, other
24 than the notes, between you and whoever was on first?
25 DR DEMPSTER: Normally, there is a handover between --
9
1 whoever was on the night passes over to the day. I am
2 sure there would have been one, but I cannot remember
3 it. I am not sure who was on that night until the next
4 day.
5 MR GARNHAM: And it must follow from that that you cannot
6 remember what you were told about Victoria.
7 DR DEMPSTER: Well, my memory is that she was admitted to
8 the ward with initial concerns about non-accidental
9 injury, but that that had been thought not to be
10 a problem after the ward round, when she was diagnosed
11 with scabies. I think someone at some stage had passed
12 that over to me.
13 MR GARNHAM: And do you know whether you got that by
14 a verbal message or from the notes?
15 DR DEMPSTER: I think I got it from both a verbal message
16 and the notes.
17 MR GARNHAM: Doctor, I do not know how easily this is going
18 to work, but I would like you to look at some documents.
19 DR DEMPSTER: Okay.
20 MR GARNHAM: Can we pull back and look at the bottom of the
21 document first, please? Can you still hear me,
22 Dr Dempster?
23 DR DEMPSTER: I can.
24 MR GARNHAM: I have asked the document to be shown at the
25 bottom first, in order to identify the page number;
10
1 however, that has now disappeared. Can we go back to
2 that?
3 DR DEMPSTER: I saw what it was. I have got that.
4 MR GARNHAM: 37/030, thank you. Could we now go to the top
5 of that same page, please? Thank you. Can you see that
6 as well, Dr Dempster?
7 DR DEMPSTER: No, but if it was the same page, yes, I have
8 got that, thank you.
9 MR GARNHAM: Thank you. At the top we have what we
10 understand to be the notes done by Dr Modi at 8.00 pm
11 the previous evening. Do you remember seeing those
12 notes?
13 DR DEMPSTER: Well, I do.
14 MR GARNHAM: You remember that you saw them; you may not
15 remember what was in them from that time, is that right?
16 DR DEMPSTER: Well, now I look at them, they are obviously
17 familiar to me, so I assume I remember seeing them, yes.
18 MR GARNHAM: Do you recall whether you discussed the
19 contents of those notes with anybody else, such as the
20 nurses who were with you on the ward round?
21 DR DEMPSTER: No, I do not recall that.
22 MR GARNHAM: You would have known from those notes for
23 certain that there had been a diagnosis of scabies?
24 DR DEMPSTER: That is right.
25 MR GARNHAM: Did you know whether by that time Victoria had
11
1 been treated for scabies?
2 DR DEMPSTER: I understood that she had been treated for
3 scabies by the time I arrived, yes.
4 MR GARNHAM: Do you know what she had been treated with?
5 DR DEMPSTER: Derbac lotion.
6 MR GARNHAM: That is a common treatment for scabies?
7 DR DEMPSTER: That is right.
8 MR GARNHAM: Used for children and adults, or just children?
9 DR DEMPSTER: Children and adults.
10 MR GARNHAM: You spoke to Kouao, and I think you asked her
11 whether she had any signs of scabies.
12 DR DEMPSTER: Yes.
13 MR GARNHAM: What did she tell you?
14 DR DEMPSTER: I think she said she had been itching, so
15 I said she should have some scabies treatment as well.
16 MR GARNHAM: And did you then prescribe the stuff?
17 DR DEMPSTER: I cannot remember. I think I must have, or
18 asked them to give her some.
19 MR GARNHAM: Another document, please; for the record, this
20 is volume 38, page 153. Do you see that?
21 DR DEMPSTER: Yes, it is a prescription for Malathion, which
22 is Derbac.
23 MR GARNHAM: So that is another name for the same drug?
24 DR DEMPSTER: That is right.
25 MR GARNHAM: And I think if we go a little further down the
12
1 page, we see you have signed that.
2 DR DEMPSTER: Yes.
3 MR GARNHAM: And is that the prescription that you wrote for
4 Ms Kouao?
5 DR DEMPSTER: Yes, it is.
6 MR GARNHAM: I think you then spoke to -- I am sorry, what
7 else was said to you in the course of the meeting with
8 Victoria?
9 DR DEMPSTER: I cannot remember the details of that
10 conversation, I am afraid. I remember talking about
11 concerns about housing with her mother, or Ms Kouao, and
12 I remember Victoria smiling at me, but I am afraid
13 I cannot remember talking to her.
14 MR GARNHAM: You say you cannot remember talking to her; was
15 that because of the language difficulty, or because you
16 did not attempt to talk to her?
17 DR DEMPSTER: I think it is probably because of the language
18 difficulty.
19 MR GARNHAM: Does that mean that you have a recollection of
20 attempting to talk to Victoria?
21 DR DEMPSTER: No, I do not have a recollection, but normally
22 when I do a ward round or meet children, I talk to them,
23 so I cannot see why that would have been any different.
24 MR GARNHAM: When you finished discussing her case with
25 Victoria and Kouao, you then went on to the next bed?
13
1 DR DEMPSTER: I think I must have.
2 MR GARNHAM: What did you understand that needed to be done
3 in respect of Victoria's case, once you had finished
4 that consultation?
5 DR DEMPSTER: Well, the main thing that I thought needed to
6 be done was that she needed a social services review,
7 and at the time of the ward round, my thoughts were that
8 she was waiting for that review.
9 MR GARNHAM: Did you understand there was anything that you
10 needed to do?
11 DR DEMPSTER: Well, I needed -- or someone had to contact
12 Social Services, so I needed to talk to them, to get
13 them to come round and see her.
14 MR GARNHAM: Anything else that you needed to do?
15 DR DEMPSTER: That was the main thing that I felt that
16 I needed to do.
17 MR GARNHAM: Thank you. Can we go back to 37/030, please,
18 at the top of the page? Do you see that now,
19 Dr Dempster?
20 DR DEMPSTER: Yes, I have that.
21 MR GARNHAM: This is the note by Dr Modi; you will see
22 halfway through that note there is a star in the left
23 hand margin, and it says:
24 "Skin swabs to be done", and then two lines further
25 down:
14
1 "Dermatology opinion."
