|
|
|
Paragraphs: 8.32 - 8.38
| 8.39 - 8.48 | 8.49 - 8.53
| 8.54 - 8.65 | 8.66 - 8.72
| 8.73 - 8.79
|
|
|
|
|
|
8.32
|
On 26 July 1999, two days after Victoria was admitted to the North
Middlesex Hospital, Nurse Sharon Jones of Rainbow ward referred
her to the Enfield hospital social work team.
|
|
8.33
|
Ruth Warne took down the details of the referral at 3.15pm and
completed an initial contact sheet in the name of 'Anna Kovao' and
wrote the address as 267 Somerset Gardens, Creighton Road, London
N17. She recorded that Victoria had been admitted on 24 July 1999
with burns. She was suffering from scabies and had poured water
on her head to stop the itching. When nurses bathed her they noticed
marks on her back and arms. Once child protection forms had been
filled out the referral was passed to Ms Johns.
|
|
8.34
|
Had Ms Johns or any of the other hospital social work team attended
the weekly psychosocial meeting earlier in the day they would have
learned something of the medical team's concerns about Victoria
from Dr Rossiter, the consultant paediatrician, and Dr Justin Richardson,
the paediatric registrar, even before the referral had been made.
The psychosocial notes for that day's meeting question whether the
scalding injuries were non-accidental and register the long time
delay between the scalding and Victoria's presentation to the accident
and emergency department. Certainly, Ms Johns or her colleagues
would have had the opportunity to explore those concerns directly
and question the extent to which non-accidental injury was suspected.
It is possible they would also have seen the body maps, which Dr
David Reynders, the paediatric senior house officer, said he prepared
in time for the meeting. However, for the reasons already given,
Enfield hospital social workers had ceased attending these meetings
some 18 months earlier.
|
|
8.35
|
Instead, Ms Johns telephoned Nurse Jones who merely repeated the
details recorded by Ms Warne on the initial contact sheet. In her
action sheet Ms Johns recorded that following the child protection
meeting there was a concern. However, according to Nurse Jones,
the completed child protection forms did not specify non-accidental
injury.
|
|
8.36
|
This was the first of a number of file notes prepared by Ms Johns
in Victoria's case and I give her credit for the quality of her
clear, accurate and comprehensive casework recording throughout.
Indeed, given the lack of any comparable notes produced at the time
by the North Middlesex Hospital, I have placed heavy reliance on
Ms Johns's notes and her evidence arising from them to provide an
account of the information exchange that took place between the
hospital and social services during the first few days of Victoria's
admission.
|
|
8.37
|
Ms Johns advised that a doctor speak to Kouao to inform her that
a referral was being made to social services and to seek her explanation
for the marks on Victoria's body. She also advised that the child
protection forms should be reviewed in order to specify whether
any of the injuries observed were believed to be non-accidental.
She did not consider it appropriate at this stage to go up to the
ward to see or speak to Victoria. Had Victoria been an Enfield child,
Enfield's child protection procedures state quite clearly the child
should be seen by the social workers as a "matter of urgency". However,
when asked why the same would not apply to Victoria, Ms Johns said:
|
|
|
"It would be inappropriate for a social worker to go marching
in ... you could not. You would have to ask parents' permission
to speak to a child anyway. Talking to a child could prejudice,
possibly contaminate evidence that the police may want later for
criminal proceedings."
|
|
8.38
|
I do not share Ms Johns's view and these were clearly not concerns
that Enfield considered relevant when drafting their own procedures.
