Part three: Health

9 Central Middlesex Hospital

Paragraphs: 9.1 - 9.10 | 9.11 - 9.26 | 9.27 - 9.35 | 9.36 - 9.43 | 9.44 - 9.60 | 9.61 - 9.72 | 9.73 - 9.83 | 9.84 - 9.95 | 9.96 - 9.105

Background to Victoria's admission

9.1

Kouao brought Victoria to Priscilla Cameron's house on 13 July 1999 at about 8.30pm. She told Mrs Cameron that she had left the Nicoll Road hostel and was now living with Manning. She asked Mrs Cameron if she would look after Victoria permanently. Mrs Cameron refused, but said that Victoria could stay the night with her.

9.2

During the course of the night, both Mrs Cameron and her daughter, Avril Cameron, noticed that Victoria had a number of injuries. They decided that she had to be taken to hospital.

9.3

The Camerons were concerned not just that Victoria had been injured, but also as to how those injuries might have been caused. In order to try and find out, Avril Cameron took Victoria the following morning to see Marie Cader, a French teacher at her sons' school. She told Ms Cader that she suspected Victoria might have been physically abused.

9.4

Ms Cader found Victoria reluctant to talk about her injuries. She also found her to be inconsistent in the explanations that she offered for them: "When I referred to how she hurt her face she did say to me that she had scratched herself, and I looked at her hands at the time, and I noticed that her nails were very short, so I asked her if she was sure about having scratched herself, and I explained that her nails were short. She then replied, 'I fell.'"

9.5

Ms Cader agreed with Ms Cameron's intention to take Victoria to hospital. She was confident that, once Victoria had been placed under the care of the hospital staff, "they would carry out the necessary procedure and ensure that the right people were contacted in order to help the child". It is clear from what followed that her confidence was misplaced.

Central Middlesex Hospital

9.6

On 14 July 1999, Ms Cameron took Victoria to the Central Middlesex Hospital, which is situated in north west London within what was then the Brent and Harrow Health Authority and is now the North West London Strategic Health Authority.

9.7

The hospital itself formed part of the North West London Hospitals NHS Trust. The Trust was formed on 1 April 1999 by the merging of the Central Middlesex Hospital NHS Trust with the Northwick Park and St Mark's NHS Trust. The current chief executive, John Pope, was appointed shortly after this merger. The current medical director, Dr John Riordan, was appointed in July 1999.

Arrival at accident and emergency department

9.8

Victoria was seen at 11.50am on 14 July 1999 by Dr Rhys Beynon, a senior house officer in the accident and emergency department. Ms Cameron told him what she knew of Victoria's background. He recorded that she had been looked after by "a neighbour" for the past month and that "lots of bruises/cuts to face/arms/hands" had been noticed. He also noted that, the previous night, Victoria's mother had asked the Camerons to "look after [Victoria] for good" and that they had noticed "lots of new cuts/bruises/red eyes".

9.9

This history led Dr Beynon to consider it a strong possibility that Victoria's injuries were non-accidental. He was aware of the requirement, laid down in the hospital's child protection guidelines, that cases of suspected abuse had to be referred to a paediatrician. Accordingly, he contacted Dr Ekundayo Ajayi-Obe, the on-call paediatric registrar.

9.10

Dr Ajayi-Obe recalled being paged by Dr Beynon some time after midday. He explained that there was a child in the accident and emergency department whom he suspected to be suffering from non-accidental injury. Dr Ajayi-Obe agreed to take over responsibility for Victoria's care.

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Dr Beynon's observations

9.11

Dr Beynon conducted only a very cursory examination of Victoria while she was under his care. His explanation for not being more thorough was as follows: "Given what I was told, she was going to have to be fully examined by the paediatric team. I did not feel any benefit from giving an eight-year-old child two full physical examinations.

9.12

He did, however, notice numerous wounds on Victoria's body. Unfortunately, precisely what he saw is unclear, due to the fact that he did not record his findings. While he accepted that he should have documented all that he saw, Dr Beynon told me that his failure to do so was due, at least in part, to the need for busy casualty officers to manage their time. He was aware that the paediatric team would be taking over Victoria's care and that they would be undertaking a thorough examination at a later stage.