2 What did you understand by those marks and those
3 words?
4 DR DEMPSTER: Well, the skin swabs, I would have thought
5 that they would have been done already, because normally
6 the nurses would take those off after they have been
7 requested, so I would not have necessarily followed that
8 up, because I thought they had been done. The
9 dermatology opinion, I accept that that is likely to
10 have not been done the night before, and I cannot
11 remember contacting the dermatologist that day, or
12 whether I did, or whether I took responsibility for it,
13 or whether the other SHO did, or whether neither of us
14 did, but I am afraid I cannot remember that, contacting
15 them at all.
16 MR GARNHAM: In respect of the skin swabs, once they had
17 been taken, if you are right that they should have been
18 taken by a nurse, they would go off to a lab, would
19 they?
20 DR DEMPSTER: That is right.
21 MR GARNHAM: Was it not your responsibility to ensure the
22 results came back?
23 DR DEMPSTER: They would not be back for 24 to 48 hours, so
24 the next morning, they would probably still be sitting
25 there waiting to be plated.
15
1 MR GARNHAM: Thank you. The dermatology opinion; you were
2 the only SHO doing that ward round, were you not?
3 DR DEMPSTER: That is right, but -- there was another SHO
4 that was involved in the afternoon. I am not sure if
5 there was anything there in the morning.
6 MR GARNHAM: But you were the doctor who had read those
7 notes and seen Victoria in the morning, so is not the
8 first obligation on you to see that the dermatology
9 opinion is obtained?
10 DR DEMPSTER: Yes, that would be right.
11 MR GARNHAM: But you did not do so?
12 DR DEMPSTER: I do not recall doing so.
13 MR GARNHAM: Is there any -- I am sorry, say that again.
14 You do not recall doing so?
15 DR DEMPSTER: Right.
16 MR GARNHAM: It is an interesting art, this, trying not to
17 speak at the same time. We missed you I think on that
18 occasion and then. Is there any means by which there is
19 a check made as to whether starred action points like
20 these are completed, first of all generally, and
21 secondly in this particular hospital?
22 DR DEMPSTER: Normally, SHOs tend to have books in which
23 they document what needs to be done on each patient, and
24 in other hospitals I have worked at, you have a handover
25 book, so you have a book that you write everything in,
16
1 and then you tick them off as they are done. I do not
2 remember there being one in this hospital. I might be
3 wrong, but I do not remember that.
4 So that is normally how you find out what has and
5 has not been done, because it is already written down.
6 MR GARNHAM: But you do not remember there being such a book
7 here?
8 DR DEMPSTER: No, I do not remember that.
9 MR GARNHAM: Thank you very much. The next star is by the
10 words that appear to read something crossed out and "no"
11 written over the top of it:
12 "No child protection issues but many social issues
13 need to be sorted out. Homeless, not at school."
14 Do you see that?
15 DR DEMPSTER: Yes, I do.
16 MR GARNHAM: Can we slide the page a little further up,
17 because I cannot read the remainder of it. The next
18 words appear to be:
19 "To see social workers tomorrow ..."
20 DR DEMPSTER: No, it says "To discuss with social workers
21 tomorrow ..."; "DW" is to discuss with.
22 MR GARNHAM: Thank you.
23 "... about the social problems."
24 Who did you understand was to do the discussion with
25 social workers?
17
1 DR DEMPSTER: It would be who did the ward round in the
2 morning. Normally with a child who there were concerns
3 about in that situation, the registrar would often
4 discuss with the social workers, but obviously there was
5 not a registrar on the ward or on the ward round, so
6 I did it.
7 MR GARNHAM: You took that to be an instruction to you, in
8 the absence of a registrar?
9 DR DEMPSTER: Well, I think it must have also been handed
10 over to me as well in the morning, but I am -- yes.
11 MR GARNHAM: Thank you. Can we go a little further up that
12 same page, please? The next entry I think begins with
13 the word "Nursing"; is that right?
14 DR DEMPSTER: Yes.
15 MR GARNHAM: "Observation stable. Debrac lotion applied
16 last night prior to bed. Due for bath this am."
17 I am struggling with the next word.
18 "Settled and slept. Wet bed. Mum says she usually
19 wets bed. This has been an ongoing problem. Review by
20 Paeds mane". Is that right? So you would have seen
21 that note as well?
22 DR DEMPSTER: That is right.
23 MR GARNHAM: And then the next entry, who made that?
24 DR DEMPSTER: That is my writing.
25 MR GARNHAM: Perhaps you could read the whole of it for us.
18
1 DR DEMPSTER: "Ward round SHO. Bright, happy. Mum says she
2 is also itching. Needs scabies treatment. Awaiting
3 social services review."
4 MR GARNHAM: What did you mean by those last words,
5 "awaiting social services review"?
6 DR DEMPSTER: I thought that she was going to be seen that
7 day on the ward, and I thought when I was doing the ward
8 round that we would basically wait for the social
9 services to come and see her on the ward, and then she
10 would be discharged after that. The general plan as far
11 as I understand it is we were looking at her going home
12 later that day, after the social services had been.
13 MR GARNHAM: Who did you think was going to be contacting
14 Social Services?
15 DR DEMPSTER: Well, I think it is the same situation as we
16 talked about before, that it had to be -- whoever was on
17 the ward would have had to do it, so I would have had to
18 do it.
19 MR GARNHAM: Did you do so?
20 DR DEMPSTER: I did.
21 MR GARNHAM: And who did you contact?
22 DR DEMPSTER: I cannot remember exactly who I phoned, but
23 I would have used the number that was already in the
24 notes, because as far as I understood, they had been
25 contacted the night before, so they already knew about
19
1 Victoria.
2 MR GARNHAM: Was it your view that she was to be seen by
3 social workers before she was discharged?
4 DR DEMPSTER: That is right.
5 MR GARNHAM: You do not remember the name of the social
6 worker you spoke to?
7 DR DEMPSTER: No, I do not remember, I am afraid.
8 MR GARNHAM: Do you remember from which social work
9 department she came?
10 DR DEMPSTER: No, I just rang the number that was in the
11 notes. I am afraid I did not know the distinctions
12 between the different departments at that time.