I return to this issue of speaking to Victoria later in paragraph
8.49 and the wider implications later in this Report.
|
|
Paragraphs: 8.32 - 8.38
| 8.39 - 8.48 | 8.49 - 8.53
| 8.54 - 8.65 | 8.66 - 8.72
| 8.73 - 8.79
|
|
|
|
8.39
|
That same afternoon at about 3.45pm, Ms Johns faxed the duty social
worker at Haringey's North Tottenham District Office a standard
request for any information known about "Anna Kovao". Although Ms
Johns was keen for the doctors at the North Middlesex Hospital to
firm up their view as to whether Victoria's burns were accidental
or not, she certainly had not ruled out non-accidental injury when
making her first contact with Haringey Social Services.
|
|
8.40
|
She relayed her reason for the request as follows:
|
|
|
"Child admitted on 24/7/99 with (?) accidental burns to head
and face when she poured hot water over her head to stop itching
caused by scabies. Other marks have been noted on her back and the
origin of these will be checked out."
|
|
8.41
|
At the time Ms Johns said, "It was the very beginning of a child
protection referral that I saw here." However, she was uncertain
whether she had enough information to convey to Haringey that this
case warranted a child protection investigation. In short, on 26
July1999 Ms Johns said she did not know whether there were suspected
child protection concerns that would have required her to do an
initial assessment of Victoria in accordance with the agreement
between Haringey and Enfield.
|
|
8.42
|
Nonetheless she marked the fax as urgent and asked for a reply
"by the next day, if possible". In fact, according to her file note,
Ms Johns received a phone call from Anil Nair at the North Tottenham
District Office, although no copy of Ms Johns's fax or any record
of Haringey's response appears on the Haringey case file. According
to Ms Johns, she was told that "the client" was not known to Haringey
Social Services. This was clearly a mistake for, albeit unknown
to Mr Nair, Dr Simone Forlee had already contacted the out-of-office-hours
Haringey social work team on 24 July 1999 to talk about Victoria's
case, and to let Haringey know that she had been admitted to the
hospital.
|
|
|
|
8.43
|
Early the next morning, 27 July 1999, Ms Johns took a call from
Nurse Sue Jennings who was checking up on the action that social
services were taking in relation to Victoria. Ms Johns explained
to Nurse Jennings, as she had previously to Nurse Jones, that social
services would not take any further action, which in Victoria's
case meant making a referral to Haringey, until they had a clear
diagnosis of non-accidental injury and the parents had been informed
of social services' involvement. When questioned, Ms Johns accepted
there was in fact no procedural hurdle that required any such preconditions
before she could take action. Nor was she prevented from doing so
because the relevant correct child protection boxes on the child
protection forms had not been ticked. However, it remained her view
the box marked "I wish to await further information before committing
myself" that Dr Forlee had ticked on 24 July was not good enough.
She told the Inquiry, "That should never exist, that box. We can
do nothing with that and I have always had a problem when that box
is filled in."
|
|
8.44
|
After updating her team manager, Ms Lipworth, Ms Johns agreed to
send a memorandum to the sister in charge of Rainbow ward and copied
it to Dr Maud Meates, the admitting consultant, repeating the advice
she had given to Nurse Jennings. She delivered the memo to the ward
nurse in charge by hand. In support of what Ms Johns understood
to be the correct procedure, she attached to her memo a copy of
the page in the social work department section of the North Middlesex
Hospital child protection procedures. These require the examining
paediatrician to specify whether the case is one of child protection
or not, and to advise the social worker of who has informed the
parent(s) that a referral has been made to social services. However,
Ms Johns accepted the procedures did not suggest, as implied by
her memo, that, in the absence of both of these, social services
could do nothing more.
|
|
8.45
|
In her memo she stated she had made preliminary checks and Victoria
was not known to either the hospital social work team or Haringey
Social Services. She also wrote, on the basis of the box on the
child protection form ticked by Dr Forlee, that she understood 'non-accidental'
injury had not been suggested in Victoria's case. This observation
was to prove remarkably at odds with the observations of Victoria's
condition over the previous three days from the staff on Rainbow
ward.
|
|
8.46
|
Ms Johns did not have to wait long for the confirmation of non-accidental
injury that she was looking for, although it was not in relation
to the scalding incident. That same morning, Dr Forlee, the senior
house officer who had first admitted Victoria on 24 July, telephoned
Ms Johns. Dr Forlee told her that when she (Dr Forlee) had completed
the child protection forms she had been unsure whether the facial
burns were non-accidental. However, other concerns had emerged.
