6 Haringey Social Services

Paragraphs: 6.172 - 6.181 | 6.182 - 6.193 | 6.194 - 6.204 | 6.205 - 6.218 | 6.219 - 6.235 | 6.236 - 6.251 | 6.252 - 6.265 | 6.266 - 6.276 | 6.277 - 6.289 | 6.290 - 6.306 | 6.307 - 6.318 | 6.319 - 6.334 | 6.335 - 6.346 | 6.347 - 6.356 | 6.357 - 6.362 | 6.363 - 6.381 | 6.382 - 6.396 | 6.397 - 6.413 | 6.414 - 6.426 | 6.427 - 6.437 | 6.438 - 6.446 | 6.447 - 6.463 | 6.464 - 6.475 | 6.476 - 6.494 | 6.495 - 6.508 | 6.509 - 6.525 | 6.526 - 6.543 | 6.544 - 6.549

Victoria in Haringey

Referral

6.172

Haringey Social Services first learned of Victoria's admission to the North Middlesex Hospital on Saturday 24 July 1999 - the day she was admitted.

6.173

That evening, it was Luciana Frederick's turn to single-handedly cover the out- of- hours duty for the whole of Haringey Social Services. She started her 12- hour shift at 6.30pm and some time between 8pm and 9pm, according to her report form, she answered a telephone call from Dr Simone Forlee. In fact, the social services duty call log shows that a telephone message from Dr Forlee was taken at 8.42pm and was passed to Ms Frederick as the duty social worker an hour later.

6.174

Ms Frederick does not remember the telephone conversation, but she believes that the report form which she completed at the time - the only record of the telephone conversation that exists - is a concise summary of the information Dr Forlee gave her.

6.175

Ms Frederick noted:

"-

child admitted to hospital - concerns about injury caused by hot water poured onto face causing facial burns;

-

it appeared to be an accident, however, mother may need support;

-

advice given - doctor agreed to discuss case with the hospital social worker the following day;

-

NFA [no further action]."

6.176

Dr Forlee disagreed with Ms Frederick's summary in one material respect. She did not recollect describing Victoria's injury as appearing to be an accident and believed she told Ms Frederick that she had admitted a child about whom she had concerns.

6.177

We cannot be certain what passed between the two because of the lack of recorded information - indeed in the case of the hospital there was none whatsoever - or whether Ms Frederick simply misunderstood what Dr Forlee was saying. That Dr Forlee had telephoned social services out of hours suggested a degree of concern about Victoria's injuries. This was understandable. Ms Frederick told the Inquiry that she made "concise notes" but admitted it would have been helpful if she had made a full recording specifying Dr Forlee's concerns. Ms Frederick accepted that more detail could have been put in her recording of the conversation, but stated, "The relevant detail is there.

6.178

Both Dr Forlee and Ms Frederick agreed that because Victoria was "safe in hospital" and there appeared to be no immediate risk of her being removed, there was no need that evening for any further investigative action, including seeing Victoria. Dr Forlee was also told to contact the hospital social work team "the following day". Since the referral came in late on Saturday night and there was no hospital social work team working on Sunday, that meant in reality a delay until Monday morning. Ms Frederick admitted that the following day was "probably not appropriate".

6.179

Working from home, Ms Frederick was in no position to do any checks to see if Victoria was known to social services or on the child protection register. She stated that she assumed - though she did not pursue this with Dr Forlee - that these checks would have been done by the hospital, which had access to the names of children on the child protection register and by the hospital social work team, as part of any follow-up.

6.180

Ms Frederick subsequently faxed the report form to the out-of-hours office for filing. She said that if there had been a clear indication of child protection concerns - especially if there had been no other professional involved - she would have made the referral herself direct to the duty team at the NTDO and undertaken whatever was necessary that evening to secure the child's safety. Ms Frederick stated that she had no doubts about what she should do if child protection concerns had been raised.

6.181

As a result of the decision to take no further action and because Victoria's injury "appeared to be an accident", the out-of-hours referral report was consigned to a filing cabinet. No copy was forwarded to the hospital social work team to put them on alert, nor to the local district duty, investigation and assessment team who may have held information about the child and family. Also, there was no system in place to ensure that Dr Forlee made contact with the hospital social work team as advised or that, once in the out-of-hours office filing cabinet, this referral could be automatically linked to any future referral. Ms Frederick accepted that if Dr Forlee had not been on duty on Monday or had forgotten to make the referral to the hospital social worker, the information from Saturday evening may never have got to the hospital social work team or Haringey Social Services. Therefore, I make the following recommendation:

Recommendation

The chief executive of each local authority with social services responsibilities must ensure that specialist services are available to respond to the needs of children and families 24 hours a day, seven days a week. The safeguarding of children should not be part of the responsibilities of general out-of-office-hours teams.

Paragraphs: 6.172 - 6.181 | 6.182 - 6.193 | 6.194 - 6.204 | 6.205 - 6.218 | 6.219 - 6.235 | 6.236 - 6.251 | 6.252 - 6.265 | 6.266 - 6.276 | 6.277 - 6.289 | 6.290 - 6.306 | 6.307 - 6.318 | 6.319 - 6.334 | 6.335 - 6.346 | 6.347 - 6.356 | 6.357 - 6.362 | 6.363 - 6.381 | 6.382 - 6.396 | 6.397 - 6.413 | 6.414 - 6.426 | 6.427 - 6.437 | 6.438 - 6.446 | 6.447 - 6.463 | 6.464 - 6.475 | 6.476 - 6.494 | 6.495 - 6.508 | 6.509 - 6.525 | 6.526 - 6.543 | 6.544 - 6.549

Contacting the North Middlesex Hospital

6.182

Karen Johns, the hospital social worker, telephoned Caroline Rodgers, the duty social worker at Haringey Social Services, at about 4.30pm. Having accepted the referral, responsibility for Victoria's case transferred to Haringey Social Services at that stage. She recorded key details about Victoria's admission to the North Middlesex Hospital as follows:

•

mum brought Anna to the A&E at about 5.25pm on Sat 24th July;

•

Anna had burns to head and face;

•

mum says Anna has scabies that are being treated by the Central Middlesex Hospital;

•

mum heard Anna scream at about 12 noon. She found that Anna had poured hot water over her head (from the tap) to stop the itching on her head;

•

next day the nurse who had bathed Anna on Rainbow ward saw old marks on Anna's body;

•

until then staff did not suspect physical abuse but they now feel sure the marks are non-accidental;

•

Dr Forlee suggests that the marks look like they were done by a belt buckle;

•

Anna seems slightly nervous of mum and "seems on edge when mum visits". Ward staff described how she "jumps to attention" when mum appears;

•

Anna also wets herself when mum is there;

•

on admission Anna appeared unkempt, dirty dress and no underwear. Mum has brought no clean clothes since Anna's admission.

