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Archived Transcript for 19 Febuary 2002:
Pages 1 to 50
1
1 Tuesday, 19th February 2002
2 (10.00 am)
3 THE CHAIRMAN: Good morning ladies and gentlemen.
4 Mr Garnham.
5 MR GARNHAM: Good morning sir. May I just indicate that
6 since the last day of oral evidence on 4th February, we
7 have received two further statements, those of
8 Cecelia Hitchen dated 5th February and Anne Bristow
9 second statement dated 8th February. We propose to
10 treat both those statements as read into the evidence.
11 Both will be added to the Inquiry's bundle and published
12 on the Inquiry website in the usual way.
13 THE CHAIRMAN: That is splendid, thank you very much indeed
14 Mr Garnham. It may help if I give an indication of the
15 business today. We will hear from Miss McGowan in
16 a moment and then Miss Hoyal and then Miss Lawson and
17 then I intend we have a break after Miss Lawson, and
18 then we will hear from Ms Boye and then we will have
19 lunch and then we will hear from Mr Garnham. So
20 Miss McGowan please. Miss McGowan I think you know you
21 have 15 minutes.
22 Closing submissions by MISS McGOWAN
23 MISS McGOWAN: Thank you sir, yes. In making closing
24 submissions on behalf of WPC Karen Jones we would seek
25 to submit that she has sought to cooperate with this
2
1 inquiry into Victoria's death. She would wish to
2 continue to assist the Inquiry in any way she can to
3 ensure if it is possible that no such tragedy be
4 repeated. Sir, in due course the Inquiry will no doubt
5 consider the missed opportunities as outlined by Counsel
6 to the Inquiry in his opening statement.
7 It is accepted on behalf of Karen Jones that there
8 were occasions on which there was unnecessary and
9 avoidable delay. However, we submit that such failings
10 that are found against her did not contribute to the
11 suffering and eventual death of this little girl.
12 Sir, the role of the police in child protection is
13 complex and still evolving. Mr Thwaites in his opening
14 on behalf of the Metropolitan Police Service said: "the
15 police attempt to strike a balance between the necessary
16 protection of children from harm and the unwelcome
17 invasion of family privacy". Sir, we submit that that
18 is right.
19 The experience of inquiries into earlier child
20 deaths shows a pattern of uncertainty between the roles
21 of investigation, prosecution, protection and society's
22 overall interest in the maintenance and support of the
23 family unit wherever possible.
24 It is not right, sir, to simply draw analogies
25 between allegations of physical abuse against children
3
1 and assaults on adults in the street. In the latter
2 case, the police I say simply have to investigate the
3 allegation, collate the evidence, pass it on to the
4 prosecution authorities, who then determine whether
5 a case can be brought. Even in this field it has only
6 recently become apparent that there is some need for
7 liaison with the complainant and even then more usually
8 only in the more extreme or sensitive cases.
9 In the case of a child the concerns are far more
10 diverse. There is obviously a duty to investigate in
11 the usual way but that is overlain by duty to act in the
12 long-term interest of the child. That may in many cases
13 involve the officer moving away from the role of
14 investigator and closer to that of a provider of family
15 support.
16 There may be cases in which it is not in the child's
17 interest for the prosecution to be brought and the
18 better course may be the involvement of the social
19 services to maintain and support the family. In such
20 cases the police quite rightly are expected to
21 contribute towards a good and close working relationship
22 with the other child protection agencies. In many cases
23 that requires them to play a secondary role.
24 In the current system a child protection police
25 officer is expected to perform their duties in an
4
1 entirely different ethos from almost any other role
2 within the service. That being the case, the need for
3 different recruitment policies and specialist training
4 are manifest. It is disingenuous for senior officers to
5 seek to persuade this Inquiry that any officer with
6 basic training should be able to fulfil the role of
7 a child protection officer.
8 In specific terms sir a child protection officer
9 takes a subservient role to the allocated social worker,
10 and in order to maintain the required level of
11 cooperation between the agencies may well have to
12 approach a case qua social worker themselves rather than
13 as an investigating officer.
14 Equally, in dealing with the medical profession, the
15 role of such an officer is to be advised and guided as
16 to the medical diagnosis and prognosis by the experts.
17 A system under which a constable is expected to argue
18 with a consultant as to the medical validity of their
19 findings is not couched in reality.
20 Sir, I deal briefly with Victoria's admission to the
21 North Middlesex Hospital in July 1999.
22 Victoria's admission to hospital and the initial
23 concerns of the medical staff were brought to
24 Karen Jones' attention in the usual and then accepted
25 way. No greater sense of care or urgency was
5
1 demonstrated or communicated to her. She attended the
2 strategy meeting and was given a number of tasks, and
3 sir you will find that document with which I know you
4 are familiar at volume 6 page 091.
5 The hospital's role was to further investigate the
6 causes of the marks on the child's body. They were to
7 report any concerns arising from that investigation to
8 the police and the social services. They were also to
9 arrange that photographs of her injuries be taken.
10 It has been suggested that Karen Jones should have
11 intervened in these investigations to duplicate them by
12 calling in a forensic medical examiner and a police
13 photographer.
14 Sir, this Inquiry is all too aware, it is a cardinal
15 rule of child protection that no unnecessary step that
16 will or might cause distress to a child be taken.
17 Victoria was in the care of one of the country's leading
18 paediatric consultants, the named doctor for the Trust.
19 Is it realistic to imagine that Karen Jones should order
20 that the child undergo a second series of examinations
21 by a doctor whose experience and standing would
22 inevitably be less than that of Dr Rossiter?
23 Equally, sir, it is generally understood that the
24 taking of such photographs can be a distressing invasion
25 of privacy for a child. One set of photographs had been
6
1 taken by the hospital's own expert photographer. What
2 was to be gained by commissioning a second set other
3 than to add to the child's distress and anxiety?
4 Sir, a further decision of that strategy meeting was
5 that once the medical reports were ready a joint home
6 visit was to be arranged. Its purpose was to explain
7 fully the Child Protection Procedures to the woman then
8 believed to be the child's mother.
9 Much heat has been created around the topic of this
10 visit and it is our submission that very little light
11 has been cast on it. The evidence of Chief
12 Superintendent Akers illustrates the general
13 misapprehension. She said in evidence, dealing with
14 Karen Jones' failure to visit the home in late July or
15 early August, that it was a grave error of judgment, and
16 I quote, "... like failing to carry out the home visit
17 which would have uncovered what was going on and then
18 not following it up."
19 That evidence was given on 11th January of this
20 year. Sir, there is no basis for saying that a home
21 visit at that time would have disclosed what was or may
22 have been going on. The opposite is true. We know that
23 Lisa Arthurworrey's home visits on later occasions
24 showed a crammed but otherwise satisfactory home.
25 Karen Jones would not have seen anything more.
7
1 All decisions taken by Karen Jones at this stage and
2 subsequently are fully recorded in her entries on the
3 CRIS. She consulted her supervisor and the social
4 worker and as a consequence the visit, the purpose of
5 which I repeat was simply to explain the procedures to
6 the apparent mother, was rearranged.