Ms Johns recorded these as follows:
|
|
"-
|
Anna has old scars all over her body. A diagram has been made.
The marks resemble the shape of a belt buckle
|
|
-
|
A skeletal survey has been carried out - results are not yet known
|
|
-
|
Concerns regarding interaction with mother. Anna wet herself when
mother came even though she had been dry all day (bed wets at night),
she seems on edge when mother visits, she was described by the ward
staff as seeming to 'jump to attention' when her mother came
|
|
-
|
On admission Anna was unkempt in a dirty dress, with no underwear.
Mother was well kempt
|
|
-
|
Mother has not brought any clean clothes for Anna since her admission."
|
|
8.47
|
Once again Ms Johns said she told Dr Forlee that the child protection
forms would need to be amended to reflect these new concerns and
that the parents needed to be told that there would be a referral
to social services. Dr Forlee agreed to let Ms Johns know when this
had happened and she (Dr Forlee) thought most likely it would be
the next day.
|
|
8.48
|
By now Ms Johns was clear there were child protection concerns.
Ms Johns's understanding of the agreement with Haringey was that
she would only be expected to complete an 'initial assessment' of
Victoria if Haringey could not respond immediately, and only then
by agreement with Haringey.
|
|
Paragraphs: 8.32 - 8.38
| 8.39 - 8.48 | 8.49 - 8.53
| 8.54 - 8.65 | 8.66 - 8.72
| 8.73 - 8.79
|
|
|
|
8.49
|
Following her phone conversation with Dr Forlee, Ms Johns paid
her second visit to Rainbow ward in connection with Victoria's case.
Victoria was pointed out to Ms Johns at a distance but Ms Johns
did not speak to her, despite what she had learned from Dr Forlee.
This was not an oversight. She told the Inquiry, "I made a deliberate
decision not to see Victoria". She gave a number of reasons for
not doing so:
|
|
|
"For one, there was no parental permission for any social worker
to see this child. The parent had not even been told of concerns
and also I would not wish to prejudice any investigation given that
there was a possibility that a crime had been committed and this
little girl was injured."
|
|
8.50
|
She was also aware that English was not Victoria's mother tongue.
In her view, "no social worker would have interviewed either the
mother or the child without a French-speaking interpreter". Yet
again, Ms Johns's decision not to speak to Victoria at the earliest
opportunity, and certainly before the referral to Haringey Social
Services, was in my opinion fundamentally wrong in principle and
practice. I shall return to this at some length later.
|
|
8.51
|
Instead she discussed Victoria's case with Nurse Jennings and read
the case notes which she summarised in the social work file. In
addition to Kouao's explanation for the scalding injury and the
concerns Dr Forlee had already conveyed by phone that morning, Ms
Johns also recorded the following facts (without pause for question):
|
|
•
|
Kouao's husband had died in June 1994.
|
|
•
|
Kouao herself was born in 1966 and yet claimed to have four other
children the eldest of whom was 24 [ thus making Kouao nine
years old at the time she gave birth to her eldest child ].
|
|
•
|
Kouao and Victoria had been in the country four months.
|
|
•
|
Kouao had visited Victoria every day but for short periods as she
was working.
|
|
•
|
Kouao was in the UK on study leave for two years having left behind
a job in France as an airport manager.
|
|
8.52
|
Ms Johns updated her team manager and they agreed that she should
make a formal referral to Haringey Social Services and that Kouao
would have to be interviewed. Ms Johns made the referral by telephone
and spoke to Caroline Rodgers in the North Tottenham District Office
at around 4.30pm on 27 July 1999.
|
|
8.53
|
It is vitally important that when a social worker from one local
authority transfers responsibility for a case in this manner that
the receiving authority is clear what its responsibilities are.