9.13

Despite the brevity of his notes, Dr Beynon said that, had he been informed that Victoria had been scratching excessively prior to her attendance at hospital, he would have recorded this information, as it would have been inconsistent with a diagnosis of non-accidental injury. Furthermore, he did not notice Victoria scratching herself.

9.14

In the context of his role as an accident and emergency senior house officer, I regard the approach that Dr Beynon took to Victoria's care to be appropriate. He described that role as being akin to that of a "switchboard operator", and that his primary responsibility was to refer Victoria on to someone with the requisite specialist knowledge and experience. This is precisely what he did, and in my view, he exhibited sound judgement in his care of Victoria by referring her immediately to a paediatric registrar.

9.15

In the normal course of events, this would be the last contact that a doctor in Dr Beynon's position would expect to have with his patient. However, he was particularly interested in Victoria's case and this led him to go up to the ward before his shift the following day to check on her progress. He was told that the child protection team was aware of Victoria's case and was going to come and assess her.

9.16

Dr Beynon's reasons for taking the time and trouble to find out what was to happen to Victoria after she had been admitted to the ward are instructive. He said that he thought that Victoria had a very interesting history and that, at the time, his concern for her was such that he thought she might end up in care.

9.17

Dr Beynon was an expert neither in paediatrics nor in child abuse - Victoria's was one of only two cases of suspected child abuse that he saw in the six months he spent in the accident and emergency department. Nonetheless, he saw and heard enough, in the brief period during which he was involved in her care, to cause him considerable concern. The obvious implication - namely that Victoria was exhibiting fairly obvious signs of physical abuse on 14 July 1999 - is reinforced by the evidence of Dr Ajayi-Obe who assumed responsibility for her care later that afternoon.

Arrival on Barnaby Bear ward and assessment by Dr Ajayi-Obe

9.18

Victoria was transferred to Barnaby Bear ward. Following her arrival, she was examined by Dr Ajayi-Obe. She found Victoria to be a "jolly child" who was not unduly distressed by what was happening to her at the hospital. Dr Ajayi-Obe felt that, despite the fact that Victoria was able to understand her questions, she was reluctant to talk about how she had come by her injuries. She recorded her as being "a very secretive child".

9.19

Dr Ajayi-Obe's examination of Victoria would seem to have been a thorough one. Of the findings that she recorded in the notes, I consider the following to be of particular significance:

•

"Scars of various sizes and ages all over body from about two days to several weeks, possibly months."

•

"Relatively fresh scars on the face, corners of mouth. Infected cuts on fingers, bloodshot eyes."

•

"A month ago Anna's Mum came knocking on the carer's door ... desperate to leave Anna with somebody for the following Monday."

•

"Does not go to school."

•

"Pungent smell, unkempt appearance."

9.20

Dr Ajayi-Obe also completed a body map, on which she recorded a number of marks on both sides of Victoria's face, on the top of her right arm, on both hands, on her back and on her buttocks. Precise details of all of these marks were not recorded by Dr Ajayi-Obe, but their location on parts of the body not normally affected by ordinary childhood accidents was sufficient in itself, in my view, to raise a suspicion of physical abuse.

9.21

In addition to their location, the nature of some of the marks was also a cause of concern: for example, the infected cuts that Dr Ajayi-Obe noted to Victoria's fingers. As to the explanation for the cuts given by Kouao to the Camerons, Dr Adjayi-Obe remarked that she had never come across a child who had deliberately cut him or herself with a razor blade. In addition, she considered that Victoria's bloodshot eyes could not have been caused by a cold, or by mere rubbing or crying.

9.22

Nor was Dr Ajayi-Obe satisfied with Victoria's explanation of how she had come by her various injuries. When asked, Victoria indicated that she had caused the injuries herself and demonstrated itching and scratching. However, Dr Ajayi-Obe did not consider this to be credible and told me that, in her opinion, only some of the marks and injuries that she recorded could conceivably have been self-inflicted.

9.23

As to the question of whether Victoria's injuries might have been attributable to scabies, Dr Ajayi-Obe said such a diagnosis did not cross her mind. This was despite the fact that she had seen a number of scabies cases while practising in Lagos.