13 MR GARNHAM: What did you say?
14 DR DEMPSTER: Again, I am a bit vague about the details of
15 the conversation at this stage, but I would have told
16 them about Victoria's admission, about which they
17 already were aware, and I would have explained to her
18 the concerns that were there at the time. I would have
19 told them Dr Schwartz's diagnosis from the ward round
20 the night before and I would have basically told them
21 what the concerns were -- the problems with the housing
22 and the other issues.
23 MR GARNHAM: Can I put to you for your comment what the
24 woman, who we think was the social worker who received
25 that call, says she said to you or you said to her?
20
1 Michelle Hines says that you said to her that you or the
2 hospital "would like the child protection withdrawn and
3 treat as a child in need, because the family needs
4 urgent housing".
5 DR DEMPSTER: I do not agree with that. It is not the SHO's
6 place to ask for the Child Protection Team to lift the
7 Child Protection Order. I would not have known how to
8 go about doing that. So I am sure I would not have done
9 that. It was not in my interests to do that, because
10 I was waiting for the social services to see her, and it
11 is easier if they are still on the ward. And again,
12 there is no -- it is not something that I would have
13 done; it is the job of the police or the social workers
14 or the Child Protection Team to make that decision.
15 MR GARNHAM: Was there any sense in which the hospital did
16 want the police protection withdrawn from Victoria?
17 DR DEMPSTER: Not that I know of.
18 MR GARNHAM: Was the existence of police protection
19 inhibiting the way the hospital was carrying out its
20 work?
21 DR DEMPSTER: It would have made no difference.
22 MR GARNHAM: Would it not have prevented Victoria's
23 discharge that morning, at least into the care of Kouao?
24 DR DEMPSTER: It would have, but I would not have thought
25 that would be a problem that the hospital -- I do not
21
1 think that the Police Protection Order would have been
2 a concern for the hospital, I think they would have been
3 happy with it being there.
4 MR GARNHAM: In any event, you were not told of any wish to
5 have police protection withdrawn.
6 DR DEMPSTER: No, not that I remember.
7 MR GARNHAM: How many telephone conversations did you have
8 with the social worker?
9 DR DEMPSTER: I do not recall exactly. I remember lengthy
10 discussions, and I think probably at least two or three,
11 but I do not recall.
12 MR GARNHAM: Was it in one of the latter conversations that
13 you were asked to put your views in writing?
14 DR DEMPSTER: It must have been in one of the latter ones.
15 MR GARNHAM: As a result, I think you wrote a letter
16 addressed to the Duty Social Worker. Was that
17 a different person or the same person to the one you had
18 been talking to?
19 DR DEMPSTER: From what I remember, I remember having
20 trouble ascertaining who was going to take
21 responsibility for seeing Victoria, because after the
22 diagnosis was made of scabies, rather than
23 non-accidental injury, it seemed to change who was going
24 to take responsibility for the review.
25 MR GARNHAM: Where?
22
1 DR DEMPSTER: With the social services, whoever I talked to,
2 made it a lot more complicated actually, because
3 I thought that whoever I talked to would come in and see
4 her, and it would be very straightforward, but it was
5 not.
6 MR GARNHAM: And your understanding was that lack of
7 straightforwardness was because of the change from
8 a child protection case to a child in need case?
9 DR DEMPSTER: I think it must have been, but I did not
10 know -- well, I did not think of the differences between
11 child protection and child in need. I did not really
12 know the two --
13 MR GARNHAM: I am not suggesting there are; I am asking
14 whether that was the way in which it was put to you?
15 DR DEMPSTER: Yes, I think because the diagnosis had
16 changed, or the thoughts had changed about her
17 admission, it seemed to be a different social team that
18 needed to be involved.
19 MR GARNHAM: So back to my question, did you think you were
20 faxing your letter to the same lady you had spoken to
21 earlier that day?
22 DR DEMPSTER: I think I was faxing my letter to one of the
23 people I had spoken to that day, just somebody I spoke
24 to that day, yes.
25 MR GARNHAM: Do I take it from that that you had spoken to
23
1 more than one person by telephone that morning?
2 DR DEMPSTER: I really cannot remember who I spoke to, but
3 I thought that I was faxing that letter through to
4 somebody I had spoken to that day.
5 MR GARNHAM: Thank you. I wonder now if you could have
6 a look at the letter, and for the record, this is
7 volume 37, page 43. If you have that in front of you --
8 DR DEMPSTER: Yes, I do.
9 MR GARNHAM: Good, that means we do not have to juggle with
10 the machinery this end. You write:
11 "To the duty social worker", and you are writing
12 from Barnaby Bear Ward, on 15th July, and there is
13 a telephone number or a fax number at the top right-hand
14 corner, and then the words "fax: 15/7/99". Is that your
15 handwriting?
16 DR DEMPSTER: No, that is not my handwriting, the "fax".
17 MR GARNHAM: Is the rest of it your handwriting?
18 DR DEMPSTER: Yes.
19 MR GARNHAM: And you write:
20 "To the duty social worker,
21 "Thank you for dealing with the social issues of
22 Anna Koura ..."
23 That was what you understood her name to be?
24 DR DEMPSTER: Kouro, K-O-U-R-O.
25 MR GARNHAM: Thank you.
24
1 "She was admitted to the ward last night with
2 concerns re possible NAI. She has however been assessed
3 by the consultant Dr Schwartz and it has been decided
4 that her scratch marks are all due to scabies. Thus it
5 is no longer a child protection issue."
6 Where did you get that information from, that you
7 were passing on in this fax?
8 DR DEMPSTER: I took it from the ward round notes, when
9 Dr Schwartz has actually seen her.
10 MR GARNHAM: Two questions arise from that. Firstly, "It
11 has been decided that her scratch marks are all due to
12 scabies"; which part of the note did you get that from?
13 Do you have the ward round note there as well?
14 DR DEMPSTER: From the line that says, "rash looks like
15 scabies and hyperpigmentation marks on skin", and then
16 the next bit is "other marks also on web spaces and
17 fingers look like scabies".