The Enfield child protection procedures required the manager in
Ms Lipworth's position to formally agree the transfer of responsibility
with the relevant service manager in Haringey. In Victoria's case
this was not done. There is a clear danger when cases are transferred
without clear and thorough procedures being followed, that confusion
may arise over who is responsible for what. In an effort to avoid
such confusion arising in the future, I make the following recommendation:
|
|
|
Recommendation
|
|
|
Where hospital-based social work staff come into contact with
children from other local authority areas, the directors of social
services of their employing authorities must ensure that they work
to a single set of guidance agreed by all the authorities concerned.
|
|
Paragraphs: 8.32 - 8.38
| 8.39 - 8.48 | 8.49 - 8.53
| 8.54 - 8.65 | 8.66 - 8.72
| 8.73 - 8.79
|
|
|
|
8.54
|
Ms Rodgers's record of what she was told, namely a summary of Victoria's
presenting problems on admission and the ward medical team's subsequent
concerns for her, appears to be a fair reflection of what Ms Johns
knew at the time and was recorded in her own case file notes. Although
Ms Johns said she also agreed with Ms Rodgers to await further contact
from Haringey before interviewing Kouao, she did not expect to do
this now that the case had been formally transferred to Haringey.
In fact, Ms Johns expected to do nothing more at all in Victoria's
case unless it was by prior negotiation, with Haringey as the lead
investigating authority.
|
|
8.55
|
Ms Johns updated both Dr Saji Alexander, the paediatric registrar,
and Nurse Jennings about the referral to Haringey Social Services
before learning from Shanthi Jacob, duty senior manager at North
Tottenham District Office, that a strategy meeting had been arranged
for 2.30pm the next day at the social services office, and not the
hospital as required by Haringey's own child protection procedures.
|
|
|
|
8.56
|
In her written statement, Ms Johns said that a hospital social
worker would not normally attend Haringey meetings unless a manager
thought it essential. When Ms Jacob's invitation arrived Ms Lipworth
was not on site. Nonetheless Ms Johns agreed to go without first
seeking permission because she said she "felt particularly concerned
for Victoria's safety and well-being". She believed she told Ms
Jacob words to the effect that she would be lucky to get any medics
to attend, although she said it was only later that she learned
that Dr Rossiter would not be able to go. According to Ms Johns,
that made it "even more crucial that I attend in order to pass all
the medical forms to Haringey Social Services".
|
|
8.57
|
Ms Johns said she was not aware it was part of Haringey child protection
procedures that strategy meetings involving Haringey children admitted
to hospital should be held in the hospital. She simply recollected
that Dr Rossiter said she had an agreement with Haringey that it
should be so. Ms Johns's lack of awareness of an important requirement
of the Haringey procedures highlights the need for a single, clear
set of procedures and reinforces the recommendation I made at paragraph
8.7 above.
|
|
8.58
|
In oral evidence, Ms Johns said she asked Ms Jacob if the strategy
meeting venue could be changed to the hospital but was told by Ms
Jacob, after checking with her manager, that the venue had to stay
as planned originally.
|
|
8.59
|
It was Dr Rossiter who told Ms Johns in a telephone conversation
that she would not be able to attend the Haringey strategy meeting.
According to Ms Johns's note of their conversation they discussed
Victoria, and Dr Rossiter queried whether there were signs of anxious
attachment. She told Ms Johns she thought at the very least there
was neglect, probable emotional abuse and possibly physical abuse.
She also mentioned in passing that Kouao visited Victoria late at
night and the photographs that had been ordered had now been taken.
In fact the photographs were not taken until 29 July 1999. I know
of no basis for Dr Rossiter's belief that the photographs had been
taken. She also gave Ms Johns the details of Dr Meates, the consultant
paediatrician with day-to-day responsibility on the ward but not
child protection responsibility. Ms Johns was told that the play
therapist on Rainbow ward, Noelle O'Boyce, had also made some observations
but Ms Johns did not pursue this as part of any 'initial assessment',
either with Dr Rossiter or Ms O'Boyce, because Haringey had accepted
responsibility for the case. She said, "All the action was now their
action and would have had to be negotiated with me." Dr Rossiter
could not recall this conversation but she did not have any note
to contradict what Ms Johns recorded as having passed between them.