7 By that stage sir the hospital had communicated
8 their concerns. They came in Isobel Quinn's letter of
9 3rd August, volume 6, page 238. No question of physical
10 abuse was raised in that letter. It is submitted that
11 Karen Jones could not have been expected reasonably to
12 go behind the conclusions of the hospital. She sought
13 advice from the Accident and Emergency department in
14 relation to the question of scabies, that was the
15 standard practice amongst the police at that time, and
16 as a result of that advice moved the location of the
17 meeting between her, the social worker and the apparent
18 mother.
19 Her actions at that time are fully contemporaneously
20 recorded and it is strenuously maintained that the
21 inquiries were made by her as set out in her evidence.
22 Sir, we know now that had she contacted the police
23 occupational health service she would have been advised
24 to wear a protective suit and other equally bizarre
25 clothing, and sir I refer to the witness statement which
8
1 I believe has been read into evidence but if not, sir,
2 it is the statement of Chandrika Makwana and it is in
3 volume 4, page 200/501.
4 Further, sir, interestingly, had she consulted
5 Dr Mann, the consultant dermatologist who gave evidence
6 in the criminal trial, she would have received from him
7 the sort of advice that she has recorded as having
8 received from a member of the staff of the Accident and
9 Emergency department, the advice which she recorded
10 fully on the CRIS.
11 No member of staff on the children's ward at the
12 North Middlesex Hospital queried her actions at the
13 time. It is perhaps sir not surprising that no member
14 of staff in the Accident and Emergency department, if
15 they can recall giving such advice, will now acknowledge
16 giving such advice.
17 Sir, despite the evidence of some of the nurses,
18 there were, it was clear, still concerns about whether
19 or not Victoria had scabies and indeed we know that she
20 was being barrier nursed in isolation as a result of
21 those existing concerns.
22 Sir, in due course the hospital wanted to discharge
23 the child. By that time it was clear to Woman Police
24 Constable Jones that neither Victoria nor Marie-Therese
25 had scabies, nor had it ever been in the flat at
9
1 Somerset Gardens and so the child went home to what was
2 believed and in due course proved to be a clean
3 environment.
4 Sir, this at that stage was not a police
5 investigation into child abuse and assault and the
6 social services commenced their role as the lead agency
7 with a view to assisting the family unit, mother, child.
8 Sir, it is important to deal with the character and
9 appearance of Marie-Therese Kouao at the stage during
10 Karen Jones' contact with her. Sir, whatever purpose
11 was achieved by calling her as a witness, she has
12 clearly left a lasting impression on all who heard her.
13 Much has been said in the press about the fact that
14 no one could possibly have been taken in by her, given
15 her performance here. It is essential, we submit, to
16 bear in mind that she is and was a manipulative and
17 intelligent woman. She very clearly succeeded in
18 answering only the questions she chose before the panel
19 and duped a very large number of people throughout her
20 involvement with Victoria from the child's own family to
21 all the statutory agencies with which she came into
22 contact. In that respect Karen Jones was no different
23 from anyone else.
24 Sir, I turn to the November allegation. We know now
25 that Marie-Therese's purpose in bringing Victoria to
10
1 Europe was to use her as a means of obtaining benefit
2 and other assistance from the social security systems
3 here and in France. That was beginning to become
4 apparent to Haringey Social Services in the autumn of
5 1999. Marie-Therese was told that unless the child was
6 in immediate danger they would not be rehoused.
7 The next day she appeared with Victoria who recited
8 an account of sexual abuse with by Carl Manning. It was
9 manifestly untrue. When the making of the allegations
10 did not achieve their purpose they were withdrawn. It
11 was after that that Karen Jones was told what had
12 happened.
13 Taking those allegations, they had not involved any
14 penetrative conduct in the recent past. Any medical
15 examination of a child of that age on the basis of what
16 was known would have been an abusive intrusion. It
17 would rightly have been the subject of grave criticism.
18 It was not requested by Karen Jones and once again all
19 the details of her conduct of the matter were recorded
20 in minute detail for inspection.
21 If, as was the case here for good reason, no one
22 believed that the allegations made were anything other
23 than a ruse then a police officer cannot have reasonable
24 grounds for suspecting that the accused has committed
25 the act complained of and consequently would have no
11
1 basis in law to carry out an arrest. Police powers are
2 rightly constrained by statute. Officers must operate
3 within them. More importantly, it was not we submit
4 appropriate to subject a child of Victoria's age to the
5 stress and anxiety of a police interview when there were
6 no reasonable grounds for suspecting that an offence of
7 indecent exposure or indecent assault had actually
8 occurred.
9 Sir, it is clearly arguable that Marie-Therese's
10 treatment of Victoria in using her in this way might
11 well be an abuse and might well have amounted to child
12 cruelty. However, one cannot ignore the special
13 features that must be borne in mind when deciding
14 whether or not to commence an investigation with a view
15 to programmes in such a case. The disruption to the
16 child and its place in the family may be such that for
17 the right and proper reasons no prosecution is or should
18 be begun. That is particularly the case where there is
19 ongoing social work involvement and any childcare issues
20 can more appropriately be dealt with in that framework.
21 Karen Jones was obliged by practice and self
22 protection to seek a withdrawal statement. It is
23 accepted that there was unnecessary delay in the
24 obtaining and sending of the translated letter.
25 Sir, in conclusion, Karen Jones has been a police
12
1 officer for 15 years. Throughout that time her annual
2 reports have been outstanding, both in the Child
3 Protection Team and before. She has received three
4 commendations from the Metropolitan Police Service
5 during her service. She was put in a position as the
6 most junior officer of being the most experienced member
7 of her team. She carried out her role in the child
8 protection team in the way in which she had inherited it
9 from her predecessors. Her conduct of the role was
10 never before this investigation the subject of even
11 comment, let alone reprimand.
12 She started work at 7 each morning so she could
13 complete the work load allocated to her. She completed
14 those tasks to the best of her ability given as we now
15 know she had not been trained to do the job expected of
16 her. She is criticised by senior officers for failing
17 to detect and investigate this case and yet she had been
18 given no training for what is now conceded to be one of
19 the most important, complex and highly specialised roles
20 within the police service.
21 Karen Jones, like all others involved in this case,
22 deeply regrets the suffering and death of Victoria. She
23 understands the horror with which her parents have heard
24 the evidence in the trial and in this Inquiry. She
25 understands the all too human desire to seek to place
13
1 blame for what has happened but asks the Inquiry to
2 maintain sight of the fact that the murderers in this
3 case were skilful at concealing their conduct, that
4 Marie-Therese in particular was an accomplished liar and
5 manipulator of people around her, that she, Karen Jones,
6 was working in a role for which she had not been trained
7 and in which she had operated for three years without
8 criticism or guidance from those far above her in the
9 service, especially those senior officers who now seek
10 to lay the blame at her door.