6.183

Ms Rodgers's good sense in following up the referral with a request for full information from the Central Middlesex Hospital is quite clear. She could no longer recall whether she spoke to Dr Schwartz, the consultant in charge of Victoria's case at the Central Middlesex Hospital, or someone else, though her normal practice would have been to go direct to the hospital social worker or possibly to staff in the accident and emergency department.

6.184

Two days later, the Central Middlesex Hospital faxed back several pages of relevant documentation. There is some doubt as to how many pages were faxed across but it is accepted that at the very least the documents seen by Haringey Social Services included a general trauma form dated 14 July 1999, a paediatric assessment record, ongoing communication sheets, a body map and a 'medical report on a child thought to have suffered abuse'.

6.185

However, it is unlikely that Ms Rodgers read any of this material because she said she found it illegible and "could not read it". Regrettably, she made no attempt to ask the Central Middlesex Hospital for help in clarifying its contents. If she had, she would have learned that Victoria had been brought to the hospital by her childminder's daughter, that Kouao was desperate to leave Victoria with the childminder "for good", and that Victoria was not attending school. The medical report identified that there were scars of various sizes and ages all over the body from two days to possibly months old. There were also fresh scars on the face, infected cuts on the fingers and bloodshot eyes. Victoria was said to have cut herself with a razor blade in the past, that she wet herself and that when she arrived at the hospital she was unkempt and had a pungent smell.

6.186

By the time the NTDO received the Central Middlesex Hospital fax - and judging by the date stamp this could have been as late as 2 August 1999 - Ms Jacob, the team manager on duty on 27 and 28 July, had already, though late in the day, arranged a strategy meeting in Victoria's case.

6.187

Having read the details set out in the referral form, Ms Jacob considered that "this could probably have been a child protection case" which needed to be explored further. As was standard practice, she then completed and signed off an action plan on 27 July which included:

•

logging the case onto the computer - this was to be done by the duty administrative clerk;

•

referring the case to the police child protection team;

•

arranging the strategy meeting;

•

completing checks with the GP and Central Middlesex Hospital and school, if open.

6.188

Ms Jacob completed the second and third of these herself the following morning. The expectation was that others in the duty team would finish the tasks, in particular that Ms Rodgers would continue her checks of the Central Middlesex Hospital, as she had already made a start on this. Health and education checks were done as a matter of routine - these showed no record of either a GP or a school for Victoria - but no similar checks would have been done of housing unless this had been identified as a problem.

6.189

According to Ms Jacob, once the case was logged, the file would be returned and placed in the specific basket labelled "urgent action". Duty workers were expected to deal with these as a matter of priority and could check with the duty manager if actions still needed to be completed.

The July strategy meeting

6.190

Ms Jacob said in evidence that the decision to call a strategy meeting was reached jointly with the police and the meeting was arranged for 2.30pm on Wednesday 28 July 1999. She was aware that another strategy meeting had already been fixed for 2pm at the NTDO, which the police were expected to attend. She therefore arranged this meeting to follow on directly at the social services office - on the face of it a sensible and convenient arrangement, at least for the police. However, Haringey's local child protection guidelines (known as the Purple Book), clearly stated that "in the event of the child being in hospital the [strategy] meeting must be held in the hospital".

6.191

There is no record of any challenge to Ms Jacob's decision to hold the strategy meeting at the social services office by the police, Ms Rodgers or Ms Johns, though all would, or should, have been familiar with the contents of the Purple Book. However, Ms Johns said that she did question the choice of location on the grounds that the doctors would be unlikely to attend, but that Ms Jacob said, after checking with her manager, that it would not be possible to change the meeting venue. Ms Jacob did not recall this conversation.

6.192

As it happens, the procedures drawn up by Ms Mairs for the day-to-day running of the DIAT in north Tottenham, already prescribed, by agreement with the police, that strategy meetings would take place on Tuesday and Wednesday afternoons and Friday mornings. According to Ms Jacob, the duty team was never fully staffed and rationalising the times when meetings were held was seen as a sensible means of managing the duty system with the resources available. She says there was a presumption that strategy meetings would be held in the office for the same reason but argues that the DIAT procedures did not preclude such meetings taking place in the hospital if necessary, and some did.

6.193

The Purple Book also makes clear that if there is to be any divergence from the procedures, this needs to be endorsed by the team manager and recorded on the file. There is nothing on the case file to suggest that on this occasion an endorsement to hold the strategy meeting outside the hospital was ever sought from, or given by, a manager.

Paragraphs: 6.172 - 6.181 | 6.182 - 6.193 | 6.194 - 6.204 | 6.205 - 6.218 | 6.219 - 6.235 | 6.236 - 6.251 | 6.252 - 6.265 | 6.266 - 6.276 | 6.277 - 6.289 | 6.290 - 6.306 | 6.307 - 6.318 | 6.319 - 6.334 | 6.335 - 6.346 | 6.347 - 6.356 | 6.357 - 6.362 | 6.363 - 6.381 | 6.382 - 6.396 | 6.397 - 6.413 | 6.414 - 6.426 | 6.427 - 6.437 | 6.438 - 6.446 | 6.447 - 6.463 | 6.464 - 6.475 | 6.476 - 6.494 | 6.495 - 6.508 | 6.509 - 6.525 | 6.526 - 6.543 | 6.544 - 6.549

Attendees

6.194

Invited to the strategy meeting on 28 July 1999 were Ms Johns, the initial referrer, and the police from the Haringey Child Protection Team. Ms Jacob said, ideally, she would have wanted the medical staff to attend too, but she cannot recall whether they were invited or indeed whether she asked Ms Johns to do that on her behalf. Ms Johns is clear that had she been asked to issue invitations to the medical staff she would have done so. She did not know who invited Dr Rossiter to the strategy meeting, but she implied in her evidence that it was Haringey.

6.195

In fact, four people attended: Ms Kozinos, a senior practitioner in the DIAT A, who chaired the meeting, Ms Johns from the North Middlesex Hospital social work team, PC Karen Jones from Haringey police Child Protection Team, and Ms Rodgers. None of the nursing or medical staff at the North Middlesex Hospital who had had daily care of Victoria were present, and none of those who were there had seen Victoria, let alone spoken to her, or to Kouao.

6.196

Ms Jacob told the Inquiry that it was her expectation that Ms Johns would represent the hospital and that she would pass on any information that the medical staff wished to share and would bring with her to the meeting the relevant medical reports. She saw nothing unsatisfactory about this arrangement.

Running the meeting

6.197

Ms Kozinos said she was asked to chair the strategy meeting at short notice. She was not on duty that week and would not have expected to chair strategy meetings in new, unallocated cases, and she went into the meeting without first reading the referral completed by Ms Rodgers. Apparently, this was common practice. Ms Kozinos said, "We normally go into strategy meetings cold unless we were the person who took the referral and had knowledge of it on duty." Ms Kozinos expected Ms Rodgers to update those present with any current concerns. These were then recorded, together with the meeting's decisions and recommendations, on a paper strategy meeting record.