9.24

In marked contrast to any of the other doctors who saw Victoria, Dr Ajayi-Obe's notes were detailed and comprehensive. She obtained a great deal of information about Victoria's social situation which, together with her examination findings, occupy some seven pages of hospital notes. The examination she gave Victoria was detailed and thorough. As such, her notes provide the best evidence available as to the information available to the hospital staff on the day that Victoria was admitted.

9.25

I am satisfied that this information, viewed as a whole, was sufficient to ground a strong suspicion that Victoria was being physically abused. In particular, the quantity and distribution of marks on Victoria's body added considerable weight to the suspicions expressed by Ms Cameron and the preliminary diagnosis made by Dr Beynon.

9.26

Dr Ajayi-Obe, it would seem, reached the same conclusion. Having examined Victoria and listened to her history, she was "strongly suspicious" that her injuries were non-accidental. She decided that Victoria should be admitted onto the ward.

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Initial action by Dr Ajayi-Obe

9.27

Dr Ajayi-Obe then made two telephone calls. The first was to Dr Ruby Schwartz, the 'on-call' consultant who was also the hospital's named doctor for child protection. Dr Schwartz remembers receiving Dr Ajayi-Obe's call while conducting an epilepsy clinic at a local school. She was told that a child was on the ward with suspected non-accidental injuries. Although she made no note of the conversation, Dr Schwartz recalled that her response was to direct Dr Ajayi-Obe to admit Victoria and advise social services of the position. She said that she would come and see the child later that day. Dr Ajayi-Obe never had the opportunity to explain her concerns to Dr Schwartz face to face - she had gone off duty by the time Dr Schwartz arrived at the hospital.

9.28

In accordance with Dr Schwartz's advice, the second call that Dr Ajayi-Obe made was to Brent Social Services, whose records indicate that the referral was received at 4pm. Dr Ajayi-Obe could not recall to whom she spoke but remembers telling someone that she had a child on the ward whom she suspected to be suffering from non-accidental injury.

9.29

At 5.30pm, Nurse Paula Johnson, ward sister and lead child protection nurse at the Central Middlesex Hospital, took a call from Michelle Hines of Brent Social Services. Nurse Johnson recorded in the hospital notes that Victoria had been placed in police protection and that she was not to leave the ward. The note also records that the child protection team preferred Mum not to visit. If she did, she was to be closely supervised.

Nursing records

9.30

At about this time, Ms Cameron left Victoria to go back to her own children. She asked one of the nurses to tell Victoria in French that, although she was leaving, the doctors and nurses would look after her. Far from being reassured, Victoria became "unusually upset" at Ms Cameron's departure and tried desperately to follow her out of the ward. Victoria's reaction was observed by several nurses, but was recorded by none of them.

9.31

In fact, the nursing notes relating to Victoria's time on the ward are bereft of any information that might have been useful in the assessment of whether or not she was the victim of abuse. For example, Nurse Carol Graham, who recalled being told at the time of her admission that there were suspicions about Victoria, was shown marks on Victoria's forearms by one of her colleagues, Nurse Mary Sexton. They both formed the view that the marks were indicative of non-accidental injury. Neither of them made any record of their findings or suspicions.

9.32

Furthermore, the fact that Victoria's admission was related to concerns about abuse is absent from the nursing records. The nursing care plan for Victoria prepared by Nurse Bob Gobin, who was the nurse assigned to Victoria from 7.45pm onwards, makes no mention of any of the child protection concerns that brought Victoria into hospital in the first place, and attributes her admission solely to the fact that she was said to be suffering from scabies.

9.33

If, as Nurse Gobin said, the plan was written after Dr Schwartz's ward round that evening, which I discuss at paragraph 9.36 below, one can understand why the issue of scabies should have featured prominently. Nonetheless, it would plainly have been preferable for the plan to have reflected the concerns relating to possible deliberate harm that had prompted Victoria's admission in the first place, and the further concerns felt by some of the nursing staff during the time that Victoria was on the ward.

9.34

The importance of accuracy applies just as much to nursing records as it does to medical notes. Nurse Johnson shared my surprise that no mention of non- accidental injuries, suspicions of abuse, police protection or concerns about Kouao found their way into the nursing care plan. She told me that this is the first document that a nurse involved in the care of a particular child will look at. In Victoria's case, she would have expected the plan to have consisted of two pages - one dealing with scabies and one relating to the suspicions of abuse which had prompted the admission.