11 In hindsight sir far better systems could have been
12 in place but Karen Jones had to work with what was
13 available to her at the time. She deeply regrets that
14 she was not able to have prevented what happened to
15 Victoria. She is willing, sir, to continue to cooperate
16 with the Inquiry to assist from her perspective as the
17 lowest ranking child protection officer in any further
18 work that it has in contemplation. Sir, thank you.
19 THE CHAIRMAN: Thank you very much indeed. That is very
20 helpful Miss McGowan, I am grateful to you.
21 MR GARNHAM: Sir for the sake of the record Miss McGowan
22 asked about the reading into the evidence of one witness
23 statement. Miss Makwana's statement was read into the
24 evidence on Day 28, it is page 204 of the transcript.
25 MISS McGOWAN: I am very grateful.
14
1 THE CHAIRMAN: Thank you very much indeed. Now, Miss Hoyal,
2 you have 30 minutes.
3 Closing submissions by MISS HOYAL
4 MISS HOYAL: Thank you. Sir, I make closing observations on
5 behalf of Lisa Arthurworrey, the Haringey social worker,
6 who has had a very short career as a social worker in
7 children's work. It commenced in January of 1998 and
8 effectively came to an end in less than three years,
9 in October 2000.
10 She qualified in 1997 with high ambitions and many
11 references and one of the references provided to this
12 Inquiry was by Dr Ellis from her university who said:
13 "All the evidence I have from six years of working
14 with Lisa is that she is inherently competent,
15 conscientious, reflective and trustworthy. These are
16 not qualities that I believe change over time ... I was
17 one of the members of the staff at the University who
18 encouraged her to go into social work training because
19 of her demonstrated qualities which made me believe she
20 would be a valuable addition to the profession. I find
21 it difficult to believe she has lost these important
22 qualities", and I submit on her behalf she has not.
23 She commenced employment in the London Borough of
24 Hammersmith and Fulham and moved to Haringey in November
25 1998. She was suspended following a critical Part 8
15
1 report in respect of Victoria's death, which solely
2 focused on her alleged faults instead of objectively
3 reviewing the actions of all the other agencies and
4 workers involved with Victoria. She herself noted 73
5 separate errors in the report, many others noted more
6 errors and the report was never agreed.
7 Subsequently, a disciplinary investigation was
8 commissioned by Haringey and commenced in early 2001
9 after the Secretary of State had found that Haringey
10 Social Services Department was failing in its services
11 for children and placed on special measures and also
12 after the announcement of this Inquiry.
13 Haringey has sought to attribute the errors in
14 Victoria's case to this junior employee, who faces
15 disciplinary action still, so as to divert attention
16 from the chaotic system it continued and probably still
17 continues to operate, if recent evidence of allocation
18 by numbers, excessive workloads, poor supervision and
19 PDR and intimidating management practices suggests.
20 Various witnesses such as Dave Duncan and
21 Rose Kozinos and others have blamed poor management and
22 the restructuring amongst other reasons for the exodus
23 of social workers from the summer of 1999 onwards.
24 Loyal, experienced and qualified staff have resigned and
25 left the services at North Tottenham District Office and
16
1 Hornsey in a critical state, dependent on agency staff
2 and with an unacceptable standard of service provision
3 for children. A downward spiral of staff turnover has
4 made recruitment and retention a priority.
5 In July 2001 the High Court postponed the
6 disciplinary proceeding Haringey had fixed for that
7 month against Lisa, and few would doubt the aptness of
8 Mr Garnham's description of Lisa put to Anne Bristow,
9 Director of Social Services for Haringey, in his
10 questioning, that Lisa had become a sacrificial lamb.
11 Fortunately Lisa's trade union Unison, the public
12 service union, has provided her with legal advice and
13 representation since her suspension. Without it she
14 could not have afforded the cost of the various legal
15 proceedings and representation at this Inquiry.
16 At no time has her employer, Haringey, been
17 representing her or purporting to. Her approach to this
18 Inquiry has been characterised by (i) her fullest
19 cooperation at all times, (ii) her compliance with the
20 Inquiry's requests, timetable and procedures, and (iii)
21 fullest disclosures.
22 When she worked at the North Tottenham District
23 Office prior to Victoria's death she was regarded by her
24 colleagues as conscientious, hard working and competent.
25 A competency assessment dated 27th July 1999 disclosed
17
1 by Haringey in December 2001 marked her either average
2 or very good in 42 specific areas covering
3 (i)~engagement and communication with clients,
4 (ii)~assessment, planning reviews and evaluation,
5 (iii)~meeting the requirements of legislation and
6 Council policy and consultation with families,
7 communities and systems, (iv) manage self and
8 professional development, and (v) working in the
9 organisation.
10 A few days later on 2nd August 1999 she was
11 allocated Victoria's file which she found on her desk.
12 She read it, she realised the work was urgent and
13 important and she attempted to implement the
14 recommendations as quickly as possible. She had at
15 least 18 other children including 10 with child
16 protection concerns which she was also responsible for
17 at that time.
18 It is suggested on her behalf that Haringey should
19 accept some responsibility for their contribution to the
20 conditions in which she was working, namely the
21 inadequate induction, the inadequate supervision, not
22 providing adequate monitoring of and a satisfactory
23 system of the allocation of cases, not providing an
24 adequate restriction on the number of child protection
25 cases and other cases she was asked to be responsible
18
1 for at any moment in time and not providing an adequate
2 system to prevent the excessively high total number of
3 cases that she had, despite clear documentary and
4 anecdotal evidence that at all material times the number
5 of cases was hugely in breach of the maximum 10 to 12
6 that she should have had instead of the 19 that she was
7 actually working on.
8 Her witness statements to this Inquiry are
9 consistent with the oral evidence that she gave over two
10 days and are wholly corroborated I would suggest by the
11 documentary records she made at the time of her actions
12 during the period of her involvement, and she relies on
13 the totality of her evidence as giving a comprehensive,
14 accurate and honest account of how, why and what actions
15 and omissions occurred.
16 Her documents are particularly important because
17 they are not constructed with the benefit of hindsight
18 after Victoria's death. They were a running record made
19 at the time with no knowledge of the horrendous events
20 that were to occur in the future, unlike some of the
21 other witnesses to this Inquiry, whose witness
22 statements were made with the benefit of hindsight,
23 without the hindrance of any documents to actually
24 remind them what was actually happening at the time.
25 In taking this course she has made few friends and
19
1 endured hostility from parts of the public and former
2 colleagues. At all times she tried do her best for
3 Victoria and all the other children she was allocated
4 responsibility for.
5 Many children's lives have been changed for the
6 better and their health protection and welfare
7 safeguarded by her actions. Perhaps she has helped save
8 some abused children's lives by her professional
9 involvement and judgment. None of those children will
10 ever been the subject of a national public inquiry. It
11 is only when a child is killed that professionals stand
12 accused of misconduct for failing to have predicted by
13 some seventh sight that a particular child would be
14 killed. It is every social worker's nightmare. The
15 reality is that the public expects social workers to be
16 able to predict the future, have infinite time,
17 resources, training, supportive management and expertise
18 to prevent the unthinkable murder of a child by her
19 carers.