6.198

Ms Kozinos was not aware of the substance of Victoria's referral and so could not have realised that the location of the strategy meeting was inappropriate. Once the meeting started, she did not take steps to adjourn the meeting to the hospital so that the medical staff could more easily attend. She told the Inquiry, "I felt we needed to proceed - we had sufficient information and it needed urgent action. There are suggestions of physical abuse, neglect which I felt needed investigating.

6.199

When pressed, Ms Kozinos confirmed that difficulties in getting police to attend strategy meetings had become an issue because, for a variety of reasons, posts in the police child protection team were not being covered. The stacking up of strategy meetings was therefore not unknown.

6.200

Strategy meetings were supposed to be chaired by team managers or child protection advisers. Yet Ms Kozinos told the Inquiry it was common practice at the time for senior practitioners to chair strategy meetings. It is not clear whether what had become common practice in north Tottenham - and was endorsed by north Tottenham's DIAT procedures - was indeed common practice across both district offices. In her evidence to the Inquiry, Ms Wilson, the assistant director for children's services, said this was not her understanding of the position before November 1999, as it was only then that agreement was reached as to the role of the new practice managers, who were to replace the senior practitioners.

6.201

There is some doubt as to exactly what information was available to the strategy meeting on 28 July 1999. It now seems certain that the faxed material from the Central Middlesex Hospital arrived too late. Ms Johns said, and in this she is supported by PC Jones, that she brought along three copies of documents from the North Middlesex Hospital. These included child protection forms, accident and emergency notes and a body map. Ms Rodgers also recalled seeing the body map and Ms Johns giving them copies. However, Ms Kozinos thought Ms Johns had not brought any medical reports with her but could no longer recall what indeed she had brought. By the time Ms Arthurworrey, the social worker allocated to Victoria's case, first received the file on 2 August 1999, she claimed that no such North Middlesex Hospital documentation was included. However, the evidence I shall refer to later suggests otherwise.

Concerns and recommendations

6.202

The sense of the meeting at the end, at least from the social services perspective, was that the cause of Victoria's scalding injuries was uncertain and that this was a child protection case that needed to be investigated thoroughly.

6.203

The strategy meeting recorded the concerns as:

"Mum - Marie-Therese Kouao brought Anna to North Middlesex Hospital on 24th July at 5.25 saying that the child had poured hot water over her head. Child has scabies and is very itchy and mum said that hot water was supposed to stop itching. Child admitted to Rainbow ward. Nurse noticed old marks on body - Dr Forlee suggests that they look like old belt buckle marks. Skeletal survey carried out - no results as yet. Delay in mother taking child to hospital. Also concerns re neglect, child very unkempt - mother was not."

6.204

It also agreed the following 18 recommendations:

"i)

Dr Forlee examining paediatrician expressing concerns re previous NAI (shaped like belt buckle). Obtain medical report re their concerns. Also need to state how old injuries are.

ii)

Obtain skeletal reports for further information.

iii)

Mother to be informed of referral to social services.

iv)

Obtain report from hospital social worker re concerns of neglect.

v)

Hospital social worker to inform social services when child ready for discharge.

vi)

Staff nurses/hospital to monitor contact with mother and child and report back any concerns.

vii)

Once we have medical reports arrange joint visit with PCPT and explain fully our child protection procedures to mother.

viii)

Need to obtain much more information re scabies - how is this obtained? Is it linked to issues of neglect?

ix)

Check with Central Middlesex Hospital for further information.

x)

Social services need to carry out a full investigation and assessment.

xi)

Social services need to complete checks re schooling and GP.

xii)

Hospital social worker to inquire re hospital photographs - can this be given to social services and police.

xiii)

Arrange interpreter when completing assessment.

xiv)

Interview of mother needs to address - a) recent incident, b) old injuries, and c) neglect issues.

xv)

Allocate to DIAT.

xvi)

Child to remain in hospital. If mum attempts to take her, hospital to contact us.

xvii)

Complete checks in France - international services.

xviii)

PCPT to complete immigration checks."

Paragraphs: 6.172 - 6.181 | 6.182 - 6.193 | 6.194 - 6.204 | 6.205 - 6.218 | 6.219 - 6.235 | 6.236 - 6.251 | 6.252 - 6.265 | 6.266 - 6.276 | 6.277 - 6.289 | 6.290 - 6.306 | 6.307 - 6.318 | 6.319 - 6.334 | 6.335 - 6.346 | 6.347 - 6.356 | 6.357 - 6.362 | 6.363 - 6.381 | 6.382 - 6.396 | 6.397 - 6.413 | 6.414 - 6.426 | 6.427 - 6.437 | 6.438 - 6.446 | 6.447 - 6.463 | 6.464 - 6.475 | 6.476 - 6.494 | 6.495 - 6.508 | 6.509 - 6.525 | 6.526 - 6.543 | 6.544 - 6.549

6.205

By the end of the strategy meeting, and in the absence of a clear, written, diagnosis of non-accidental injury by a doctor, no decision was made to proceed to a child protection case conference at that stage. No explicit directions were recorded as to who would carry out the 18 tasks agreed, no timescales were settled, neither was a review date set to monitor progress. Ms Kozinos said that it was understood by all present that tasks not allocated to other agencies would be done by the allocated case worker from the NTDO, though no such person had yet been identified. It was also not the practice in Haringey at the time to hold a review of strategy meetings. The expectation was that decisions and recommendations would be reviewed in supervision between the responsible team manager and allocated social worker - an expectation that was to prove misplaced.

6.206

Ms Kozinos had no further contact with Victoria's case until November 1999.

Allocation of Victoria's case

6.207

On 30 July 1999, Ms Baptiste, the manager for the B investigation and assessment team based at Haringey's NTDO, allocated the case to Ms Arthurworrey, a social worker in her team. In deciding who to allocate the case to, she said she believed Ms Arthurworrey had space for several more cases but said nothing about her assessment, if any, of Ms Arthurworrey's capacity and experience to tackle such a case.

6.208

In fact, by the time Ms Arthurworrey picked up Victoria's case, she had had 19 months' post-qualification experience and half her caseload was composed of child protection cases. Yet despite this, she had yet to complete a joint section 47 child protection inquiry with the police or a section 47 inquiry about a child in hospital.

6.209

August was also to prove one of Ms Arthurworrey's busiest months. She had a workload of 19 cases, including Victoria's - seven more than the maximum to be held by staff in the investigation and assessment team according to the local procedures handbook. Ms Arthurworrey said that most of these cases were "active" and she "was on the go all day long with no time to reflect".

6.210

Ms Arthurworrey told the Inquiry that she was not on duty the day the case was allocated to her but found the papers on her desk on 2 August 1999. The case file contained:

•

the referral of 27 July as recorded by Ms Rodgers;

•

the strategy meeting notes;

•

a faxed message from Dr Schwartz to Ms Rodgers, dated 28 July requesting that Ms Rodgers contact her urgently;

•

a fax from Ms Rodgers to the medical records library;

•

a first contact sheet showing no records of a GP or school.