18 MR GARNHAM: So you read that as indicating that all the
19 marks, the rash, the hyperpigmentation marks and the
20 other marks were all scabies?
21 DR DEMPSTER: That and the fact that it had been passed over
22 to me that the concerns about non-accidental injury were
23 not a problem any more, so the diagnosis with her was
24 she had scabies.
25 MR GARNHAM: That is what you had been told verbally?
25
1 DR DEMPSTER: Yes.
2 MR GARNHAM: "Rash looks like scabies and hyperpigmentation
3 marks on skin"; it might be said that that means, "Rash
4 looks like (1) scabies and (2) pigmentation marks"; in
5 other words, two different sources for the rash.
6 DR DEMPSTER: From what I understood from the notes and
7 other things, and also from things I have seen in the
8 past, you can get hyperpigmentation with -- you could
9 have got it from scabies lesions, from what
10 I understood, so I did not think of that as a separate
11 problem.
12 MR GARNHAM: Thank you. The second observation in your
13 letter is:
14 "Thus it is no longer a child protection issue."
15 It may well be obvious, but I will ask you all the
16 same: where did you get that from?
17 DR DEMPSTER: Again, from in the notes.
18 MR GARNHAM: And if we look at those notes -- perhaps you
19 would read the portion that led you to that conclusion?
20 DR DEMPSTER: "No child protection issues but many social
21 issues need to be sorted out."
22 MR GARNHAM: Thank you. The letter goes on:
23 "There are however several social issues that need
24 to be sorted out urgently."
25 Again a direct lift from the notes?
26
1 DR DEMPSTER: That is right.
2 MR GARNHAM: And then you list two:
3 "Anna and her mother are homeless [underlined].
4 They moved out of their B&B accommodation three days
5 ago."
6 Where do you get that from?
7 DR DEMPSTER: I think that Mrs -- I may have got that from
8 Ms Kouao.
9 MR GARNHAM: "Anna does not attend school."
10 Same question; same answer?
11 DR DEMPSTER: I am not sure where I got that from, but
12 possibly the same, yes.
13 MR GARNHAM: "Anna and her mother recently arrived from
14 France, and do not have a social network in this
15 country.
16 "Thank you for your help.
17 "Yours sincerely", and then your name; is that
18 right?
19 DR DEMPSTER: That is right.
20 MR GARNHAM: Did you have any information as to whether or
21 not Victoria was registered with a GP?
22 DR DEMPSTER: No, I did not have any information about that.
23 MR GARNHAM: The file I think contained a document where the
24 space for inserting the name of the GP is left blank; do
25 you remember that?
27
1 DR DEMPSTER: Only when I saw the notes again.
2 MR GARNHAM: That had not struck you as something of
3 significance when you first saw the notes for Victoria?
4 DR DEMPSTER: It is not something that I kept on at the
5 time, because sometimes things are left blank without
6 actually being filled in, so maybe she did have a GP and
7 it just had not been filled in.
8 MR GARNHAM: For the notes, it is at 37/022. I am pausing
9 for a moment while I look at something, Dr Dempster.
10 (Pause).
11 On a medical report called "Medical report on
12 a child thought to have suffered abuse" -- I do not know
13 whether you have that there with you, it has our
14 reference number 37/020. You are shaking your head.
15 DR DEMPSTER: No.
16 MR GARNHAM: I will show it to you in a moment. It is said,
17 after Anna's name and details:
18 "Where seen: school/day nursery/other", the words
19 are written, "Does not go to school."
20 I was wondering whether that was where you got that
21 information from. It will come up on the screen now in
22 the top right-hand corner of that page; do you see that?
23 DR DEMPSTER: Yes, I do.
24 MR GARNHAM: Do you remember whether you saw that medical
25 report on that morning?
28
1 DR DEMPSTER: No, I am afraid I do not remember whether
2 I saw it that morning.
3 MR GARNHAM: Thank you very much, we can take that one away.
4 If you look also at the notes done by Dr Modi that we
5 have looked at earlier, there is another reference to
6 her not going to school, about a third of the way down
7 the page.
8 DR DEMPSTER: That is right, yes.
9 MR GARNHAM: Would that have been where you got it from?
10 DR DEMPSTER: Quite possibly.
11 MR GARNHAM: Were you aware when you wrote the letter to the
12 social worker that Victoria's mother, as she was thought
13 to be, had asked the carer, Mrs Cameron, to look after
14 Victoria permanently?
15 DR DEMPSTER: No, I do not think I was aware that she had
16 asked her to look after her permanently. I knew that
17 she had been looking after her.
18 MR GARNHAM: Amongst Victoria's notes, there is a form
19 headed "General Minors Protocol", completed by an SHO
20 called Dr Beynon, which contains a note to that effect.
21 I will show it to you in a moment, but I will read it to
22 you first, completed the previous day:
23 "Anna and mother go to friend's last Wednesday, and
24 appear again last night. Mother asks neighbour to look
25 after Anna for good."
29
1 Could you look at that? Do you see the passage to
2 which I am referring?
3 DR DEMPSTER: Yes, I do.
4 MR GARNHAM: Do you recall whether you saw those notes
5 before you examined Victoria?
6 DR DEMPSTER: I am afraid I do not recall whether I did or
7 not.
8 MR GARNHAM: Do you recall whether you were aware of that
9 observation, "Mother asks neighbour to look after Anna
10 for good"?
11 DR DEMPSTER: No, I do not think I was aware of it.
12 MR GARNHAM: Would you have regarded that as significant if
13 you had seen it?
14 DR DEMPSTER: Yes, I would have.
15 MR GARNHAM: What would have been the significance for you?
16 DR DEMPSTER: The fact that the mother had asked someone
17 else to look after her.
18 MR GARNHAM: And the words "for good", suggestive of
19 a mother wanting somebody else to take the child away
20 for ever?
21 DR DEMPSTER: That is right.
22 MR GARNHAM: So potentially significant?
23 DR DEMPSTER: Significant, yes.
24 MR GARNHAM: Did you know anything about the woman who had
25 been looking after Victoria immediately before she was
30
1 admitted to the CMH?
2 DR DEMPSTER: No, I did not.
3 MR GARNHAM: You did not know, for example, whether she was
4 a registered childminder?