20 Lisa's social work career is over. Nationally
21 social work is at a very low ebb. The culture of blame
22 and persecution referred to by Rose Kozinos in her memo
23 is embedded. Unless a realistic approach can be taken
24 of what it is reasonable to expect front line social
25 workers to be able to do, the numbers of front line
20
1 social workers will continue to fall. The job vacancies
2 in deprived, inadequately resourced London boroughs
3 inundated with homeless families and children in need of
4 protection and family support services will increase.
5 Few London boroughs can afford the services for
6 children which they are legally obliged to give and
7 would wish to provide. The burden on front line social
8 workers is poorly understood by those who have not done
9 the job; daily investigating, assessing and visiting
10 families who may be dangerous but most of which need
11 family support services and decent housing.
12 Social workers can barely cover the monitoring of
13 children on the Child Protection Register subject to
14 legal proceedings or looked after, let alone the
15 thousands of children like Victoria considered a child
16 in need. As eligibility for services narrows, pressures
17 on services become greater. Victoria was never one of
18 the thousands of children on the Child Protection
19 Register or looked after. Housing was the main reason
20 her file was not closed on 12th August 1999 when the
21 Section 47 investigation concluded on the evidence that
22 was available at the time that she had not suffered or
23 was likely to suffer significant harm.
24 The letter from Central Middlesex Hospital which
25 Mr Egan referred you to yesterday is critical in this
21
1 case in understanding the sequence of events that
2 followed on. When Lisa read it on 12th August and it
3 referred to Dr Schwartz's diagnosis stating that there
4 were no child protection issues and that the marks were
5 all from scabies or scratching from scabies, she
6 considered that this was as clear and as powerful legal
7 evidence as a consultant paediatrician could give.
8 At the time that diagnosis seemed consistent with
9 the medical opinion given to Lisa by Nurse Quinn in her
10 fax and Dr Rossiter's telephone consultation on
11 3rd August; namely, there were no references to physical
12 abuse or non-accidental injury, but the clear linkage
13 from Dr Rossiter and Dr Schwartz that the old marks were
14 linked with scabies, scratching from scabies or from
15 treatment.
16 The home visit on 16th August coupled with the
17 interviews of Kouao and Victoria provided at the time
18 evidence of a loved child, well cared for, happy and
19 confident. There were no signs of serious emotional
20 harm or neglect. It is arguable but very unlikely that
21 if Lisa had seen Victoria alone on 16th August or
22 28th October Victoria might have told her a different
23 story. However, in view of Victoria's loyalty, coaching
24 and what she said on 6th August, it is very unlikely.
25 One must remember she did not tell the people in the
22
1 churches, the other friends or the relatives that she
2 saw right up to shortly before her death of what she was
3 enduring at the hands of Kouao and Manning.
4 The failed attempts by Lisa to contact and locate
5 Victoria and Kouao after the strategy meeting on
6 5th November have to be seen against the context of the
7 police having posted only one letter some two months
8 later, and the evidence that we now know that Kouao had
9 actually returned to France as she intended to twice
10 in November.
11 At least Lisa made a series of phone calls, spot
12 visits to Manning's home and other enquiries to try and
13 locate Victoria. If indeed Kouao and Victoria had
14 remained in France after the two weeks that they went at
15 the end of November to the middle of December, it is
16 unlikely any one would have questioned the wisdom of
17 what was done at the time.
18 Dealing with the police, if Lisa and Haringey Social
19 Services have been given a written or even an oral
20 report from Dr Rossiter or another doctor when
21 questioned to do so on 3rd August, which referred to
22 non-accidental injury, it is likely that the whole
23 Section 47 investigation would have proceeded
24 differently. For a start, if the police had had the
25 medical evidence and the photographs that were made
23
1 available after Victoria's death, it is likely that
2 a thorough criminal investigation would have included
3 interviews with Manning, Kouao and Victoria and all the
4 lay and medical witnesses who have made statements for
5 this Inquiry in the criminal trial, and collecting that
6 evidence was the paramount duty and responsibility of
7 the police, as was a forensic examination of the home,
8 as was the reinvestigation of the Central Middlesex
9 Hospital evidence in the light of evidence from North
10 Middlesex Hospital.
11 Now, if the police had obtained that evidence and
12 provided social services with a summary of it, then of
13 course social services would have been able to act.
14 There would have been sufficient evidence to convene
15 a case conference, take legal advice and possible legal
16 proceedings to protect Victoria in early August 1999,
17 and Victoria may not thereafter have returned to live
18 with Kouao.
19 Neither the police nor North Middlesex Hospital
20 could or should have expected Lisa to perform their
21 clear responsibilities, namely the investigation and
22 prosecution of crimes and the diagnosis from the medical
23 evidence of non-accidental injuries. The evasion or
24 avoidance of their legal duties by these agencies was
25 compounded by Haringey's willingness to join them in
24
1 shifting the blame to a non-medically qualified,
2 non-memorandum trained junior social worker after the
3 death of Victoria.
4 Nothing less than a competent diagnosis of
5 non-accidental injury, documented and communicated to
6 Lisa in a medical report, coupled with a competent
7 police investigation would have been capable of
8 providing the evidence a court would have required for
9 Victoria's protection.
10 Lisa is not a paediatrician, detective or
11 a psychiatrist, yet other agencies have sought to shield
12 behind her back. The hospitals. If North Middlesex
13 Hospital had liaised with Central Middlesex Hospital,
14 and one bears in mind Victoria was not there for a few
15 hours, she was there for 13 days, and at no time did
16 North Middlesex Hospital even ask to see the notes of
17 her admission at Central Middlesex Hospital or speak to
18 any of the doctors.
19 If they had done it is likely that a speedy and
20 clear diagnosis of non-accidental injury would have been
21 able to have been made by the 25th July 1999 and an
22 urgent police investigation would have been likely to
23 have ensued. This is what happens in lots of similar
24 cases every day all over the country.
25 The intervention of the social services is dependent
25
1 upon the correct diagnosis being provided to them by the
2 hospital. By the time of the North Middlesex Hospital
3 admission there was plenty of medical evidence
4 potentially available. Speed is critical for the
5 obtaining and preservation of evidence. Clear
6 comprehensive medical recording is essential for legal
7 proceedings. The admissions made by Mr Mason on behalf
8 of the Trust constitute a full acceptance of liability
9 for the failure to not only document medical findings
10 but to competently communicate them in a legible,
11 accurate and effective manner.
12 Subsequently, for Lisa to be blamed for not acting
13 on the Central Middlesex Hospital copy notes or
14 understanding them rather than relying on Dr Dempster's
15 letter, when the North Middlesex Hospital had not even
16 bothered to obtain them, is really quite remarkable.