6.211

Although not at the strategy meeting, Ms Arthurworrey did not think she needed to speak to either Ms Rodgers or Ms Kozinos to clarify the decisions they had reached. Nor did she pursue with Ms Rodgers whether she had in fact contacted Dr Schwartz - Ms Rodgers told us she was not aware of ever having seen the fax - or what response if any had been received from the medical records library.

6.212

However, she did speak to her manager, Ms Baptiste, who told her that this was "a case about a child who was in hospital with scabies" and that she should implement the strategy meeting decisions. No date was set to review her progress in completing these tasks, nor did Ms Arthurworrey think it was her job to suggest such a review.

6.213

Ms Arthurworrey said she understood from the outset that she was dealing with a section 47 investigation. She also knew from the papers that Victoria was 'safe' in hospital at the time of the referral the previous week and that the hospital had been asked to notify social services when Victoria was ready for discharge or if Kouao attempted to remove her prematurely.

6.214

In her case file contact sheets, Ms Arthurworrey sets out 11 of the 18 strategy meeting recommendations for completion. These included obtaining a medical report from Dr Forlee, which covered the hospital's concerns regarding previous non-accidental injuries, as well as a report from the hospital of its concerns of any neglect. Both of these, Ms Arthurworrey told us, were necessary before visiting Victoria, "because social services rely on evidence from the hospital into the causes of a child's injuries and we need to know what we are dealing with".

6.215

Ms Arthurworrey makes no mention in the contact sheets of at least four strategy meeting decisions that, on the face of it, she needed to complete. These were to:

•

obtain skeletal reports for further information;

•

check with the Central Middlesex Hospital for further information;

•

obtain more information about scabies; and, most importantly,

•

carry out a full investigation and assessment.

6.216

While I accept Ms Arthurworrey's evidence that she was clear when she was allocated the case that she was dealing with a section 47 investigation and that she had to complete the tasks outlined in the strategy meeting, I am far from satisfied with the way she then went about this, and the way Haringey as an organisation allowed her to do so.

6.217

I heard no evidence of what I would term a section 47 inquiry ever being carried out by Haringey Social Services. I deal with the failure of the police to conduct a criminal investigation later in section 14. At the very least, after the strategy meeting, Ms Arthurworrey should have spoken to Ms Kozinos, its chair, to go through the recommendations in detail. I am also surprised that she chose not to speak to Ms Rodgers, especially in light of the 'urgent' message from Dr Schwartz that was on the file. I believe that this initial 'inaction' by Ms Arthurworrey was based on her assumption that Victoria was 'safe' in hospital.

6.218

On 3 August 1999, Ms Johns sent Ms Arthurworrey a note by fax. In it Ms Johns said that she had been informed by the nurse in charge of Rainbow ward (Nurse Isobel Quinn) that Victoria was ready for discharge, and that the ward would like that to happen as soon as possible. The fax also made clear that Victoria's scabies had been successfully treated.

Paragraphs: 6.172 - 6.181 | 6.182 - 6.193 | 6.194 - 6.204 | 6.205 - 6.218 | 6.219 - 6.235 | 6.236 - 6.251 | 6.252 - 6.265 | 6.266 - 6.276 | 6.277 - 6.289 | 6.290 - 6.306 | 6.307 - 6.318 | 6.319 - 6.334 | 6.335 - 6.346 | 6.347 - 6.356 | 6.357 - 6.362 | 6.363 - 6.381 | 6.382 - 6.396 | 6.397 - 6.413 | 6.414 - 6.426 | 6.427 - 6.437 | 6.438 - 6.446 | 6.447 - 6.463 | 6.464 - 6.475 | 6.476 - 6.494 | 6.495 - 6.508 | 6.509 - 6.525 | 6.526 - 6.543 | 6.544 - 6.549

'Fit for discharge'?

6.219

At the time, Ms Arthurworrey says she understood the phrase 'fit for discharge' to mean that the hospital no longer had any concerns about Victoria in the general sense. By contrast, several hospital staff in their evidence to the Inquiry said that 'fit for discharge' meant that Victoria was medically fit to leave and they assumed the social workers would make the necessary inquiries of her home and family before that actually happened.

6.220

In response to Ms Johns's fax, Ms Arthurworrey telephoned Nurse Quinn. It appears to have been a fairly lengthy call. Among other things, Ms Arthurworrey said that she was told by Nurse Quinn (and recorded in her contact sheet for 3 August 1999) about Victoria's behaviour in Kouao's presence ("she appeared to come straight to attention"), that the hospital accepted the explanation that Victoria had sustained the burns by pouring hot water over her own head "from a kettle" to relieve the itching caused by scabies, that there were concerns about a discrepancy between the timing of the incident and Victoria's arrival at hospital, that the hospital had noticed old injuries on Victoria's body, which appeared to be non-accidental, and therefore the hospital had concerns about these as well as Kouao's response to the accident. In evidence Ms Arthurworrey also said that Nurse Quinn mentioned that Dr Rossiter had carried out a ward round, possibly on 1 August, and had noticed signs of deliberate emotional harm - a 'master-servant' relationship between Victoria and Kouao.

6.221

Nurse Quinn's recollection of the telephone conversation is somewhat different in one material respect. Like Dr Forlee, she denied ever saying that the hospital was satisfied with Kouao's explanation for the burns. Rather she claimed to have said precisely the opposite, in other words, that there were remaining concerns about how Victoria received the scalding injuries.

6.222

Nurse Quinn recorded in the critical incident log that she had spoken to Ms Arthurworrey, that Ms Arthurworrey needed to make a home visit before Victoria could go home, and that she had requested Nurse Quinn fax through any concerns the hospital had. Given that on 1 August 1999 Dr Rossiter had already come to the view that Victoria's scalding injuries were self inflicted, it seems highly unlikely that Nurse Quinn, as the nurse in charge of Rainbow ward, did communicate to social services two days later a different hospital view to that of the consultant paediatrician responsible for Victoria. I therefore conclude that, in early August, social services were left with the impression that the hospital had accepted Kouao's explanation for the scalding injuries.

6.223

Nurse Quinn also sent across a fax which Ms Arthurworrey believed would address all the hospital's concerns and meet two of the strategy meeting recommendations, namely to obtain a medical report from Dr Forlee and to obtain further information from the hospital regarding neglect.

Nurse Quinn's fax

6.224

Contained in the fax were three of the local child protection forms (CP1, 2 and 3) signed by Dr Forlee, and a letter from Nurse Quinn summarising ward staff observations regarding emotional neglect. Ms Arthurworrey accepts that she did not notice that the date on which the child protection forms had been completed - 24 July 1999 - preceded the strategy meeting and therefore could not possibly be said to meet the strategy meeting recommendation for an updated medical report.