|
|
8.60
|
Ms Johns believed, though she no longer had any independent recollection
of this, that she and Dr Rossiter would have discussed updating
the child protection forms. It was not unreasonable for Ms Johns
to have focused so much attention on the proper completion of the
child protection forms. The child protection forms she had seen
on the ward at that time related only to the scalding injuries for
which Victoria had been admitted. The hospital medical team was
yet to confirm for Ms Johns whether they believed those burns injuries
were non-accidental. In addition, the ward staff had now raised
new concerns, conveyed to Ms Johns by Dr Forlee, on the basis of
marks seen on Victoria's body which appeared to bear no direct relationship
to the scalding incident. Ms Johns had yet to see any new child
protection forms completed in respect of these concerns and this
was the position she found herself in when she attended the strategy
meeting at the North Tottenham District Office on 28 July 1999.
|
|
8.61
|
On her way to the meeting, Ms Johns visited Rainbow ward a third
time, to collect and photocopy the child protection forms, the accident
and emergency card and the body "diagrams". She did not have the
skeletal survey results or the photographs because they were not
yet available. In fact, contrary to the information she had been
given by Dr Rossiter, Ms Johns noted after her visit to the ward
that the whole-body photographs had still to be taken. She did not
have any of the information from the nurses' critical incident log
because she did not know of its existence, nor was she aware of
the significance of that document.
|
|
8.62
|
If Ms Johns had looked at the log on this occasion, the only additional
information she would have gleaned was that Kouao and a gentleman
had visited Victoria at about 10.30pm, had woken Victoria from her
sleep and that Kouao kept pointing a finger to her. It was also
on the critical incident log that Nurse Jennings observed on 27
July 1999 that 'Anna' would like to communicate and that a French
link worker would be a good idea. The important point is that without
looking at the log Ms Johns did not know whether she was missing
critical pieces of information.
|
|
8.63
|
Apart from the critical incident log, there were significant pieces
of information contained elsewhere in Victoria's notes. For example,
there was a reference to Victoria's earlier admission to the Central
Middlesex Hospital in her ward notes and, on the CP 1 form completed
by Dr Forlee, it said that Kouao and Victoria had previously had
dealings with an unspecified social services department. Neither
of these pieces of information were drawn to the attention of Haringey
Social Services in time for the 28 July 1999 strategy meeting.
|
|
8.64
|
While on the ward, Ms Johns said she had been told that Kouao had
been informed of the referral to social services but Kouao had not
been asked for any explanation of the marks on Victoria's body.
Ms Johns did not know why this was but said she noted it down nonetheless.
|
|
8.65
|
Ms Johns expected the child protection forms to have been amended
as she had asked and as she thought had been agreed, but they were
not. However, despite having no clear, updated medical report from
the hospital, she was aware of Dr Forlee's concerns and she conveyed
these to the strategy meeting. She also gave each of the participants
- Rosemarie Kozinos, Ms Rodgers and PC Karen Jones - a copy of the
hospital documentation she brought with her. As a result, by way
of written material from the hospital, the strategy meeting had
an unresolved view as to whether the scalding incident was non-accidental.
They also had a set of body maps showing a series of marks on Victoria's
body but no direct written opinion to confirm whether these, too,
could possibly be non-accidental injuries.
|
|
Paragraphs: 8.32 - 8.38
| 8.39 - 8.48 | 8.49 - 8.53
| 8.54 - 8.65 | 8.66 - 8.72
| 8.73 - 8.79
|
|
|
|
8.66
|
Therefore, perhaps not surprisingly, Ms Johns wrote "request medical
report regarding skeletal survey and old injuries (dates etc)" in
the case file as the first action from the strategy meeting. According
to her note, the rest of the action plan was agreed as follows:
|
|
"-
|
when medical information is available, undertake joint visit/interview
with police child protection team
|
|
-
|
if appropriate, interview Anna
|
|
-
|
mother to be informed regarding social services intervention
|
|
-
|
check scabies and its relationship to possible neglect
|
|
-
|
check school attended
|
|
-
|
full child protection investigation."