5 DR DEMPSTER: No, I was not aware of those details. As
6 I said, I did not meet this lady, she had been seen the
7 night before.
8 MR GARNHAM: I am trying to understand the process -- or the
9 failure of the process which means that a piece of
10 information which you would have regarded as potentially
11 significant is not conveyed to the social work team,
12 namely the observation about Anna's mother wanting
13 someone to look after Anna for good. Where do you think
14 the problem lies?
15 DR DEMPSTER: I think the problem lay in the fact that when
16 I wrote that letter to Social Services, I was using that
17 letter as a referral to get them there that day, and
18 I expected Social Services to come and see her and go
19 through those sorts of details on the ward with her, so
20 I was using that more as a referral, rather than listing
21 every piece of information that I could get by going
22 through all the notes.
23 MR GARNHAM: The trouble with that, Doctor, is that your
24 letter thanks the social worker for dealing with the
25 social issues. It does not, as far as I can see, extend
31
1 an invitation or a request that the social worker come
2 into the ward that day.
3 DR DEMPSTER: That was my understanding of what they were
4 doing; when we were talking on the telephone, that was
5 what I understood they were doing.
6 MR GARNHAM: So although that is not in the letter, that
7 arose out of your conversation with them?
8 DR DEMPSTER: That arose out of my understanding of what
9 I thought was going to happen that day.
10 MR GARNHAM: This may be of some significance, so let me put
11 it to you straight: were you told that a social worker
12 was going to come into the ward to see Victoria that
13 day?
14 DR DEMPSTER: I do not remember being told that.
15 MR GARNHAM: So it is an understanding the origin of which
16 you cannot identify?
17 DR DEMPSTER: No, but possibly from the notes the night
18 before, when they said that she was going to be seen the
19 next day.
20 MR GARNHAM: The trouble is that the night before, it was
21 thought that she presented child protection concerns,
22 which might have prompted one reaction from Social
23 Services, whereas that morning, you were writing to
24 Social Services saying "no child protection concerns",
25 which might have prompted a rather different reaction.
32
1 DR DEMPSTER: Well I also listed things that I thought were
2 so significant, like the fact that she did not have
3 anywhere to live, that I thought they would have to come
4 and see her anyway to help find some accommodation for
5 her.
6 MR GARNHAM: With the benefit of hindsight, that marvellous
7 device, would it have been more sensible to make express
8 your wish that they come in and see her in your letter?
9 DR DEMPSTER: With the benefit of hindsight, definitely.
10 MR GARNHAM: Do you see the letter now as being inadequate?
11 DR DEMPSTER: For the way that it was taken, because
12 unfortunately I wrote it with one thought in mind, which
13 was to refer it to them, and they obviously read it with
14 a different thought, which was more to do with the
15 information, so with the way that it was read, yes,
16 I would definitely put a lot more information in it.
17 MR GARNHAM: And in particular, you might have mentioned the
18 point about Victoria's mother believing that she was
19 hoping to get rid of Victoria -- no, that is not right:
20 asking the carer to look after Victoria for good, you
21 would have put that in now?
22 DR DEMPSTER: Well, I would now, but we did have very long
23 discussions about things on the telephone as well, and
24 they had been aware of Victoria the night before, so
25 again, they should have had quite a lot of information
33
1 verbally.
2 MR GARNHAM: Was there anything in your conversation to
3 suggest they knew that point, about mother wanting to
4 leave Victoria for good?
5 DR DEMPSTER: No, I do not remember, I am afraid.
6 MR GARNHAM: Was there anything in your conversations with
7 the social worker about Victoria having cut herself?
8 DR DEMPSTER: No, I did not know anything about Victoria
9 having cut herself.
10 MR GARNHAM: Was there anything in your conversation about
11 Victoria having wet the bed?
12 DR DEMPSTER: No, there was not.
13 MR GARNHAM: Although you knew that from events that
14 morning.
15 DR DEMPSTER: Yes, but it is not that uncommon for a six or
16 seven year old little girl to wet her bed at night, so
17 it is not something I would necessarily have mentioned
18 to the social workers.
19 MR GARNHAM: Had you picked up from the notes concerns about
20 Victoria's state of hygiene, when she came into the
21 hospital?
22 DR DEMPSTER: To do with the scabies, yes.
23 MR GARNHAM: What about the fact that she was giving off
24 a pungent odour, as it was put?
25 DR DEMPSTER: No, I did not pick that up from the notes.
34
1 MR GARNHAM: Because that was not passed over to Social
2 Services, because you had not picked it up?
3 DR DEMPSTER: That is right.
4 MR GARNHAM: If you had picked it up, would you have passed
5 that over, would you have informed them of that?
6 DR DEMPSTER: I would have told them verbally.
7 MR GARNHAM: But you do not think you did, because you did
8 not pick it up?
9 DR DEMPSTER: No, I do not think I did.
10 MR GARNHAM: Whilst you were writing to Social Services the
11 letter we have just looked at, your colleague,
12 Dr McMahon, wrote to the Housing Department, I think.
13 DR DEMPSTER: That is right.
14 MR GARNHAM: So there must have been some conversation
15 between you, sharing out the tasks.
16 DR DEMPSTER: There must have been.
17 MR GARNHAM: Do you recall it?
18 DR DEMPSTER: No, I do not, I am afraid.
19 MR GARNHAM: Victoria was discharged later that day.
20 DR DEMPSTER: That is right.
21 MR GARNHAM: Do you recall the time at which she was
22 discharged?
23 DR DEMPSTER: No, I do not actually recall the discharge at
24 all.
25 MR GARNHAM: I would like to ask you a little more about
35
1 that. What is the process normally for the discharge of
2 a patient from a hospital ward?
3 DR DEMPSTER: Normally the decision is made by one of the
4 senior doctors. Then a discharge is formally done, and
5 when we do that, we write a discharge letter and
6 document it in the notes.
7 MR GARNHAM: So that one would expect, would one, to see in
8 the case of a patient discharged a note indicating that
9 the senior doctor had decided that the patient should be
10 discharged?