6.225

Moreover, the child protection forms, a body 'diagram' and accident and emergency department notes (all on the Haringey file) were, according to Ms Johns and PC Jones, already available from the strategy meeting. In addition, the Haringey file contained a copy of the North Middlesex Hospital paediatric assessment form. Ms Arthurworrey maintained that she never saw any of the medical material until she received the fax from Nurse Quinn. However, she could not remember how many pages Nurse Quinn sent her. Nurse Quinn told me that the documentation she sent to Ms Arthurworrey consisted of a cover sheet, her handwritten note, child protection form CP1, and probably also child protection forms CP2 and CP3, making a total of six pages in all. If, as seems likely, and contrary to Ms Arthurworrey's earlier evidence, she already had in her possession on 2 August a set of child protection forms, a paediatric assessment form, an accident and emergency department form and a set of body maps, only Nurse Quinn's memo summarising ward staff observations about emotional neglect would have constituted new medical evidence.

6.226

In addition, there was some doubt as to which version of the CP3 form Ms Arthurworrey was sent. Judging from the timing on the fax header sheet, it seems probable that the CP3 form she received was the one confusingly annotated by Dr Rossiter on 1 August 1999 in which she drew an arrow from the box ticked by Dr Forlee 'I wish to await further information before committing myself' to the tick box immediately above 'I consider the incident is likely to be non-accidental' and added the following words "what is uncertain is the category".

6.227

Ms Arthurworrey accepted that it is likely she saw this version but did not recall noticing Dr Rossiter's endorsement which, although unspecific, mentioning neither belt buckle marks nor any suggestion of deliberate physical harm, did at least suggest it was "likely to be non-accidental".

6.228

Ms Arthurworrey told the Inquiry she believed that Nurse Quinn's fax summarised the hospital's concerns in their entirety and, in that sense, superseded the information contained in the initial referral. But even if true, and Ms Arthurworrey had grounds for believing this, by 3 August 1999 she was aware from her conversation with Nurse Quinn that there were unresolved questions about old and possibly non-accidental injuries. Although I conclude that anyone reading the documentation provided by the North Middlesex Hospital would have been very hard pressed to find any indication that the hospital suspected deliberate physical harm, she had been given up-to-date information about the hospital's concerns regarding deliberate emotional harm.

6.229

What she did not have were any medical photographs of Victoria. Ms Johns had already faxed over a memo annotated by Dr Maud Meates, which suggested that although ordered, none had yet been taken, and that if the police wanted copies of them they "should follow the usual procedures". Ms Arthurworrey never pursued with PC Jones whether she understood, let alone followed, the 'usual procedures' and obtained the photographs.

Obtaining information on medical concerns

6.230

To get a better understanding of the medical concerns, Ms Arthurworrey telephoned Dr Rossiter. Dr Rossiter remembered a conversation with Ms Arthurworrey occurring some time that week, but their recollections of what was said are rather different. Ms Arthurworrey said she made a note at the time of what was said. Unfortunately, Dr Rossiter kept no such record.

6.231

Ms Arthurworrey agreed that Dr Rossiter told her Victoria may be subject to emotional harm but said, "I did not know she had grave concerns." She recorded in her notes:

"[Dr Rossiter] believes she is displaying evidence of anxious attachment. Anna appears to seek attention and praise from all the nursing staff but when mother arrives rushes to her side as if she has been called to attention. Dr Rossiter described that as a master/servant relationship."

6.232

She also mentioned to Ms Arthurworrey, as recorded in Ms Aurthurworrey's notes, Victoria's fear of being undressed and of her being frightened of Kouao's partner, and that Kouao may have over-treated the scabies. But, according to Ms Arthurworrey, Dr Rossiter did not suggest that the marks on Victoria's body were indicative of physical harm. She was "unclear whether these were caused by Victoria scratching herself or infection from the scratching". She also noted two old - and unexplained - thumb marks on Victoria's body.

6.233

In describing her telephone conversation with Dr Rossiter, Ms Arthurworrey said:

"It was not really a discussion. It was a very factual conversation. It was one-way. Dr Rossiter gave me all this information and I wrote it down at the time ... At the end of the conversation I agreed to update her following the home visit."

6.234

Having made no record of their conversation, Dr Rossiter was not able to dispute Ms Arthurworrey's note of it. (See paragraphs 10.131 - 10.135.)

6.235

Ms Arthurworrey admitted that she never questioned Dr Rossiter as to whether there was any indication of physical harm. Nor did she use the opportunity to systematically explore with Dr Rossiter the possible causes of all the marks found on Victoria's body, or resolve any outstanding concerns - particularly in relation to the belt buckle marks identified by Dr Forlee and the 'new' observations of thumb marks. She said she never asked about the scalding incident because she understood from Nurse Quinn that the hospital was happy with Kouao's explanation. In any event, it was Ms Arthurworrey's view that if Dr Rossiter, as the senior paediatric consultant who had examined Victoria, had had any concerns regarding physical harm she would have communicated those to her directly. I do not consider this an unreasonable view to take. On the other hand, it was Ms Arthurworrey's job to pull together and evaluate all the information available to her and, if by some oversight, she had been given no explanation - or no plausible explanation - for all the marks on Victoria's body, she should have sought one directly.

Paragraphs: 6.172 - 6.181 | 6.182 - 6.193 | 6.194 - 6.204 | 6.205 - 6.218 | 6.219 - 6.235 | 6.236 - 6.251 | 6.252 - 6.265 | 6.266 - 6.276 | 6.277 - 6.289 | 6.290 - 6.306 | 6.307 - 6.318 | 6.319 - 6.334 | 6.335 - 6.346 | 6.347 - 6.356 | 6.357 - 6.362 | 6.363 - 6.381 | 6.382 - 6.396 | 6.397 - 6.413 | 6.414 - 6.426 | 6.427 - 6.437 | 6.438 - 6.446 | 6.447 - 6.463 | 6.464 - 6.475 | 6.476 - 6.494 | 6.495 - 6.508 | 6.509 - 6.525 | 6.526 - 6.543 | 6.544 - 6.549

Failure to make a home visit

6.236

Ms Arthurworrey then discussed the case with her supervisor Ms Baptiste and with PC Jones. Ms Baptiste told her to arrange a home visit before Victoria was discharged from hospital. Accordingly she arranged for PC Jones and herself to visit Somerset Gardens on 4 August 1999.

6.237

By this stage Ms Arthurworrey's concerns about Victoria were beginning to crystallise around emotional abuse and neglect. In her statement to the Inquiry she said that the hospital's "ambivalence" about the marks on Victoria's body "left her with no option but to pursue this as an investigation into social issues". The "ambivalence" ought to have led to Ms Arthurworrey keeping an open mind about the possibility of physical harm while she conducted her inquiry.

