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Paragraphs: 8.80 - 8.92
| 8.93 - 8.102
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8.80
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Viewed as a whole, Ms Johns's role in Victoria's case was limited
to that of a 'postbox' for information passing between the hospital
and Haringey Social Services. Ms Johns's description of herself
as a "conduit of information" is difficult to challenge and I have
to question whether that can be a sensible use of an experienced
social worker's time.
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8.81
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Having heard all the evidence, I fully accept that in her clear
and unambiguous referral to Ms Rodgers on 27 July 1999, and in the
information she conveyed to the strategy meeting on 28 July, Ms
Johns provided Haringey Social Services both orally and in writing
with the fullest details she possessed at the time. I am left in
no doubt that if Ms Johns had been given the full picture by the
North Middlesex Hospital staff, as they described to me in their
evidence, she would have recorded it and passed it on to Haringey.
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8.82
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The inadequacies in the initial assessment may in part be attributable
to the fact that the Enfield-Haringey protocol in place at the time
stipulated the following two options in relation to Haringey child
protection cases:
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Where there are clear concerns of child protection needs in a case,
Enfield hospital social workers find that usually Haringey Social
Services respond immediately, whether the case is known to them
or not. If they cannot respond immediately they agree a plan of
action with the team manager.
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Where child protection needs are not clear but are suspected, if
the case is not known to Haringey, the hospital social worker will
do an initial assessment in consultation with the duty team manager,
ie getting any background information. This assessment will then
be discussed with the duty team manager and, if agreed that it is
clearly child protection, the district team will continue the work.
If hospital social workers feel it is child protection and the district
does not, the team leaders of hospital and district need to discuss.
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8.83
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On 26 July 1999, having established that Victoria was unknown to
Haringey, Ms Johns had sufficient information in relation to the
scalding incident to firmly put Victoria's case into the second
of these two protocol options; in other words child protection needs
were not clear but suspected. When asked, Ms Johns accepted that
she had responsibility for Victoria from 3.15pm on 26 July - though
in her mind the responsibility went no further than seeking to clarify
the referral. Counsel to the Inquiry then pressed her as to which
child protection protocol option she thought the case fell into
at that stage. Ms Johns was less than clear in her response. I have
no such doubts.
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8.84
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Ms Johns had already conceded that she did not, contrary to the
advice she gave to the nursing and medical staff on Rainbow ward
in her memo, require clear specification by a doctor of non-accidental
injury and confirmation that the carers had been told of a referral
to social services before she could become involved. Indeed, arguably
the whole purpose of the second option, the 'not clear' category,
was to kick-start an initial assessment at the earliest opportunity
(in conjunction with Haringey) in order to firm up the child protection
concerns and assess the risk to Victoria.
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8.85
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Admittedly, through no fault of Ms Johns, the child protection
process had already got off to a false start. Dr Forlee's first
discussion with Haringey Social Services on the evening of 24 July
1999 had prompted no immediate investigative action. Ms Johns, however,
soon had an opportunity to get matters back on track. In my view,
the time she spent from 26 July onwards - reminding hospital staff
of the procedures to be followed - would have been better spent
talking to Victoria and Kouao and ascertaining the views of the
medical and nursing staff responsible for Victoria's care. The only
advantage in pressing for the proper completion of the child protection
forms with a clear diagnosis of child protection, from Enfield's
perspective, was that it would move Victoria's case into the first
option, and provided that Haringey accepted the case and could respond
immediately, which they did, responsibility for undertaking any
assessment would pass to them. As a result, any obligation on an
Enfield hospital social worker to do more than the most rudimentary
first checks would have disappeared.
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8.86
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In the 24 hours or so that Victoria's case rested with Ms Johns,
and despite there being no clear child protection concerns, Ms Johns
did little more social work investigative tasks than check whether
Victoria was known to Haringey, speak to medical staff, read Victoria's
case notes on the ward and consult with her manager. There were
no phone calls to any other agencies. For example, a phone call
to the Central Middlesex Hospital would have opened a whole trail
of inquiries leading back to Brent and Ealing Social Services. However,
Ms Johns thought these were part of the secondary checks that Haringey
would perform. The fact they did not is clearly not the responsibility
of Enfield Social Services, but once again an opportunity to pull
together information known about Victoria by those whose remit it
was to do so, and for however short a period, was lost.
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8.87
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When asked what she thought was meant by an 'initial assessment',
Ms Johns was anything but clear because there was no clear definition
at the time:
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"At the time ... it was very unclear ... initial assessment
could just simply mean gathering the information that was available
and clarifying from that what kind of referral there was or was
not, or perhaps even interviewing a parent ... You might actually
be assessing what kind of case this is, because if child protection
needs are not clear, that does need to be clarified at some point.
Before the case can be passed to Haringey properly and appropriately,
that does need to be clear."
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8.88
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Both Ms Carr and Ms Lipworth supported Ms Johns's notion that it
was sufficient as of 26 July 1999 to do no more than clarify the
kind of referral Enfield was dealing with before passing it on to
Haringey. Enfield's own management review of Victoria's case took
a different view:
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"It must be pointed out that an initial assessment would normally
include gathering background information and the Child Protection
Guidelines for North Middlesex Hospital state that a hospital should
do preliminary checks on all cases."
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8.89
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However, while the author of that report conceded it was acceptable
for those initial checks, which according to the guidelines ought
to include health visitor, GP, police child protection team and
school if relevant, to be undertaken by Haringey, it was the author's
clear opinion that an initial assessment would normally include
contact with a parent.
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8.90
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The doubts expressed by many to the Inquiry about what constitutes
an initial assessment will hopefully be remedied with the full-scale
implementation of the new National Assessment Framework. For any
experienced social worker in the summer of 1999 to believe that
undertaking an initial assessment - or as Ms Johns would have it,
clarifying the nature of a possible child protection referral -
could be done without seeing and speaking to the child, the child's
carer and the ward staff who had daily care of the child, is difficult
to credit.