9.35

The observations of nurses during the day-to-day care of children on the ward can be of enormous value in cases of possible deliberate harm. In order for this resource to be most effectively utilised, it is vital that the nursing staff are made aware of which children are the subject of concern. I therefore make the following recommendation:

Recommendation

When a child is admitted to hospital and deliberate harm is suspected, the nursing care plan must take full account of this diagnosis.

Paragraphs: 9.1 - 9.10 | 9.11 - 9.26 | 9.27 - 9.35 | 9.36 - 9.43 | 9.44 - 9.60 | 9.61 - 9.72 | 9.73 - 9.83 | 9.84 - 9.95 | 9.96 - 9.105

Dr Schwartz's ward round

9.36

Dr Schwartz examined Victoria on the paediatric assessment unit with Dr Anita Modi, an experienced paediatric registrar, at around 8pm. Dr Schwartz said she left Victoria's examination until last because her case was a "complicated one" and she wanted to make sure that she had sufficient time to carry out a full assessment without interruption. Dr Schwartz told me that, prior to examining Victoria, she read all the notes taken since her admission.

9.37

By the time that Dr Schwartz arrived at Victoria's bedside, Kouao was on the ward and the examination was carried out in her presence. Dr Schwartz was not concerned about the way Kouao and Victoria interacted, but she was troubled to hear they were homeless and that Victoria was not attending school. She had a discussion with Kouao (largely in French but using some English words) during the course of which Kouao explained how Victoria had come by her injuries, giving an explanation that Dr Schwartz regarded as plausible.

9.38

Dr Schwartz could not recall whether she spoke directly to Victoria. What is clear, however, is that she did not seek to speak to her alone. With the benefit of hindsight, she accepted this would have been a sensible course of action, but at the time she expected a full investigation to be carried out by social services and was wary of compromising any interview they might wish to conduct.

9.39

I take the view that paediatricians should not be discouraged from speaking directly to a child, or from seeing a child alone, solely on the grounds that this might compromise a future joint investigation. I hold to this view especially when concerns about possible child abuse are presented initially to doctors so that they are the first members of the multi-disciplinary team with an opportunity to evaluate what has happened to a child. I therefore make the following recommendation:

Recommendation

When the deliberate harm of a child is identified as a possibility, the examining doctor should consider whether taking a history directly from the child is in that child's best interests. When that is so, the history should be taken even when the consent of the carer has not been obtained, with the reason for dispensing with consent recorded by the examining doctor. Working Together guidance should be amended accordingly. In those cases in which English is not the first language of the child concerned, the use of an interpreter should be considered.

9.40

When Dr Schwartz finished examining Victoria, she concluded that she had scabies and this had caused her to scratch herself vigorously. She described the findings that led her to this conclusion as follows: "What I found were the marks, particularly on her hands, the scratch marks, the areas that looked as if they had pus in, and the fact that there were scratches on the body as well." She was also influenced by what she considered to be the resemblance between Victoria's symptoms and those of scabies sufferers she had seen in the past.

9.41

As to Dr Ajayi-Obe's alternative interpretation of Victoria's injuries, Dr Schwartz said that, in her judgement, neither the quantity nor the distribution of the marks on Victoria's body were indicative of physical abuse. Furthermore, the marks on Victoria's hands looked to her like superficial scratches rather than cuts inflicted by a razor blade and she noticed nothing significantly abnormal about Victoria's eyes.

9.42

Dr Schwartz could not recall whether she looked at Victoria's fingernails to see if they were long enough to cause the type of marks visible on Victoria's body, nor could she recall asking Victoria whether she scratched herself. In addition, Dr Schwartz found no evidence of the burrows commonly associated with scabies infection.

9.43

Dr Schwartz also accepted that a scabies diagnosis could not account for all of the marks visible on Victoria's body, many of which did not appear in the characteristic sites of scabies in children. However, she took the view that none of these other marks were indicative of physical abuse. She said that, in her view, "Some of them could have been old insect bites, some of them could have been secondary to knocks that she had sustained during the course of play and movement around, some of them could have been things that had occurred prior to her coming to this country. I did not feel that they had the configuration that would worry me of a child that has suffered non-accidental injury.