6.238

It remains unclear from her evidence just how Ms Arthurworrey expected to resolve this uncertainty or how, given that Victoria was still in hospital and yet to be seen by any social worker, emotional abuse and neglect could be properly assessed by a home visit.

6.239

Ms Arthurworrey said that at the time she had understood that Victoria had contracted scabies from her home address. Her purpose in conducting a home visit was therefore to check that 267 Somerset Gardens was a safe and fit environment for Victoria to be discharged to.

6.240

In the event, the home visit never took place before Victoria's discharge from hospital. PC Jones rang Ms Arthurworrey on 4 August 1999 to report the outcome of a conversation she said she had with the North Middlesex Hospital about scabies. According to Ms Arthurworrey's notes, she was told by PC Jones that scabies was highly infectious and that any contact with the family home would require them to wear protective clothing. PC Jones made it quite clear that she was not prepared to conduct a home visit.

6.241

Ms Arthurworrey did not question the advice given by PC Jones. She updated Ms Baptiste who, according to Ms Arthurworrey, advised that the home visit should be cancelled and Kouao invited to the office for an interview instead. Ms Baptiste claimed to have told Ms Arthurworrey to do no more than speak to the doctor and obtain more information about scabies. Unfortunately the case record shows no evidence to support either version of what was said.

Meeting with Kouao

6.242

Kouao was offered an appointment to attend the NTDO the next day, Thursday 5 August 1999. Ms Arthurworrey also rang the North Middlesex Hospital and found that Kouao had not visited Victoria since Monday morning.

6.243

PC Jones met Ms Arthurworrey about half an hour before the meeting with Kouao was scheduled to start. Neither the police nor any social worker had yet visited Victoria in hospital. In evidence, Ms Arthurworrey relied on Haringey's child protection procedures to explain this. She said, "We needed to interview the carer ... We needed to obtain permission from the carer to interview the child."

6.244

Ms Arthurworrey saw the purpose of the interview with Kouao to explore the recent scalding injury, the old markings and the neglect concerns reported by the hospital as part of her initial assessment. She hoped to use the interview to clear up any ambivalence regarding deliberate physical harm. Little preparation was needed beforehand because, according to Ms Arthurworrey, the topics to be covered were already set out in the strategy meeting recommendations.

6.245

During the course of the interview, Ms Arthurworrey and PC Jones learned, and recorded on a paper initial assessment form, the following:

•

Kouao and Victoria came to England from France in March 1999, following the death of Kouao's husband, to try to start over again.

•

While in France, Kouao had been in full-time employment as an information assistant at the airport.

•

Her purpose in coming to England was to learn English.

•

Manning was a close family friend who agreed to help her by offering accommodation to Kouao and Victoria in his studio flat until they had somewhere of their own to live.

•

Conditions in the studio flat were cramped. Manning shared the flat with his girlfriend (fiancée); however, their relationship had become rather stressed since Kouao and Victoria moved in.

•

A couple of weeks earlier Manning had needed his flat for the weekend so Kouao and Victoria had booked into a bedsit. The conditions were very poor and it was after they had checked out that Victoria had started to scratch herself and scabies was diagnosed at the Central Middlesex Hospital.

6.246

Kouao went on to explain that it was while Victoria was taking a bath she poured a beaker of hot water from the bath tap over her head to reduce the skin irritation, which resulted in the burns and her subsequent admission to the North Middlesex Hospital.

6.247

Although in oral evidence Ms Arthurworrey says she asked Kouao whether she had ever hit Victoria, there is no reference to this in her record of the interview. The only neglect issue she addressed was Victoria's lack of clean clothes while in hospital. Kouao's answer to this was that they had entered the country with few belongings and Victoria had few clothes. In any event the hospital had given Victoria what she needed.

6.248

Ms Arthurworrey (and PC Jones) made a number of observations during the interview. Most significantly they noted that although an interpreter was present, Kouao's command of English was good and she would often reply in English before the interpreter had time to do so. Ms Arthurworrey recorded, "Marie-Therese presented as smart in appearance, proud and a woman who articulated very well." However, her grasp of the English language would fail her whenever she was asked specific child protection questions. Then she appeared not to understand, was evasive and would turn to the interpreter for support.

6.249

Kouao also made clear that she wanted help with housing, finance and finding a school for Victoria and she confirmed - as she had to Ealing and Brent Social Services, the Central Middlesex Hospital and, inadvertently, to the North Middlesex Hospital before - that Victoria had not attended school since her arrival in England.

Hospital visit

6.250

Ms Arthurworrey raised her concerns about Kouao's evasiveness with her manager, Ms Baptiste, who told her to visit Victoria in hospital. Ms Arthurworrey also noted as a further action that she should do a home visit to assess the home situation.

6.251

The next day, Friday 6 August 1999, Ms Arthurworrey and PC Jones travelled together to visit Victoria on the Rainbow ward at the North Middlesex Hospital. They took no interpreter along, despite the fact that Victoria was a seven-year-old child who had arrived in Britain from the Ivory Coast via Paris only four months previously. Ms Arthurworrey says that any doubts she had about Victoria's ability to speak in English were put aside by Kouao's assertion that she spoke good English and by the hospital who had earlier told Ms Arthurworrey that "Victoria had been chatting in English most of the time, all of the time". She also thought that Victoria might find the presence of three adults, rather than two, intimidating. Therefore, I make the following recommendation:

Recommendation

When communication with a child is necessary for the purposes of safeguarding and promoting that child's welfare and the first language of that child is not English, an interpreter must be used. In cases where the use of an interpreter is dispensed with, the reasons for so doing must be recorded in the child's notes/case file.

Paragraphs: 6.172 - 6.181 | 6.182 - 6.193 | 6.194 - 6.204 | 6.205 - 6.218 | 6.219 - 6.235 | 6.236 - 6.251 | 6.252 - 6.265 | 6.266 - 6.276 | 6.277 - 6.289 | 6.290 - 6.306 | 6.307 - 6.318 | 6.319 - 6.334 | 6.335 - 6.346 | 6.347 - 6.356 | 6.357 - 6.362 | 6.363 - 6.381 | 6.382 - 6.396 | 6.397 - 6.413 | 6.414 - 6.426 | 6.427 - 6.437 | 6.438 - 6.446 | 6.447 - 6.463 | 6.464 - 6.475 | 6.476 - 6.494 | 6.495 - 6.508 | 6.509 - 6.525 | 6.526 - 6.543 | 6.544 - 6.549

6.252

It is important to recall that this was the first meeting between Victoria and anyone from the police or social services in the 13 days since Victoria had been admitted to the North Middlesex Hospital. The interview lasted less than 30 minutes and is summarised in barely a side and a half of handwritten A4 notes on the case file.

6.253

In oral evidence Ms Arthurworrey recalled, "Victoria presented as shy and withdrawn and she was reluctant to answer any of the questions that we were asking her. PC Jones then said a few words to Victoria in French and this seemed to relax and make her more comfortable." In her note of the visit she also commented that Victoria had a very big smile.