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8.91
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While responsibility for sharing medical information and other
observations about Victoria during her stay on the ward clearly
rested with the hospital, it seems likely that conversations with
the ward and medical staff might have uncovered much that the hospital
failed to pass on.
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8.92
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Enfield accepted that the 'initial assessment' they carried out
while Victoria was in hospital was limited, but they submitted that
in the circumstances of the case being accepted as a child protection
referral by Haringey within 26 hours of Ms Johns receiving the referral
and while Victoria was safe in hospital, Ms Johns's actions were
quite appropriate. Had Victoria been about to be discharged, or
had Haringey responded differently and not accepted the case, Ms
Johns said she would have investigated further. I do not accept
this. Even at the most basic level Ms Johns did not take the basic
steps necessary to ensure that Haringey staff received the fullest
information.
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Paragraphs: 8.80 - 8.92
| 8.93 - 8.102
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8.93
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Enfield has also accepted that none of its social workers spoke
to Kouao while Victoria was in hospital, but again claim that the
window of opportunity to do so was small and they question what
relevance such an interview would have had.
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8.94
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Ms Johns said in evidence, and the records confirm her understanding
of the conversation with Ms Rodgers on 27 July 1999, that she would
await contact from Haringey before interviewing Kouao. However,
as has been pointed out already in paragraph 8.54, it was not Ms
Johns's expectation that she would have to interview Kouao once
Haringey had accepted the case, unless this had been negotiated
between her and Haringey. In assessing the failure by an Enfield
social worker to interview Kouao, the following ought to be borne
in mind.
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8.95
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Although the North Middlesex Hospital guidelines say it is sufficient
to discuss with the consultant paediatrician or registrar when the
parents/carers should be seen and by whom, the Enfield Area Child
Protection Committee guide to inter-agency procedure and practice
for professional staff states:
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"Parents need to be clear from the start what procedures are
being involved, who makes what decisions, the statutory powers,
duties and roles of the agencies involved and their own legal rights.
This should all be explained by the social worker."
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8.96
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By the time of the strategy meeting on 28 July 1999, neither Ms
Johns nor any of the medical staff involved in Victoria's care had
spoken to Kouao for the purpose of eliciting her explanation for
the old marks found on Victoria's body and observing her reaction
to the concerns felt by the hospital. Information of this nature
may have proved highly valuable for the strategy meeting. Ms Johns
was aware, as a result of her dealings with the case so far, that
Kouao had yet to be spoken to for these purposes. In my view, she
should have done so herself in time for the strategy meeting.
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8.97
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Finally I come to Ms Johns's decision neither to see nor speak
to Victoria. Ms Johns visited Rainbow ward on five different occasions
but made no attempt to speak to Victoria. She gave several reasons
why she did not. Ms Johns was not alone in expressing reservations
about speaking to a child in Victoria's circumstances. Several witnesses
said they had seen guidance that said they must be cautious about
contaminating evidence or forming any kind of relationship with
a child. Ms Johns was the person with a vital role in communicating
the concerns of the hospital staff to Haringey Social Services in
as comprehensive and helpful a manner as possible. In the situation
in which Victoria found herself, this was a more important consideration
than the possible 'contamination' of any investigative interview
that might prove necessary. I note that by this point, in any event,
Victoria had already been spoken to by a significant number of other
people, including Kouao. In such circumstances, it is difficult
to see what further damage to the investigative process Ms Johns
might have done.
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8.98
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It is agreed that, as of 27 July 1999, Haringey had accepted full
case responsibility for Victoria and that the ball was firmly in
their court when it came to arranging a formal interview, which
complied with the Home Office Memorandum of Good Practice (a 'memorandum
interview') jointly with the police. That this should be done strictly
within the good practice guidelines is not in question. However,
those guidelines do not prevent a simple exchange of conversation
with the child, the content of which should be properly recorded.
Seeing, listening to and observing the child must be an essential
element of an initial assessment for any social worker, and indeed
any member of staff routinely working with children, and this can
be of great importance when dealing with child protection cases.
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8.99
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Ms Johns should have had such a conversation with Victoria on 26
July 1999, when she had clear case responsibility. She offered two
explanations for her failure to do so. First, that she did not wish
to "form a relationship" with Victoria. Second, that she did not
wish to compromise any future investigation. I reject these. The
social worker's role in these circumstances is simply to listen
without interruption and to record and evaluate what has been said.
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8.100
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Enfield went on to suggest that even if Ms Johns had spoken to
Victoria, since she had said nothing of significance about her circumstances
to the numbers of nurses and others with whom she had had contact
on a daily basis in the ward, there was little likelihood of Ms
Johns discovering anything of forensic significance. It is a matter
of speculation as to whether that is true, but by not seeing and
speaking to Victoria Ms Johns passed up an opportunity to form her
own impressions about this little girl, and it is these impressions
which must go to the core of what a social work assessment is about.
Therefore, I make the following recommendation:
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Recommendation
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Hospital social workers must always respond promptly to any referral
of suspected deliberate harm to a child. They must see and talk
to the child, to the child's carer and to those responsible for
the care of the child in hospital, while avoiding the risk of appearing
to coach the child.
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8.101
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Finally, Enfield concluded: "The reality is that had Victoria been
seen or interviewed by a Haringey social worker on say 29th July
no one would be critical of Ms Johns for not seeing her before that."
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8.102
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Sadly this seems to miss the point entirely. Each individual practitioner
must accept accountability for their own practice. They have a job
to do and cannot put their trust in what might follow by others
to justify their own actions or inaction.
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