|
|
8.67
|
She took from the meeting the following tasks to perform:
|
|
"-
|
seek report from the ward staff regarding neglect
|
|
-
|
check with Dr Meates whether photographs can be passed to the police
|
|
-
|
alert ward to call the police if attempt to remove Anna from the
ward is made
|
|
-
|
ask the ward staff to monitor mother/daughter interaction
|
|
-
|
keep Haringey Social Services informed of any discharge plans."
|
|
8.68
|
Ms Johns only recorded 12 of the 18 action points that appear in
the Haringey case file. That she was not entitled automatically
to receive a copy of the minutes of the meeting, according to Haringey's
child protection procedures, meant that she was unable to remedy
any discrepancy between the two.
|
|
8.69
|
The expectation was that Ms Johns and the chair of the strategy
meeting, Ms Kozinos, would jointly undertake the first, second and
fifth tasks. In her record of the action plan Ms Kozinos had indicated
"hospital social worker" against each of the three tasks. That Ms
Johns should have assumed responsibility for the other two tasks,
namely to alert the ward to call the police if an attempt was made
to remove Victoria, as well as asking the ward staff to monitor
mother/daughter interaction, is less than clear, particularly as
Ms Kozinos told the Inquiry: "Unless otherwise stated as hospital
social worker or police child protection team, it is the social
worker from our office that carries the decisions out with the lead
agency".
|
|
8.70
|
Given no such 'hospital social worker' indication was made against
these two tasks, the scope for confusion was obvious, particularly
for Lisa Arthurworrey, to whom the case was subsequently allocated
and who had not been present at the strategy meeting.
|
|
8.71
|
On her return to the North Middlesex Hospital, Ms Johns wrote and
then delivered a memo for the ward notes addressed to the sister
in charge of Rainbow ward. She also updated Nurse Jennings on the
outcome of the strategy meeting. In the memo she asked if the ward
staff could provide a summary of the observed interaction between
Kouao and Victoria that had given cause for concern and if they
could continue to monitor and record the interaction between the
two. Ms Johns said this was how she interpreted her task from the
strategy meeting to seek a report from the ward staff concerning
neglect. In terms of the third task that she took from the strategy
meeting, Ms Johns advised Nurse Jennings that if Kouao did attempt
to remove Victoria from the ward before discharge was agreed
jointly by the hospital and Haringey Social Services, the police
should be alerted immediately and asked to step in. She also gave
notice that Haringey would be contacting Dr Meates for further medical
information.
|
|
8.72
|
On 29 July 1999, Ms Johns paid her fifth visit to Rainbow ward,
to return the original child protection forms she had taken away
to photocopy for the strategy meeting and to update Nurse Beatrice
Norman. She also tried twice to contact Dr Meates by telephone but
she was unavailable. Ms Johns sent her a memo to let her know that
Haringey Social Services would be undertaking a child protection
investigation in respect of Victoria, and that the duty social worker,
Ms Rodgers, would try and contact her in the near future. She also
wanted Dr Meates's advice as to the procedure for letting the police
have the hospital's medical photographs of Victoria "so as to avoid
the need to repeat the procedure twice". According to Ms Johns's
statement, Dr Meates replied within two days by annotating Ms Johns's
original memo to her - the date stamp suggests it was received by
the hospital social work team on 2 August 1999. The reply gave permission
for the police to have copies of the photographs provided they followed
the procedures. Ms Johns passed on this information to Haringey
Social Services.
|
|
Paragraphs: 8.32 - 8.38
| 8.39 - 8.48 | 8.49 - 8.53
| 8.54 - 8.65 | 8.66 - 8.72
| 8.73 - 8.79
|
|
|
|
8.73
|
On 2 August 1999, Ms Johns also received a telephone call from
Nurse Jennings on Rainbow ward to say that Victoria was fit for
discharge. Ms Johns told the Inquiry she was quite clear that fit
for discharge meant only that Victoria was 'medically' fit enough
to go home or to go elsewhere. Nurse Jennings expressed her view
that she would like the discharge to happen as soon as possible.