17 The issue of medical negligence by both these hospitals
18 is not for this Inquiry but insofar as Lisa has been
19 blamed for acting on their medical evidence, it is
20 a relevant feature.
21 Victoria spent 13 nights in this hospital and this
22 Inquiry has heard moving evidence from nurses and
23 doctors that was not given to Lisa when she asked for it
24 on 3rd August. Or to social services at all.
25 The loyalty of these agencies to their employees is
26
1 a factor that one has to notice in passing. In the
2 appendix to the written submissions in relation to this
3 evidence there are some 37 general criticisms made of
4 the North Middlesex Hospital and 15 of Dr Rossiter, with
5 a comparison of the evidence that she has given at the
6 Central Criminal Court to this Inquiry and in her
7 written statements, and on behalf of Lisa we would
8 invite you to read carefully those submissions when you
9 make your report.
10 In relation to the discharge summary, the omission
11 of any written document purporting to be a report or
12 a discharge summary is glaring. The discharge summary
13 that was subsequently sent was never sent to
14 Lisa Arthurworrey. It was not sent to Ms Kitchman until
15 2nd September. It could have been faxed or posted to
16 Lisa on or about 6th August and should have been.
17 Dr Rossiter never discussed it with her or even
18 attempted to contact her and we note that it contained
19 serious errors.
20 Dealing with the old injuries, a failure at any time
21 during Victoria's life to provide this written report to
22 police or social services giving a clear and accurate
23 diagnosis effectively meant that a misdiagnosis was
24 communicated.
25 Lisa was never informed that the old injuries were
27
1 other than from scabies or the infection from scabies or
2 scratching from scabies and from the treatment of
3 scabies. She was never informed that there was
4 non-accidental injury caused as a result of physical
5 abuse or chastisement. She was never told that the
6 injuries were in fact recent and caused after the
7 discharge from hospital on 15th July.
8 The failure to correct this impression is crucial to
9 not only hers but social services' understanding of the
10 medical evidence. CP forms were grossly defective and
11 confusing.
12 At no stage did Dr Rossiter ever distinguish between
13 old injuries and recent injuries. She made the
14 distinction between the scalds, which were recent, and
15 old injuries.
16 Turning to Manning, Kouao and Victoria. With
17 hindsight it does seem extraordinary that such an
18 experienced police officer as Karen Jones should not
19 have taken the lead in the interview of Kouao on
20 5th August. It was Lisa's first joint child protection
21 investigation with the police, first investigation
22 involving a child in hospital, first investigation in
23 which there were potentially serious crimes having been
24 committed.
25 It may not have made any difference. Kouao's
28
1 deceptive skills and plausible explanations might have
2 convinced the most sceptical of experienced police
3 officers. She portrayed a moving and convincing story
4 of life before she came to the UK, the bereavement of
5 Victoria's father and the efforts she was seeking to
6 make to start a fresh life for her and Victoria.
7 Victoria's interview on 6th August was equally
8 convincing. Her explanation for the injuries was
9 consistent with Kouao's and had been accepted by the
10 hospital: accidental scalds. The interview lasted some
11 20 or 30 minutes. At the end Victoria was clear that
12 she wanted to go home and it was not to the Ivory Coast,
13 it was to accompany Kouao. She was delighted to see
14 her, she held her hand and the two left the hospital
15 happily together.
16 The interviewing of young children, potential
17 witnesses, is a legal minefield. Even if a child makes
18 clear allegations there has to be clear corroborative
19 medical evidence for legal proceedings. Over 100
20 children were removed from their families on the basis
21 of so called clear medical evidence and interviews with
22 children which later faced substantial criticisms by the
23 panel that constituted the national public inquiry into
24 the removal of children in Cleveland in 1987, and the
25 evidence was severely criticised by the courts.
29
1 Scale of the problem. Research and guidance such as
2 contained in "Child Protection - Messages from the
3 Research", "Paternalism and Partnership" and other
4 authoritative HMSO publications have guided social
5 services departments towards concluding Section 47
6 investigations speedily, reclassifying into Section 17
7 assessments where appropriate and taking no further
8 action.
9 One has to remember that out of the 160,000
10 Section 47 investigations considered in that year in
11 that research, 120,000 resulted in no further action.
12 This is a huge burden for social services in being able
13 to come to the right decisions.
14 Out of those remaining 40,000, 24,500 led to
15 children's names being entered on the Child Protection
16 Register and a very small percentage, namely 6,000 were
17 either accommodated or went into care. It has to be
18 remembered that investigations are very stressful for
19 families and children and may be abusive to children
20 unless there is a solid legal evidential basis for them
21 to proceed.
22 The relationships families make with social workers
23 are critical for the subsequent protection of children.
24 Perhaps realistically we expect far too much and I would
25 refer you now to the conclusion of the report of the
30
1 panel of inquiry into the death of Liam Johnson which
2 concluded:
3 "The death of a child is not always preventable,
4 children do die, sometimes tragically and sometimes at
5 the hands of those who should care for them.
6 Responsibility for these deaths lies overwhelmingly with
7 those who kill them, not those whose role has been to
8 try and help the family."
9 Lastly, in conclusion, if I can quote from the
10 editorial in Community Care, the leading social work
11 journal, for 29th November as follows.
12 "There are many overloaded social workers around the
13 country attempting to juggle high workloads while
14 learning on the job. Children remain protected because
15 the child protection system is built on the premise that
16 inexperienced members of staff receive regular
17 supervision, support and back up from their line
18 managers ...
19 "Agencies alone cannot protect vulnerable children.
20 This difficult task also relies on the public, who give
21 agencies their mandate to intervene, to make decisions
22 and inevitably sometimes to fail. If the public lose
23 their trust in and respect for social workers they will
24 be far less likely to report concerns about children,
25 and will eagerly condemn mistakes rather than ensuring
31
1 they -- as well as the professionals -- learn from
2 them...
3 "Social workers must not be scapegoated, but how can
4 they not be scapegoated in the media when they are
5 neglected, blamed, intimidated and unsupported within
6 their own departments."
7 THE CHAIRMAN: Miss Hoyal I am grateful to you, thank you
8 very much indeed. Now Miss Lawson and Miss Lawson as
9 you know you have an hour.
10 MISS LAWSON: Yes sir, shall we synchronise our watches?
11 10.45.
12 THE CHAIRMAN: I have some assistance.
13 Closing submissions by MISS LAWSON
14 MISS LAWSON: Sir, in this country we allow families the
15 freedom to bring up their children as they choose. That
16 most basic human right is one which is protected by law.
17 The state interferes only so far as is necessary to
18 prevent crime or to protect the rights and freedoms of
19 others. That includes the freedom to make choice which
20 others might consider unwise or even damaging to their
21 children's welfare.