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The merits of Dr Schwartz's diagnosis

9.44

In her evidence before me, Dr Schwartz was unshakeable in her conviction that Victoria had scabies. Although the definitive evidence of scabies provided by sight of the scabies mites or their burrows was not available, she believed that she saw sufficient signs to make her confident of her diagnosis. I was told that the scabies mite and its burrows can often be difficult to detect, particularly in children, and that the fact that Dr Schwartz did not see them in Victoria's case does not demonstrate that her diagnosis was flawed.

9.45

In addition, Dr Ajayi-Obe, even though she herself had not considered a diagnosis of scabies when she examined Victoria, was prepared to accept that such a diagnosis might account for at least some of Victoria's history and presentation.

9.46

While this matter is plainly one that cannot be definitively resolved so long after the event, I heard no compelling evidence to demonstrate that Dr Schwartz was wrong to conclude that Victoria had scabies. In the absence of such evidence, I have decided that the account of this highly experienced paediatrician should be accepted on this point, and that Victoria was suffering from a scabies infection when she was admitted to the Central Middlesex Hospital on 14 July 1999.

9.47

However, the more important question is whether Victoria was suffering from scabies alone or a combination of scabies and physical abuse. In her statement to this Inquiry, Dr Schwartz was clear that, in her judgement, Victoria was not exhibiting signs of physical abuse when she saw her on the evening of 14 July 1999. While she moved slightly from this position during the course of her oral evidence, admitting that she "could not entirely exclude physical abuse", the tenor of her evidence was that there was very little, if any, visible indication that Victoria had been abused when she examined her.

9.48

Having considered all the available material, I reject Dr Schwartz's evidence on this point. I conclude that Victoria was exhibiting visible signs of physical abuse on 14 July 1999 and that Dr Schwartz failed to recognise them. I prefer the conclusions reached by both Dr Beynon and Dr Ajayi-Obe, both of whom took the view, having seen Victoria's injuries and listened to her history, that there was a strong possibility that she had been abused. While this conclusion is based upon the totality of the evidence I heard on the issue, I set out below the specific matters which I found to be of particular relevance.

9.49

Dr Schwartz told me during the course of her oral evidence that the lesions on Victoria's body, which she considered to be compatible with scratching caused by scabies, were to be found "predominantly on her hands and her arms". It is plain from the notes and, in particular, the body map completed by Dr Ajayi-Obe, that Victoria's injuries were by no means restricted to her arms and hands. In fact, Dr Ajayi-Obe recorded that Victoria had scars of varying ages "all over" her body, including on the legs, back, neck and face.

9.50

The only explanation for any of Victoria's injuries that had been provided by the time that she was seen by Dr Schwartz was that she had inflicted them herself, either by scratching or cutting herself with a razor blade. There is nothing to suggest that Kouao put forward any alternative explanation when Dr Schwartz spoke to her at Victoria's bedside. What, then, was Dr Schwartz's diagnosis of the marks on Victoria's body other than those on her hands and arms?

9.51

Her view was that these were the result of old insect bites and ordinary childhood injuries caused by running around and playing. The obvious initial difficulty with this diagnosis is that, as far as can be determined from the notes, nobody had ever suggested that these injuries might have been caused by insect bites or childhood rough and tumble. Therefore, it would appear that Dr Schwartz's diagnosis of these injuries was based upon her assumptions, rather than any information obtained from Victoria or her carer. Nor is there any indication that she took the trouble to test those assumptions by asking them. She certainly did not go through each of the visible injuries and ask Victoria or Kouao how they had been caused.

9.52

Of course, the simple fact that it was based upon untested assumption does not necessarily mean that Dr Schwartz's diagnosis of the marks on Victoria's body was incorrect. However, in my judgement, it is not a diagnosis that withstands close analysis.

9.53

First, the pattern of injuries on Victoria's body is striking. Children who hurt themselves while running around and playing will normally sustain cuts and grazes to their fronts and, particularly, to those parts of their bodies not protected by clothing. When they fall, they tend to fall forwards. However, there is a marked absence of injuries recorded to the front of Victoria's body. The majority of the marks are noted as having been on her back, buttocks and backs of her legs. Therefore, I find that the records completed at the time provide little support for Dr Schwartz's view that a significant proportion of Victoria's injuries could have been caused by childhood rough and tumble.