6.254

Only two matters were discussed: Victoria's account of the scalding injury which seemed to tally with Kouao's (in PC Jones's words Victoria made 'no allegation of crime'), and when she could go home.

6.255

At no time during the visit did Ms Arthurworrey raise with Victoria the other marks on her body - though she recorded in her notes that Victoria's face "had lots of old dark marks and her hair was very dry and covered with bits of dry scalp". Nor did she explore any of the hospital's concerns about neglect. Although Ms Arthurworrey told the Inquiry "I did not know how to raise the issue of master/servant relationship without sounding offensive," the fact is she believed she already had a plausible explanation from Kouao. She was also beginning to form a view in her mind that the neglect issues needed to be looked at against this family's particular social circumstances - namely a family who appeared to have no fixed abode, who were living temporarily with friends and struggling to find their feet in a new country.

6.256

However, she did observe that Victoria seemed reluctant to talk about her home life, but she put this down to the fact that Victoria had recently lost her father and was in a foreign country, in a strange environment talking to two complete strangers.

6.257

By the end of the interview, Ms Arthurworrey admitted that she had learned precious little other than that Victoria had confirmed Kouao's account of the incident by graphically playing out the actions of pouring hot water over her head.

6.258

Together, she and PC Jones decided there was no evidence of a crime, no grounds for seeking an emergency protection order and that any remaining social issues were a matter for social services alone. As the hospital had told social services that Victoria was ready for discharge and they would like that to happen as soon as possible, Ms Arthurworrey recorded in her notes: "Karen (Jones) and I agreed that the injuries (in particular the scalding injury) were probably accidental and that discharge into the mother's care was appropriate." This appears to be a decision that was endorsed by Ms Baptiste who told Ms Arthurworrey, "OK phone mother, Victoria can go home". Ms Arthurworrey duly phoned Kouao, then the hospital, and Victoria went back to Somerset Gardens later that same day.

Referral to Tottenham Child and Family Centre

6.259

Meanwhile on 5 August 1999, the day of the office interview with Kouao, Ms Arthurworrey spoke to Mr Almeida, a practice manager in the investigation and assessment B team at the NTDO and duty manager for the day, about the health and safety issues raised by doing a home visit at Somerset Gardens. She wanted some advice in the absence of Ms Baptiste but she says she never asked him to undertake any tasks in relation to Victoria's case.

6.260

Nonetheless, it was following this brief conversation that Mr Almeida referred Victoria to the Moira Close Tottenham Child and Family Centre managed by the NSPCC.

6.261

It was an extraordinary referral by any account, because Mr Almeida knew virtually nothing about the case at the time. He said in evidence that his reasons for making the referral were twofold - to obtain advice about the precautions Ms Arthurworrey might take when visiting Somerset Gardens, and secondly to prompt some form of action by the centre directed at Victoria's welfare. However, he was unclear as to what action he expected the centre to take. According to the Tottenham Child and Family Centre records, they understood the purpose of the referral was to provide "help with advisory health/hygiene, meeting Anna's developmental needs and antipathy with the interaction between mother and child". They also told Mr Almeida that it would take up to two months for an assessment to be done.

6.262

Mr Almeida admitted that at the time he made the referral he had not read the file, was not aware that there had been a strategy meeting at which 18 recommendations had been made, and did not know that there were section 47 inquiries under way. Nor did he know that Kouao was coming into the office later that day to talk about the various concerns for the very first time. All he did know was that Victoria was in hospital and that there were ongoing concerns about scabies and possible issues of neglect.

6.263

Mr Almeida passed on Ms Arthurworrey's name as the allocated social worker and assumed that the centre would contact her for more information. Surprisingly, he made no mention of the referral to Ms Arthurworrey, who says she first learned of it after Victoria's death. Although there is a record of the referral signed by Mr Almeida and dated 5 August 1999 on Victoria's file, Ms Arthurworrey believes the contact sheet with the referral details was inserted at a later date. Mr Almeida was not able to tell the Inquiry when he wrote his record. Therefore, I make the following recommendation:

Recommendation

Directors of social services must ensure that when children and families are referred to other agencies for additional services, that referral is only made with the agreement of the allocated social worker and/or their manager. The purpose of the referral must be recorded contemporaneously on the case file.

Fax from the Central Middlesex Hospital

6.264

On 12 August 1999, Ms Arthurworrey received the faxed information from the Central Middlesex Hospital that had been requested by Ms Rodgers - a fax that was to fundamentally alter Ms Arthurworrey's view of Victoria's case and to provide a crucial turning point in Haringey's whole approach to its handling thereafter.

6.265

The date stamp on the fax shows 2 August 1999, despite being sent on 29 July. I can only assume that because the fax was addressed to Ms Rodgers and she was no longer on duty on 2 August, it first went to her in the long-term children and families' team before being returned to duty and finding its way at a snail's pace to Ms Arthurworrey as the allocated social worker. That an important piece of information should arrive in the childcare office and take 10 days to reach the allocated social worker in the case is quite unacceptable.

Paragraphs: 6.172 - 6.181 | 6.182 - 6.193 | 6.194 - 6.204 | 6.205 - 6.218 | 6.219 - 6.235 | 6.236 - 6.251 | 6.252 - 6.265 | 6.266 - 6.276 | 6.277 - 6.289 | 6.290 - 6.306 | 6.307 - 6.318 | 6.319 - 6.334 | 6.335 - 6.346 | 6.347 - 6.356 | 6.357 - 6.362 | 6.363 - 6.381 | 6.382 - 6.396 | 6.397 - 6.413 | 6.414 - 6.426 | 6.427 - 6.437 | 6.438 - 6.446 | 6.447 - 6.463 | 6.464 - 6.475 | 6.476 - 6.494 | 6.495 - 6.508 | 6.509 - 6.525 | 6.526 - 6.543 | 6.544 - 6.549

6.266

The effectiveness of the 'front door' systems within children's services is of critical importance in the protection of children. The 'loss' of such an important piece of information for some 10 days cannot in my view be down to coincidence alone.

6.267

Like Ms Rodgers before her, Ms Arthurworrey found it very difficult to read the Central Middlesex Hospital material. She read the first page - the handwritten letter from Dr Charlotte Dempster - and flicked through the rest. She registered that Victoria had been in police protection briefly. More importantly Victoria had been assessed by the consultant paediatrician Dr Schwartz and, according to Dr Dempster's letter, "It has been decided that her scratch marks are all due to scabies. Thus it is no longer a child protection issue." However, had she spoken to the doctors at the Central Middlesex Hospital she might have obtained a different picture and one that should have prompted broad new avenues of investigation that would have involved Ealing and Brent Social Services, and exposed the many inconsistencies in the stories Kouao told in explaining the injuries to Victoria.