22 One of the consequences of the freedom that all
23 families enjoy is that some children are damaged by the
24 upbringing they receive. Some of course go on to be
25 high achievers; the lives of other children are
32
1 permanently blighted by the abuse they suffer; some
2 tragically will die at the hands of members of their own
3 families. Their deaths are part of the price which our
4 society pays for that freedom. It is an uncomfortable
5 truth looking at a case as appalling as Victoria's but
6 it is a truth nevertheless.
7 It is very difficult for any outsider to know or to
8 find out what is really going on in the privacy of
9 people's homes. It might be done but only by
10 a significant intrusion into the freedom of every parent
11 to choose how to bring up their children.
12 In deciding how to improve the system which failed
13 to protect Victoria, it is important to bear in mind not
14 only that your recommendations may have unforeseen
15 consequences for the poor and disadvantaged families who
16 need the Council's services, but for thousands of other
17 families who will never cross the threshold of a social
18 services office or join the housing waiting list.
19 There is a second uncomfortable truth. This country
20 can have the quality of public children's services that
21 it is prepared to pay for. Victoria's death has shocked
22 the nation. It is easy for people to say that no
23 resources should have been spared to save her from her
24 fate. But is it prepared to spend the money necessary
25 not only to assess the needs of children who come to
33
1 social services' attention, but to provide all the
2 resources to meet those needs? Ms Mayer yesterday, for
3 example, spoke of the first opportunity to intervene in
4 Victoria's life, two days after Mrs Kouao's arrival in
5 England with Victoria, when she went to their offices
6 asking for housing and for money.
7 If we stop the clock at that point and look at
8 intervention, and ask whether people would be prepared
9 to ensure that children in those circumstances should
10 immediately be offered decent housing, money to live on,
11 a place in school, access to free health and dental care
12 and so on, and not just for this child but for thousands
13 of others as well because we cannot be sure which of
14 those children may die, some people of course would say
15 "yes, we must," but not everyone would.
16 Haringey, like every other authority, would welcome
17 such a massive injection of money into the system but
18 are we as a society really prepared to meet the cost of
19 that sort of provision? In saying that, Haringey is not
20 suggesting that within the financial constraints that
21 exist, its service cannot be improved or that poor
22 practice is acceptable. Nor does it suggest that there
23 is a simple equation between what is spent and the
24 quality of service provided.
25 Haringey, as you are aware, has looked closely at
34
1 the failings in its systems. On behalf of Haringey
2 Council before this Inquiry began, Ms Bristow said we
3 are appalled by this tragedy which we should have been
4 able to prevent. The system failed Anna and we are part
5 of that system. She has apologised to the family and we
6 do so again now.
7 Turning then to look at the points we make in our
8 written submissions, they emphasise the following. We
9 begin, because I am a lawyer, by looking at the legal
10 framework within which Victoria's and other cases
11 involving children have to be resolved. As far as its
12 approach to its task is concerned, we say that this
13 Inquiry should be slow to criticise any individuals in
14 relation to any conduct which occurred after Victoria's
15 death, and in deciding on its approach to fact finding
16 it should make findings only where it is satisfied as
17 a court has to be that the matter has been proved as
18 more probable than not to have occurred.
19 The Inquiry must have regard to the legal framework
20 within which social workers operate in carrying out
21 their duties and in particular child protection.
22 We also suggest that no one who has given evidence
23 is the person they were over two years ago, when they
24 were dealing with Victoria's death. Those who were
25 junior doctors or student nurses have over two years
35
1 more experience and maturity, which has to be borne in
2 mind when assessing their evidence. Others have been
3 psychologically affected by Victoria's death and its
4 aftermath to an extent that they are probably no longer
5 recognisable as the practitioners they were in 1999.
6 In relation to the question of what action could or
7 should Haringey staff have taken, there are two separate
8 processes which have not been properly disentangled.
9 The first is whether the social workers were given
10 information which ought to have prompted investigation
11 or inquiry on their part. The second is whether there
12 was evidence that Victoria was being abused available to
13 them at the time and, if so, whether it was sufficient
14 to have satisfied the statutory grounds for taking
15 proceedings or taking some other action.
16 This has not been done rigorously during the course
17 of the questioning. Terms such as "neglect" or
18 "emotional abuse" have been exchanged in a general way
19 without any analysis of whether they meet the statutory
20 definition of significant harm under Section 31 of the
21 Children Act or even the definitions of abuse which are
22 required to put the child's name on the Child Protection
23 Register.
24 "Significant harm" in the Children Act is defined as
25 "significant ill treatment (which includes sexual abuse
36
1 and forms of ill-treatment which are not physical) or
2 significant impairment of [the child's] physical or
3 mental health or significant impairment of his physical,
4 intellectual, emotional, social or behavioural
5 development."
6 The Government guidance in Working Together defines
7 "neglect" as:
8 "The persistent or severe neglect of a child, or the
9 failure to protect a child from exposure to any kind of
10 danger, including cold or starvation, or extreme failure
11 to carry out important aspects of care resulting in the
12 significant impairment of the child's health or
13 development, including non-organic failure to thrive."
14 "Emotional abuse" is defined as:
15 "Actual or severe adverse effect on the emotional
16 and behavioural development of a child caused by
17 persistent or severe emotional ill-treatment or
18 rejection. All abuse involves some emotional
19 ill-treatment. This category [it is suggested] should
20 be used where it is the main or sole form of abuse."
21 These are rigorous standards and rightly so. They
22 have to be met in order to justify the interference by
23 the state in family life under Article 8 of the
24 Convention.
25 In considering the action taken by Haringey social
37
1 workers, the Inquiry has to consider the sort of
2 concerns being raised by the North Middlesex Hospital at
3 the time such as Victoria wetting the bed in hospital,
4 her large appetite, the fact she was wearing a dirty
5 dress with no knickers on when she was brought to the
6 hospital, and the master and servant observation to
7 which reference has already been made in closing
8 submissions.
9 Those we suggest are all matters which may amount to
10 evidence that Victoria was suffering significant
11 impairment of her emotional health or development, or
12 persistent or severe emotional ill-treatment or
13 rejection, or extreme failure to carry out important
14 aspects of her care, but they are all capable of other
15 explanations as well.
16 Haringey does not suggest that these were matters
17 which did not require investigation. We say that they
18 were investigated and looked at by Lisa Arthurworrey.
19 Haringey does submit, however, that without a proper
20 clinical opinion from Dr Rossiter or a psychiatrist
21 explaining how these observations satisfied the
22 statutory criteria for taking proceedings or even for
23 including her name on the Child Protection Register,
24 their ability to intervene effectively in Victoria's
25 life at that time using the legal framework was limited.
38
1 This Inquiry cannot proceed on the basis that child
2 protection work does not need to be based on evidence.
3 It does. The evidence has to be cogent enough to
4 persuade a court that the statutory grounds for
5 intervening are proved to the required standard. The
6 Cleveland Inquiry highlighted the damage and injustice
7 caused to children and their families when they were
8 removed from home without there being sufficient
9 evidence to justify doing so.
10 Haringey, like the other authorities involved in
11 this Inquiry, is dealing with exceptionally high levels
12 of need and deprivation. Those social problems will
13 remain, whatever the outcome of this Inquiry.