According to Ms Johns it was normal for the ward to say that because
they are always in need of beds. Nurse Jennings also told Ms Johns
that the scabies was no longer active. Ms Johns agreed to let North
Tottenham District Office know the position.
|
|
8.74
|
For the reasons already noted, Ms Johns did not attend the psychosocial
meeting that afternoon. The notes of the meeting, kept in a book
in the psychiatry department, identified signs of emotional abuse
and noted that Victoria seemed scared of mother's visits with her
male friend, though she was not fearful when just mother visited.
In fact Victoria seemed "clingy with mother".
|
|
8.75
|
Had Ms Johns attended the psychosocial meeting she may have noticed
the inconsistency between this description of Kouao's interaction
with Victoria and that contained in Dr Forlee's notes. Dr Forlee's
notes revealed concerns regarding Victoria's interaction with Kouao,
in particular that Victoria wet herself when her mother visited,
Victoria seemed "on edge when her mother visits" and that Victoria
seemed to "jump to attention" when Kouao visited. Dr Rossiter did
attend the meeting that day and she recalled asking for a psychiatric
assessment because of her concerns about emotional abuse. According
to Dr Rossiter, the psychiatrist was not prepared to see Victoria
without further background information and until she had been assessed
by social services. However, as the hospital never wrote to Haringey
to pursue this, and partly because Ms Johns did not attend the meeting,
this exchange of views never reached Haringey.
|
|
8.76
|
Ms Johns subsequently made four separate telephone calls. First
she rang the North Tottenham District Office to speak to Ms Kozinos.
Ms Kozinos told her that Victoria's case had been allocated to Ms
Arthurworrey. Ms Johns recorded speaking to Ms Arthurworrey that
same day and in her oral evidence Ms Arthurworrey said that they
probably did have a conversation. Ms Arthurworrey remembered saying
she had not yet been given the file but that she would contact Ms
Johns when she had it. Ms Johns then left a message for Dr Meates
to telephone her. She rang Nurse Jennings on Rainbow ward twice,
first to let her know the outcome of her contact with the North
Tottenham District Office and then later in the afternoon to say,
as she had yet to hear from Ms Arthurworrey, she would fax her and
invite her to make contact directly with the ward.
|
|
8.77
|
The next morning, Ms Johns faxed a memo to Ms Arthurworrey letting
her know that Victoria was "ready for discharge" and the ward would
like this to happen as soon as possible. Ms Johns did not qualify
this remark or indicate in any way it was her understanding that
although Victoria was medically fit for discharge, discharge should
only happen if social services agreed jointly that it was in fact
safe for Victoria to be discharged. She indicated to Ms Arthurworrey
that she might want to talk to the ward directly to discuss social
services' involvement and gave her Nurse Isobel Quinn's details
as the nurse in charge for that day. She also mentioned that Victoria's
scabies had been successfully treated and was no longer active and
she passed on Dr Meates's message for the police with regard to
the photographs. She admitted she did not know what the usual procedures
were for the police to obtain the photographs but assumed that PC
Jones would know.
|
|
8.78
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Finally, Ms Johns contacted Nurse Quinn to update her and pass
on Ms Arthurworrey's contact details. Ms Johns was to have no more
involvement in Victoria's case from 3 August 1999. She completed
and signed off the necessary paperwork on 9 August, including a
brief closing summary. The summary did not address the hospital's
view as to whether the scalding incident was non- accidental, the
significance of the other marks discovered on Victoria's body and
whether there was anything other than a query around possible emotional
abuse and neglect. Against the box marked 'risk factors' Ms Johns
wrote "N/E" (not established). The reason for this, according to
Ms Johns, was that Victoria's case had been transferred to Haringey
Social Services and they had accepted responsibility. Therefore,
it rested with Haringey to identify the relevant risk factors.
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8.79
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Ms Lipworth closed Victoria's file in Enfield on 13 September 1999.
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