6.268

Ms Arthurworrey said she relied on Dr Dempster's letter, believing it provided an overview and summary of the Central Middlesex Hospital's involvement with Victoria. It also reinforced the need to address a number of social issues that Ms Arthurworrey had already been made aware of, namely help with housing and a school for Victoria.

6.269

She said she felt reassured by the letter because it seemed to clear up any uncertainty about the old marks on Victoria's body. She also thought it offered a possible explanation for Kouao's avoidance of child protection issues in interview. Since Victoria had previously been in police protection for a short time, it is likely that Kouao had already been questioned about child protection concerns by other agencies and was most likely reluctant to answer these questions again.

6.270

Ms Arthurworrey said she felt annoyed that the Central Middlesex Hospital information had not been made available to the strategy meeting. She recalled 'running' with the fax to Ms Baptiste: "I gave her it, she read the letter, she flicked through the fax, she smiled and she said, 'it is obvious that we made the right decision'."

6.271

Ms Baptiste remembered discussing the Central Middlesex Hospital fax, but she told the Inquiry that in August 1999 she was "confused about the chronology of the concerns" and that she asked Ms Arthurworrey to go back to the doctor and get a letter to confirm what was being said. Again, no record of this management decision appears on the case file.

6.272

The failure of both Ms Arthurworrey and Ms Baptiste to:

•

read the Central Middlesex Hospital fax fully;

•

seek clarification of the hard-to-read contents from the Central Middlesex Hospital;

•

discuss the implications of its contents with staff from both the Central Middlesex Hospital and the North Middlesex Hospital;

is poor social work practice in the extreme. Without doing any of the above, Ms Arthurworrey and Ms Baptiste immediately and wrongly re-framed the case in their eyes to one of 'family support'. At that point, any semblance of urgency was removed.

6.273

Moreover, that the diagnosis provided by the Central Middlesex Hospital could have resolved all the concerns about old marks on Victoria's body raised by her later admission to the North Middlesex Hospital makes absolutely no sense with, or without, hindsight. It clearly could not account, for instance, for injuries that may have been sustained between the two admissions. In her evidence to the Inquiry, Ms Arthurworrey accepted this must be the case.

6.274

She also accepted that Dr Rossiter could not have seen the Central Middlesex Hospital material before the strategy meeting, otherwise it would have been included in the information brought to the meeting by Ms Johns. Nor did she know whether Dr Rossiter had seen it since. Ms Arthurworrey agreed that she should have copied over the notes to Dr Rossiter for her opinion, especially as following their telephone conversation a week or so earlier, Ms Arthurworrey had agreed to get back to Dr Rossiter: "It would have been a perfect time, but it was something that I overlooked due to my other cases." In fact it was not until mid October, some two months later, that Dr Rossiter was finally sent the Central Middlesex Hospital notes.

Dr Rossiter's concerns

6.275

In the meantime, Dr Rossiter had mentioned Victoria's case in passing to Ms Kitchman, a child protection adviser in Haringey Social Services and the designated link worker for the hospital. They had run into each other following a meeting at the North Middlesex Hospital on 17 July 1999. Ms Kitchman says she did not see it as her place to take down the details there and then, nor did she believe that Dr Rossiter was making a referral, which would normally have gone through the duty social worker.

6.276

On 13 August 1999, some four days after Dr Rossiter discovered that Victoria had been discharged, she wrote to Ms Kitchman. If Ms Kitchman had had any doubts before that Dr Rossiter was seeking her assistance with this case, those doubts must have been dispelled on receipt of the letter. It read:

"Re Anna Kouao."

This is the child I wanted to speak to you about."

I never managed to speak to a social worker face to face (you have heard my concerns about this) and my understanding was that there would be a social assessment prior to an urgent planning meeting and then referral to our child psychiatrist. Unfortunately the ward staff seem to think that social workers can discharge patients who are under the care of a doctor and although I probably would have let the girl go home (she was very eager to do so) at least the consultant should have been informed. I have enormous concerns about this child who is now lost to follow-up somewhere in Haringey. What are you going to do?"

Paragraphs: 6.172 - 6.181 | 6.182 - 6.193 | 6.194 - 6.204 | 6.205 - 6.218 | 6.219 - 6.235 | 6.236 - 6.251 | 6.252 - 6.265 | 6.266 - 6.276 | 6.277 - 6.289 | 6.290 - 6.306 | 6.307 - 6.318 | 6.319 - 6.334 | 6.335 - 6.346 | 6.347 - 6.356 | 6.357 - 6.362 | 6.363 - 6.381 | 6.382 - 6.396 | 6.397 - 6.413 | 6.414 - 6.426 | 6.427 - 6.437 | 6.438 - 6.446 | 6.447 - 6.463 | 6.464 - 6.475 | 6.476 - 6.494 | 6.495 - 6.508 | 6.509 - 6.525 | 6.526 - 6.543 | 6.544 - 6.549

6.277

Perhaps even more unfortunate than the four days it took for that letter to be sent is the fact that it took a further seven days before it was read by its addressee. Ms Kitchman says she saw it for the first time on 20 August 1999. Her immediate response was to telephone Dr Rossiter and record in her 'blue book' the following details:

"Poured boiling water over her head due to scabies. Inappropriate ... lesions more than scratch marks. Mum turned up to the ward in the middle of the night 10 o'clock. Jumped out of bed and stood to attention. Said if she had another social worker she would leave. Behaviour on ward: anxious attachment, clinging to mum. Poured boiling water on herself due to itching."

6.278

This entry is not dated nor did a copy of the note ever find its way to Victoria's file.

6.279

Ms Kitchman believes she rang the NTDO on the same day and discovered that Victoria's allocated social worker was Ms Arthurworrey. She says she spoke to her on the telephone - although she now has no independent recollection of the phone call - and was told that Ms Arthurworrey and PC Jones were jointly carrying out a section 47 investigation.

6.280

Ms Kitchman relayed this information back to Dr Rossiter by phone and in so doing believed she had addressed the doctor's concerns. Most importantly Victoria was not, as she understood it, "lost to follow-up somewhere in Haringey". She had an allocated social worker and a joint investigation was under way which would include a social work assessment and could result in an urgent planning meeting and a referral to a child psychiatrist. Ms Kitchman told the Inquiry that she had confidence in the management of the duty system in north Tottenham at the time - a confidence that was to prove woefully misplaced - and saw no reason to probe with Ms Arthurworrey whether each of the concerns Dr Rossiter had raised (and that she had recorded in the 'blue book') were being addressed as part of that assessment.

6.281

Ms Kitchman admitted that despite being asked to respond to the "enormous concerns" of a highly regarded paediatrician, she did not ask to check the file for herself. If she had taken the trouble to give even a quick glance at the file she would have quickly discovered that nothing that Dr Rossiter had expected to happen had happened.

6.282

In fact it would have been rather surprising if section 47 investigations were still continuing by 20 August 1999, since the case had already shifted from being child protection to family support on 12 August, after the receipt of the fax from the Central Middlesex Hospital