9.54

Second, Dr Schwartz's theory as to insect bites is substantially undermined by the history taken by Dr Beynon. He recorded that Victoria had arrived in England two to three months earlier, having previously lived in France. Dr Schwartz told me that she had been influenced in her diagnosis by the fact that Victoria had lived "in poor conditions" in the Ivory Coast. She said, "She had lived in poor conditions, I had been informed that she had come from abroad, that she may have had marks from insect bites or the like abroad."

9.55

While I accept that it can sometimes be difficult to accurately assess the age of injuries visible on a child's body, I have no reason to doubt Dr Ajayi-Obe's assessment, recorded in the notes, that the injuries she saw on Victoria ranged in age from "two days to several weeks, possibly months". For any of Victoria's marks to have been attributable to insect bites received in the Ivory Coast, they would have to have been over eight months old. I conclude, in light of Dr Ajayi- Obe's evidence on the point, that the marks she saw on Victoria's body were not that old, and so were not the result of insect bites. I suspect that, had Dr Schwartz taken the trouble to find out how long it had been since Victoria left Africa, she would have reached a similar conclusion.

9.56

The inadequacy of the alternative explanations for Victoria's injuries offered at the time does not, in itself, establish that those injuries were indicative of abuse. In determining what was the correct interpretation of the evidence available to Dr Schwartz, I have found the nature and location of the marks on Victoria's body to be the decisive factor.

9.57

The Central Middlesex Hospital child protection guidelines include a list of factors in a child's presentation and history that should alert a health professional to suspicion of abuse. These include marks to the skin in unusual sites and patterns. As set out above, this was plainly the case with Victoria's marks. She had a number of old and new lesions on her body at sites that could not be explained by either Dr Schwartz's diagnosis of scabies or by the normal rough and tumble of childhood.

9.58

In addition, the guidelines indicate that a lack of supervision by the carer and/or an inappropriate story as to how the injuries might have been sustained can also be suggestive of abuse. The explanation offered as to how Victoria's injuries had been sustained, namely that she had scratched herself and cut her own hands with razor blades, falls in my view into both of those categories. In this regard, Dr Schwartz should also have taken account of the fact that it was the childminder's daughter and not the mother who had actually sought treatment for Victoria's injuries.

9.59

Therefore, I conclude that the marks visible on Victoria's body and the history with which she presented at the hospital were sufficient to ground a strong suspicion of physical abuse of the sort felt by Dr Ajayi-Obe. I also conclude that Dr Schwartz failed properly to assess the evidence available to her at the time in discounting the possibility that some of Victoria's injuries may have been non-accidental.

9.60

It is unclear to what extent Dr Schwartz challenged Kouao on the issues noted by Dr Beynon and Dr Ajayi-Obe because no details of Dr Schwartz's interview with Kouao are recorded. Dr Schwartz said that she should have gone through each of Victoria's injuries and asked Kouao for an explanation, but admitted that she probably did not do this. I consider this a major oversight in Victoria's care. As with any serious medical condition, the proper treatment of deliberate harm requires a thorough and systematic approach so that important matters which might prove crucial to the future welfare of the child are not missed. In order to encourage the use of such an approach, I make the following recommendation:

Recommendation

When a child has been examined by a doctor, and concerns about deliberate harm have been raised, no subsequent appraisal of these concerns should be considered complete until each of the concerns has been fully addressed, accounted for and documented.

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Failure to reconcile differences in medical opinion

9.61

I wish to make one additional point that I consider to be a major factor in determining the outcome of Dr Schwartz's evaluation of Victoria. Dr Schwartz said she was unable to speak to Dr Ajayi-Obe on the evening of 14 July because, by the time she had finished her assessment of Victoria, Dr Ajayi-Obe had gone off duty for the day. Whatever the circumstances that made contact difficult, it is unacceptable that no conversation took place between the two doctors when Dr Schwartz reached such a dramatically different conclusion to Dr Ajayi-Obe as to the cause of Victoria's marks.

9.62

The difference in the diagnoses reached by Dr Schwartz and Dr Ajayi-Obe was plainly of enormous significance to the future management of Victoria's case. Dr Schwartz should have been aware that her diagnosis would have a profound impact on the child protection investigation that had started (albeit ineffectively) that evening. Therefore, it was imperative that, before arriving at the view she did, she ensured that she had a full appreciation of the matters which had led Dr Ajayi-Obe to reach a different view a few hours earlier.