11 DR DEMPSTER: That is right.
12 MR GARNHAM: Then a discharge letter, which would set out
13 the circumstances of the admission, the treatment and
14 the discharge?
15 DR DEMPSTER: That is right.
16 MR GARNHAM: And that letter would be sent to whom?
17 DR DEMPSTER: There is a copy of it in the notes, there is
18 a copy that goes to the patient, and one to the GP.
19 MR GARNHAM: In this case, it could not have gone to the GP,
20 because we do not appear to have had a note -- or you do
21 not appear to have had a note of the GP's name or
22 address.
23 DR DEMPSTER: That is right.
24 MR GARNHAM: Victoria was a child, so would a copy have gone
25 to --
36
1 DR DEMPSTER: Her mother.
2 MR GARNHAM: -- her apparent mother?
3 DR DEMPSTER: Yes.
4 MR GARNHAM: So the only people who would have the discharge
5 letter, were it written, is your file and the mother.
6 DR DEMPSTER: That is right.
7 MR GARNHAM: Do you know whether a discharge letter was
8 written in this case?
9 DR DEMPSTER: Well, I do not think there was a discharge
10 letter, because I could not find one in the notes, and
11 that is what makes me think I did not actually formally
12 discharge her.
13 MR GARNHAM: Because you would have written a note and
14 a letter?
15 DR DEMPSTER: At the very least, I would have written it in
16 the notes, and it is my usual practice to write
17 a discharge letter at the time they go home.
18 MR GARNHAM: After those steps had been taken, what then
19 happens before the patient leaves the ward? Once that
20 has all been done, presumably the patient is told that
21 that is going to happen?
22 DR DEMPSTER: Well, yes, you go through and make sure
23 everything has been done, go ahead, write the discharge
24 letter, and the patient obviously knows that they are
25 going to be going home, and they usually take it with
37
1 them on their way.
2 MR GARNHAM: And in the case of a child, it is the parent
3 who is told that the child is fit for discharge, and
4 then presumably they pack up and go?
5 DR DEMPSTER: That is right.
6 MR GARNHAM: Dr Schwartz says in her statement to this
7 Inquiry, and for the note, it is paragraph 29, that
8 Victoria would have been discharged by the most senior
9 doctor available on the ward at the time. Do you know
10 who the most senior doctor on the ward was?
11 DR DEMPSTER: Well, there should have been a registrar in
12 the hospital, or -- I cannot remember the registrar on
13 the ward, but there should have been a registrar.
14 MR GARNHAM: Do you remember whether there was a registrar
15 on the ward?
16 DR DEMPSTER: No, I do not remember a registrar.
17 MR GARNHAM: If there was no registrar, who would then have
18 been the most senior doctor?
19 DR DEMPSTER: The decision would have been made by either
20 the registrar or the consultant. It would not have been
21 made by the SHO.
22 MR GARNHAM: That I understand, but in the absence of
23 a consultant or a registrar, would the SHO have written
24 the discharge letter?
25 DR DEMPSTER: The discharge letter, yes, but the decision --
38
1 once the authority had come through.
2 MR GARNHAM: Given that there was no note in the hospital
3 papers indicating who the GP was, should the discharging
4 doctor have ensured that Victoria's case was referred to
5 the Community Child Health Service?
6 DR DEMPSTER: It is not something that I would have known to
7 do, but it would be nice if it was done, but I would not
8 have automatically -- I would not have known to have
9 done that.
10 MR GARNHAM: What would you have done if you had a case
11 where there was no note in the records as to the GP's
12 name and you were discharging a child?
13 DR DEMPSTER: Usually, the child would take the letter with
14 them, and be advised to take it to their GP, and then --
15 I do not know how much further it would go than that
16 really.
17 MR GARNHAM: Thank you. Just, I think, four last questions:
18 during the ward round you conducted with Victoria, did
19 you examine Victoria?
20 DR DEMPSTER: No, I did not.
21 MR GARNHAM: Is that normal, on a ward round, that you do
22 not examine the patients?
23 DR DEMPSTER: We examine the patients if medically they need
24 to be examined. Victoria had been thoroughly examined
25 by the consultant the night before, the diagnosis of
39
1 scabies had been made, so there was not really any
2 reason for me to examine her, because nothing would have
3 changed since 8.00 the night before.
4 MR GARNHAM: Although you did not examine her, did you
5 notice any marks to her face?
6 DR DEMPSTER: Yes, I think I remember some marks on her face
7 that were like scabs.
8 MR GARNHAM: Did you at that time have much -- are you okay?
9 DR DEMPSTER: Yes, fine, I just have a dry eye.
10 MR GARNHAM: Did you at the time have much experience of
11 scabies?
12 DR DEMPSTER: No, not very much.
13 MR GARNHAM: Have you ever seen a case before?
14 DR DEMPSTER: Yes, I had seen some when I was a student on
15 the Solomon Islands, but that had been four or five
16 years before that.
17 MR GARNHAM: Did you form a view as to whether the marks on
18 the face that you could see when you talked to Victoria
19 looked like scabies?
20 DR DEMPSTER: I did not really have enough experience in
21 looking at scabies to make an opinion on that.
22 MR GARNHAM: Did you see bruises or wounds on the face?
23 DR DEMPSTER: No, I did not.
24 MR GARNHAM: Thank you. The second of these last four
25 questions: did you have any expectation as to the
40
1 timescale in which the social services would act? Were
2 you expecting them to turn up at a certain time or
3 within a certain time?
4 DR DEMPSTER: No, I just thought they would arrive that day;
5 it would probably be in the afternoon, I would have
6 thought.
7 MR GARNHAM: Were you expecting them to arrive before she
8 was discharged?
9 DR DEMPSTER: Yes.
10 MR GARNHAM: Was accommodation, the fact that Anna appeared
11 to be homeless, the only reason you were expecting
12 Social Services to turn up before she was discharged?
13 DR DEMPSTER: Well, that was one of the main reasons,
14 because I thought that she had nowhere to go.
15 MR GARNHAM: Next, would you have discharged Victoria before
16 she was seen by the social worker, if you had been the
17 person making that decision?