14 Superficially attractive though it appears, there is no
15 reason to believe that a national agency with the same
16 resources will be any more effective than local
17 authorities in protecting children from significant
18 harm. It will not increase the number of social workers
19 or deal with the salary problems arising from the fact
20 that some parts of the country have much greater social
21 pressures than others and that Haringey is at the top of
22 that scale. The problems of integrating the technology
23 nationally with the police, health, education and social
24 services who would remain liable for other services are
25 formidable.
39
1 The difficulties of maintaining an accurate national
2 database of personal information are experienced already
3 by agencies such as the Inland Revenue, the Benefits
4 Agency and even the Child Support Agency. There are
5 serious disadvantages to a scheme which considers child
6 protection in isolation from the other social problems
7 suffered by the poor and vulnerable or from children
8 with disabilities or who are in need of respite care or
9 who are in long-term care and for whom arrangements have
10 to be made for their adoption.
11 The advantage of local government is that it offers
12 a range of services shaped by the needs of the local
13 community for the management of which its members are
14 accountable to the electorate.
15 Haringey accepts that it should be held to account
16 for the delivery of its services but an inquiry such as
17 this does nothing for morale within the Children's
18 Service nor does it encourage the recruitment of social
19 workers.
20 This Inquiry has damaged confidence in services in
21 Haringey which the Council now has to try to restore.
22 If it has done so fairly or if the Council has brought
23 it on itself, Haringey cannot complain, but in its
24 apparent determination to blame everyone from top to
25 bottom this Inquiry has, we suggest, failed to look at
40
1 the wider context of the work carried out by individuals
2 from all the agencies and has often appeared satisfied
3 with easy point scoring.
4 Haringey welcomed this Inquiry and hoped that it
5 would be able to learn lessons from this fuller
6 investigation into the facts of Victoria's case and the
7 agency's practice. But we fear that the approach taken
8 to the evidence and the procedure it has adopted has
9 severely limited this Inquiry's scope to do so. In
10 particular, we suggest that it has not actually
11 uncovered any significant new facts about Victoria's
12 life and death which were not already in the
13 contemporaneous written material or obtained for the
14 criminal proceedings. Many of the matters on which it
15 has concentrated and which have grabbed media attention
16 have no demonstrable bearing on Victoria's death.
17 The Inquiry and its preoccupation with compliance
18 with procedures has rarely if ever asked the question,
19 "What difference would this have made to what happened?"
20 We give examples in our written submissions of things
21 that we say would not have made any difference. But
22 perhaps more importantly, the atmosphere of blame and
23 criticism in which the witnesses have given evidence
24 means that this Inquiry has lost the opportunity to
25 allow those actually involved in doing the job at all
41
1 levels to offer their reflections in an atmosphere of
2 open minded inquiry on what might have made a difference
3 or how practice might be improved.
4 It has also at times appeared willing to disregard
5 the realities faced by Haringey, the other local
6 authorities and indeed other agencies in dealing with
7 exceptionally high levels of need and deprivation.
8 Those agencies operate as I have suggested under
9 financial constraints, which mean that they do not have
10 sufficient financial and human resources, service
11 provision and adequate housing to meet all the demands
12 made upon them. Recommendations which do not take this
13 fully into account are likely to be at best unworkable
14 and at worst completely valueless.
15 This Inquiry has looked in intense detail at every
16 aspect of Victoria's case. In opening I urged you of
17 the need to remind yourselves repeatedly that this was
18 not the only case with which those involved had to deal.
19 Many of those cases about which this Inquiry will hear
20 nothing will have presented as more grave, urgent or
21 pressing than Victoria's at the time. In 1999 Haringey
22 dealt with around 4,000 referrals concerning children of
23 which about 10 per cent were child protection referrals.
24 Mr Garnham too said in opening that we must remember
25 the very many cases in which the present arrangements
42
1 work effectively from the efficient and timely
2 intervention by social workers, police officers and
3 hospital staff.
4 We would do children like Victoria no favours if we
5 demonise entire professions as we seek to understand and
6 remedy the weaknesses and deficiencies highlighted by
7 a single case. The Inquiry has not appeared to
8 acknowledge this truth in its questioning of a single
9 witness from that day to this.
10 There is very good social work going on in Haringey.
11 Some of it was highlighted by the SSI report. Hundreds
12 of children and their families are helped every month by
13 the provision of care and services which go unsung and
14 ignored.
15 We do recognise that Haringey's front line social
16 workers work under intense pressure. That pressure has
17 been increased by the criminal trial and by the hostile
18 publicity which followed it and by the publicity
19 surrounding this Inquiry.
20 I said in opening that the strong emotions that
21 a case like this generates lead inevitably to a search
22 for scapegoats and social workers are an easy target.
23 There can hardly have been a director of social services
24 in the country who does not know that Victoria's tragedy
25 could have happened in his or her patch and given thanks
43
1 it did not. There is a very real danger that with its
2 narrow focus on Victoria and what might have protected
3 her, this Inquiry will result in other cases being
4 insensitively handled and other children who might
5 safely have remained with their birth families being
6 taken into care.
7 Because Victoria was never in care this Inquiry has
8 not had to evaluate the damage done to children by the
9 care system in itself but social workers do in deciding
10 whether or not to take action.
11 There have been enquiries into the abuse suffered by
12 children in public care as well as by those in the
13 family home. I urged in opening that this Inquiry
14 should not judge the conduct of those involved with
15 hindsight as previous inquiries have often done, because
16 it means that findings are made on a basis which is
17 divorced from the reality of front line child protection
18 work.
19 This Inquiry still does not know what was actually
20 happening to Victoria at home between August and October
21 1999 when Miss Arthurworrey was visiting. It is widely
22 assumed outside this Inquiry that the abuse on the scale
23 revealed by the post mortem was occurring throughout
24 that time. That has not been substantiated by evidence.
25 You should not assume that it was or that physical signs
44
1 indicative of abuse either were or should have been
2 apparent to Miss Arthurworrey during her visits. In
3 contrast with the position before her hospital
4 admissions, there is no evidence from other witnesses,
5 and we list them, who saw Victoria during this period
6 that they saw any marks or injuries on Victoria at all.
7 There was nothing in their dealings with Mrs Kouao or
8 Mr Manning which should have alerted the social workers
9 to the possibility that they were dealing with people
10 who were capable of the systematic and sadistic cruelty
11 towards a child which the post mortem was to reveal.
12 After Mrs Kouao had given her evidence, Imran Khan,
13 Mr and Mrs Climbie's solicitor, is reported to have said
14 in their press conference that nobody from the public
15 services spending any time with Kouao should have been
16 hoodwinked by her. Haringey disagrees with that
17 superficial judgment. At this Inquiry her assertions
18 are judged with the full benefit of hindsight knowing
19 that she is a convicted murder.