18 DR DEMPSTER: Only if I had had it authorised by the
19 consultant or the registrar. I would not have made the
20 decision to discharge her. And even once she had been
21 seen by the social services, I would not have discharged
22 her until I had had it authorised by a senior doctor.
23 MR GARNHAM: Last topic, Dr Dempster. Was there any
24 discussion between you and any other doctor about
25 Victoria that morning, other than Dr McMahon?
41
1 DR DEMPSTER: I think someone must have handed over to me in
2 the morning.
3 MR GARNHAM: I am sorry, you are quite correct, you told me
4 that. Thereafter was there any?
5 DR DEMPSTER: I cannot remember whether or not I talked to
6 anybody else about it.
7 MR GARNHAM: Is this the sort of case that you would have
8 wanted to discuss with the consultant, Dr Schwartz?
9 DR DEMPSTER: Usually, yes, I would.
10 MR GARNHAM: So why not discuss it with her? Was she not
11 available?
12 DR DEMPSTER: I may have, but I cannot remember whether
13 I did or not. I cannot remember having any
14 conversations.
15 MR GARNHAM: Would it not have been beneficial to have
16 discussed the case with Dr Schwartz before writing the
17 letter to Social Services that we have seen?
18 DR DEMPSTER: Well, as I was saying, the reason -- when
19 I contacted Social Services and then wrote a letter, the
20 reason was that they (inaudible), so I was following the
21 instructions that were in the notes to contact them, and
22 then the letter came after that, as a request from the
23 social services, and then if I had any concerns about
24 social services, then I would have phoned Dr Schwartz.
25 MR GARNHAM: Dr Dempster, thank you very much. I think
42
1 there may be some more questions for you.
2 THE CHAIRMAN: Thank you very much indeed, Mr Garnham.
3 Dr Dempster, I will now invite Mrs Mason if she would
4 like to ask you some questions.
5 MRS MASON: Just a few things, Charlotte, which I think it
6 would be helpful to go over again. The first one is as
7 I understand it, you accept that the responsibility for
8 writing the discharge letter lay with yourself as SHO or
9 the other SHO on duty.
10 DR DEMPSTER: That is right, or the registrar, depending on
11 who was there at the time.
12 MRS MASON: As I understand it, you do not accept that the
13 responsibility for the decision to discharge was yours.
14 DR DEMPSTER: That is right.
15 MRS MASON: There is some suggestion that there was in fact
16 no registrar available that day at the hospital, and
17 certainly as I understand it Dr Schwartz was not
18 available at the hospital. If they were not at the
19 hospital, would you have then thought, "I am the most
20 senior doctor here, I will make the decision"?
21 DR DEMPSTER: No, I would not have, I would have contacted
22 whoever was responsible that day, so Dr Schwartz or the
23 registrar, but probably Dr Schwartz.
24 MRS MASON: So if in fact it does turn out that there was no
25 registrar and we know that Dr Schwartz was not at the
43
1 hospital, is it likely that you did speak to Dr Schwartz
2 that day?
3 DR DEMPSTER: It is likely that I did.
4 MRS MASON: Counsel has taken you to the letter that you
5 wrote to the social services and has gone through that
6 with you in some detail. He suggested at one point that
7 you had expressed your views in that letter; would you
8 say that was correct?
9 DR DEMPSTER: No, they are not my views, they are the views
10 that were noted down on the ward round the night before,
11 so I very much lifted those views from the notes.
12 MRS MASON: Would you have seen it as your role to form your
13 own view in that situation?
14 DR DEMPSTER: No, especially since I had come on new to the
15 ward, and had not been involved the night before, I felt
16 that I could not really form my own views, because it
17 was a short time, so I would have taken it from the
18 notes.
19 MRS MASON: Would you have had any reason to doubt the view
20 that was reached by Dr Schwartz?
21 DR DEMPSTER: No.
22 MRS MASON: If we could just go over the purpose of the
23 letter that you wrote to Social Services, as you now
24 remember it -- I appreciate your memory is not very good
25 now, but was it your understanding that the purpose of
44
1 that letter was to convey all of the information about
2 Victoria's condition, and any background circumstances,
3 to the social services?
4 DR DEMPSTER: No, not at all. As I explained to Mr Garnham,
5 my view was that the letter was to let them know that we
6 would like an urgent review, and as I said, I thought
7 that the review would be on the ward.
8 MRS MASON: And lastly, Mr Garnham has taken you to the rest
9 of the notes relating to Victoria, and I think you have
10 a set there, and certainly in my set, which I think is
11 the same as your set, there are some eight and a half
12 sides of notes before you came on duty, and wrote your
13 note about the ward round. You have explained to us
14 that you would have probably first seen those notes when
15 you were standing, seeing Victoria, on the ward round.
16 DR DEMPSTER: That is right.
17 MRS MASON: And I think there has been some discussion about
18 the length of time that you would have had to read those
19 notes, and obviously, that would depend on how many
20 patients you would have to see, the extent to which you
21 could read those notes, but do you think it is likely
22 that you would have had the time to read every single
23 line of those notes?
24 DR DEMPSTER: No, I think it is unlikely that I would have.
25 MRS MASON: Thank you.
45
1 THE CHAIRMAN: Thank you very much indeed, Mrs Mason.
2 Dr Dempster, may I just ask you a small amount of
3 questions, please? Firstly, could you tell me what
4 experience you had in working with social services
5 departments before you were dealing with Victoria on the
6 ward?
7 DR DEMPSTER: Not a great deal, because usually it is -- if
8 there are child protection issues, a registrar would
9 deal with them. I had -- I am trying to think of times
10 when I saw them. I had seen them on the ward when they
11 had come in to review children who had been reviewed on
12 the ward. That would probably be the time when I had
13 mostly to deal with them.
14 THE CHAIRMAN: Right, thank you. Would that have been three
15 or four contacts during your time here or would it have
16 been 20 or 30 contacts? Just give me some idea.
17 DR DEMPSTER: We are looking more at the three or four.
18 THE CHAIRMAN: Thank you. What did you understand to be the
19 significance of police protection?
20 DR DEMPSTER: That while she was under a Police Protection
21 Order, she could not be taken from the ward. It was
22 a safe place for her to be.