20 We think that that remark overlooks the fact that
21 Mr Garnham had available to him a wealth of material
22 collected since Victoria's death to contradict almost
23 every point made by Mrs Kouao in her evidence, but none
24 of that material was available to the social workers at
25 the time. Mrs Kouao gave them as she gave every other
45
1 agency a plausible but completely false account of her
2 and Victoria's history and circumstances, but she gave
3 them little reason to suspect that that was the case.
4 The staff of any agency providing services to the
5 members of the public work on the basis that they are
6 being given a truthful account of the history or
7 relevant facts until something is said or done by the
8 person they are dealing with which casts doubt on that.
9 Social workers are used to challenging deception,
10 for example about how injuries are caused to a child.
11 They are not used to dealing with wholesale deception
12 which includes fictitious personal details like being
13 the mother of a child who is not hers, facts that appear
14 to be substantiated by a fake passport and her
15 immigration papers. The normal places that Mrs Kouao's
16 plausible words would show up as untrue were not
17 available in her case. There was no immediate family,
18 no neighbours or friends who knew them, no school and no
19 GP records, the places that deception of this order
20 might be found out.
21 Interestingly neither Mrs Kouao nor Mr Manning seek
22 to blame Lisa Arthurworrey or to hold her or the
23 agencies responsible for what happened to Victoria.
24 Mr Manning accepted that it is he and Mrs Kouao who are
25 responsible for Victoria's death, not the doctors, not
46
1 the police, not the social workers.
2 Haringey's position in relation to this part of the
3 Inquiry is this. It remains of the view that I stated
4 in opening, that we cannot now say what would have
5 happened if the Council's workers and other agencies had
6 acted differently, but given what we now know, it is
7 likely that the only action that would have protected
8 Victoria was removing her from her home. It remains to
9 be persuaded otherwise. The question therefore remains
10 whether at any stage Haringey had sufficient evidence,
11 not merely to justify bringing emergency or care
12 proceedings but to satisfy a court that Victoria should
13 be removed from her home. Haringey still believes that
14 it did not.
15 Haringey still emphatically rejects on behalf of its
16 staff that they were given clear evidence by others of
17 non-accidental injury or serious neglect of Victoria
18 which they failed to investigate or act upon.
19 As far as Haringey is concerned, its child
20 protection, case recording and supervision procedures
21 were sound and if followed would have raised the
22 standard of some of the work done in Victoria's case.
23 Equally, the Council would not seek to defend the
24 practices which some staff concerned have admitted or if
25 the Inquiry finds that they did occur. In particular,
47
1 it considers the following indefensible: Those
2 responsible for supervision not familiarising themselves
3 with relevant case files; those responsible for
4 allocation or closure of case files not reading them
5 before doing so; the process of allocation which just
6 placed the file on the desk of a member of staff or
7 which did not involve some assessment of whether the
8 case was suitable for a particular social worker to
9 handle. There is a dispute about whether that happened
10 in Victoria's case. If you find it did, Haringey does
11 not seek to defend it.
12 Nor does it seek to defend staff who say they did
13 not read the guidance which they received but put it in
14 a drawer.
15 There are as you will appreciate a number of
16 disputes of fact between members of Haringey staff and
17 former staff about the handling of Victoria's case which
18 the Inquiry will have to resolve. Haringey has not
19 taken sides in those disputes between staff, most of
20 whom are now separately represented, and it does not do
21 so now.
22 Haringey agrees with Miss Hoyal that the best
23 contemporaneous evidence of what went on in Haringey is
24 provided by Lisa Arthurworrey's detailed notes. Where
25 there is a conflict between her notes and the evidence
48
1 of other witnesses, whose account is unsubstantiated by
2 their own contemporaneous record, we say that
3 Lisa Arthurworrey's account is to be preferred.
4 Crucial to a proper evaluation of Haringey's
5 handling of Victoria's case is the information available
6 to the social workers from the staff at North Middlesex
7 Hospital. It is our submission that no other part of
8 the evidence looks more different now from the way in
9 which it was put by Mr Garnham in opening. The records
10 from the North Middlesex Hospital give a picture which
11 is largely consistent with what Haringey was being told
12 by Dr Rossiter and the nursing staff at the time. It
13 does not include many of the matters which subsequently
14 came to light and indeed does not include much of the
15 information about more serious abuse and non-accidental
16 injury.
17 On this point we adopt many of the points made by
18 Miss Hoyal, if not all of them. Had Haringey staff been
19 given clear medical evidence which stated that either
20 the burns or the other injuries to Victoria were not
21 accidental, there is every reason to believe that
22 Victoria's case would have been conducted differently.
23 They were not. The witness statements prepared almost
24 two years later with knowledge of the circumstances of
25 Victoria's death by the nursing staff are unreliable and
49
1 of no assistance to you in reaching your conclusions.
2 Much of that evidence is inconsistent. It is
3 impossible to believe that the level of serious concerns
4 about physical injuries which some of them now claim to
5 have had went unrecorded or unmentioned at the time.
6 You cannot, as you have been urged to do, regard them as
7 a valuable source of information which was not tapped at
8 the time by social services. The impression created
9 particularly by Dr Rossiter during the criminal trial
10 that the hospital staff had all these concerns about
11 Victoria which were not acted upon by social services,
12 despite them being told about them, is in Haringey's
13 submission quite false.
14 We too have set these out in detail in our written
15 submissions. It is now clear as I suggested that the
16 picture in the medical notes made at the time about
17 Victoria is closer to the reality than any of the
18 versions given by Dr Rossiter either in the criminal
19 trial or in her witness statements, which we say were
20 coloured by hindsight or, as she prefers to term it,
21 "clouded by rethinking". Those notes correspond far
22 more closely to what Dr Rossiter and Nurse Quinn
23 actually told Lisa Arthurworrey at the time.
24 The crucial points of her evidence are that she
25 never fully examined Victoria herself during her stay in
50
1 the North Middlesex Hospital, nor did any other
2 paediatrician. Secondly, neither she nor any member of
3 the paediatric or nursing staff ever took a full history
4 from Victoria or from Mrs Kouao about how she came by
5 her injuries. Although they had the information from
6 the outset that Victoria had had a previous admission to
7 the Central Middlesex Hospital, neither she nor any
8 other member of the medical staff asked to see those
9 notes or discuss the details of that admission with
10 anyone at that hospital.
11 By 1st August 1999 when she amended the child
12 protection form, her clinical opinion was that the burns
13 were likely to have been self-inflicted. Nowhere is it
14 documented that she considered the burns to be evidence
15 of either emotional abuse or neglect.
16 When she amended those child protection forms she
17 did not say that there was suspected physical abuse
18 based on the old injuries. Her documented concerns
19 about Victoria on that date do not include
20 non-accidental injury. Her concerns alleged later about
21 looped wire marks are not documented anywhere in the
22 medical notes at the time.
23 Dr Rossiter had previously claimed that she had done
24 all she could to bring her concerns to the attention of
25 social services. In her oral evidence she was asked by
|