23 THE CHAIRMAN: And what was your understanding about how
24 police protection is withdrawn?
25 DR DEMPSTER: I thought that the police and the social
46
1 workers withdraw that. I did not think that the medical
2 staff had anything to do with that really.
3 THE CHAIRMAN: And were you aware of the hospital discharge
4 policy for children?
5 DR DEMPSTER: Not a formal discharge policy, no.
6 THE CHAIRMAN: Or a protocol with Social Services, on
7 matters of this kind?
8 DR DEMPSTER: For Central Middlesex?
9 THE CHAIRMAN: Mm -- yes, between Central Middlesex and the
10 local social services department.
11 DR DEMPSTER: No.
12 THE CHAIRMAN: Nobody had told you what the local
13 arrangements were?
14 DR DEMPSTER: No.
15 THE CHAIRMAN: So when you were asked to write this letter,
16 or when you did write this letter, in what context were
17 you writing the letter?
18 DR DEMPSTER: I was writing the letter to try and get social
19 services to come and see Victoria, because after
20 discussion with her, that is what I was asked to do.
21 THE CHAIRMAN: And just one final question, please. You
22 mentioned, in a reply to a request put to you by
23 Mr Garnham, that in that telephone conversation with
24 social services, it became complicated. I wonder if you
25 could just enlarge on that for our understanding,
47
1 please.
2 DR DEMPSTER: I have trouble, because I do not actually have
3 a very clear memory of the conversation, but I remember
4 feeling quite frustrated about not being able to get
5 things done as easily as I thought it would be, and
6 I think it was -- from that, I mean that people who
7 I thought were going to review her ended up saying that
8 someone else was going to review her.
9 THE CHAIRMAN: And did they give you an indication as to why
10 they were not going to review her? Just tell us exactly
11 what you understood was happening, if you can.
12 DR DEMPSTER: What I understood was happening was that the
13 reason that they changed teams, or changed people, was
14 because of her diagnosis, and because it was thought to
15 have been not a non-accidental injury any more, and so
16 that meant that although there were significant concerns
17 about her -- well, if I take it from the notes, social
18 issues, with her homelessness and lack of social
19 (inaudible) and everything else, that still did not come
20 under the same group of social workers, so it would make
21 it a different one.
22 THE CHAIRMAN: Thank you very much indeed. Mr Garnham?
23 MR GARNHAM: Nothing further from me, thank you, sir.
24 THE CHAIRMAN: Dr Dempster, thank you very much indeed for
25 your help this evening for you, this morning for us.
48
1 I am very grateful to you.
2 DR DEMPSTER: Thank you.
3 (Videotape stopped)
4 THE CHAIRMAN: Mr Garnham, please?
5 MR GARNHAM: Sir, thank you for that. It seemed to us that
6 this was a reasonably satisfactory way of adducing
7 evidence from witnesses who are currently living abroad,
8 and a long way abroad. There are other witnesses for
9 whom we have in mind adopting a similar procedure. Sir,
10 I indicate that now simply so that if there are any of
11 the interested parties who have representations to make
12 about this method of putting evidence before you, to
13 invite them to do so. That aside, sir, we will proceed
14 with today's business and I will ask Miss Gibson to call
15 the next witness.
16 THE CHAIRMAN: Thank you very much indeed, Mr Garnham.
17 If there are any concerns, perhaps you could raise
18 them -- now or with Mr Garnham, whichever would suit
19 you. Ms Boye?
20 MS BOYE: It is not actually that, sir, I have been asked to
21 say by Mr and Mrs Climbie at the soonest possible
22 opportunity that I have sent them home, because the
23 interpreter has not attended today, but they were very
24 concerned that I should let you know as soon as possible
25 and they are going to check the transcript to make sure
49
1 I have said it, so I am saying it at a suitable
2 opportunity.
3 THE CHAIRMAN: That is thoughtful of you, Ms Boye.
4 I appreciate that very much indeed, thank you.
5 Mr Turner?
6 MR TURNER: Sir, I am sorry to take time, but we have had
7 a letter this morning from the witness manager saying
8 that Yolande Viljoen, who is one of our witnesses, is
9 required to give evidence at the Inquiry in person.
10 When I discussed this with Mr Garnham informally, he
11 said that thought was being given to the possibility of
12 again a television link; clearly she is in South Africa,
13 and we would welcome that, if it is achievable. I am
14 not sure otherwise what the plans or thought is, but sir
15 I will, if I may, discuss that informally with
16 Mr Garnham when we get an opportunity.
17 THE CHAIRMAN: That is most helpful.
18 MR GARNHAM: Sir, Ms Viljoen was one of those who I had in
19 mind when I said that. I suspect the letter that one of
20 my friends is referring to was written before we had
21 seen how well this appears to have worked, but we will
22 deal with it today.
23 THE CHAIRMAN: That is very helpful indeed. I am grateful
24 to you, Mr Turner. Thank you very much indeed.
25 Ms Gibson?
50
1 MS GIBSON: Thank you, sir. The next witness is
2 Kate Thrift.
3 MS KATE THRIFT (sworn)
4 MS GIBSON: Perhaps you could be supplied with a copy of
5 your statement. Thank you. Could you begin by giving
6 the Inquiry your full name and professional address,
7 please?
8 MS THRIFT: My name is Kate Emma Thrift and my professional
9 address is Brent House Annexe, Wembley High Road,
10 Wembley, Middlesex.
11 MS GIBSON: You have a copy of the statement you made on
12 6th June this year in front of you.
13 MS THRIFT: Yes.
14 MS GIBSON: Are the contents of that statement true?
15 MS THRIFT: Yes, they are true.
16 MS GIBSON: Thank you. You were a duty social worker from
17 November 1998 to February 2000; is that right?
18 MS THRIFT: That is correct.
19 MS GIBSON: And you were working in the team that was led by
20 Edward Armstrong?
21 MS THRIFT: Yes, that is correct.
22 MS GIBSON: Are you still employed by Ealing?
23 MS THRIFT: By Brent.
24 MS GIBSON: I am sorry.
25 MS THRIFT: Yes, I am still employed by Brent, and I am in
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