9.63

Although the basis of Dr Ajayi-Obe's concerns was clearly recorded in her notes, finding time to discuss the case with Dr Ajayi-Obe after her own examination might have led Dr Schwartz to reassess her conclusions about the cause of the marks on Victoria's body. At the very least, it might have resulted in a more conscientious attempt by Dr Schwartz to ensure that the concerns that she said she had about Victoria at the time of her examination were clearly reflected in the hospital notes.

9.64

I appreciate that the working practices and shift patterns at the Central Middlesex Hospital at the time could often make contact between two particular doctors difficult to arrange. However, whatever the practical difficulties may have been in this particular case, they do not provide an excuse for the failure of Dr Schwartz to speak to Dr Ajayi-Obe to gain a full understanding of the reasons why she had come to the view that Victoria was likely to be the victim of deliberate harm.

9.65

I conclude that a diagnosis of possible deliberate harm should never be superseded by an alternative diagnosis, without a discussion taking place between the doctors concerned. When major differences of opinion occur, such as in Victoria's case, it is the responsibility of the consultant in charge of the case to make sure that the views of all those concerned are properly taken into account before a conclusion is reached. The diagnosis of deliberate harm is far from an exact science and failure to recognise it can be fatal. In those circumstances, it is imperative that when it is suspected, it is not subsequently ruled out without careful consideration of the alternative view. In an effort to ensure that such consideration takes place, I make the following recommendation:

Recommendation

When differences of medical opinion occur in relation to the diagnosis of possible deliberate harm to a child, a recorded discussion must take place between the persons holding the different views. When the deliberate harm of a child has been raised as an alternative diagnosis to a purely medical one, the diagnosis of deliberate harm must not be rejected without full discussion and, if necessary, obtaining a further opinion.

Notes of Dr Schwartz's assessment

9.66

The notes of Dr Schwartz's assessment of Victoria were written by Dr Modi and occupy about one-third of a page in the hospital records. Dr Schwartz told me that her normal practice was to write her own notes, particularly in complicated cases such as Victoria's, and her failure to do so on this occasion was likely to have been due to her being called away on an urgent matter.

9.67

As to the quality of the notes, Dr Schwartz told me that they did not reflect the totality of what took place during the course of her examination and assessment of Victoria. In particular, they did not reflect the fact that, although she had ruled out non-accidental injury, she was still concerned that Victoria might be suffering from "other forms" of abuse. She stated that, in light of subsequent events, it was a disaster from her point of view that they did not.

9.68

Dr Modi said that she felt that her notes were adequate, save that she should have written "no physical abuse issues" instead of "no child protection concerns". While it might be possible to criticise Dr Modi for failing to reflect this distinction in the notes, particularly in light of what was to transpire the following day, I take the view that the notes provide a fairly accurate reflection of the conclusions that Dr Schwartz expressed at this point. I am not satisfied that she had pressing "child protection" concerns regarding Victoria, or that she went very much beyond her diagnosis of scabies in her consideration of the case.

9.69

The fact that Dr Schwartz disputed the accuracy of Dr Modi's note illustrates why it is extremely important for consultants, wherever possible, to write their own notes. It is a matter of grave concern that two senior doctors, both of whom were present at the time, were unable to agree as to what was said on a topic of this importance. If the notes confused and misled them, how much more misleading and confusing would they be for others who came to read them later?

9.70

For this reason, I regard it as vitally important that doctors make a full record of their history-taking, observations and findings at the time they are carried out. This is particularly important when dealing with sensitive and potentially contentious issues, such as child protection. Medical opinion is often sought in the context of a multi-agency child protection investigation well after the date on which a child is seen and examined. Medical opinion based on incomplete or imprecise records is virtually worthless.

9.71

In addition, doctors will often have to speak about their concerns for a child in the context of a later strategy meeting, a case conference, or even a criminal trial. In order for them to be able to provide a clear and accurate account of what they saw and thought at the time they examined the child concerned, precise and detailed notes are essential.

9.72

Dr Schwartz was aware that there was likely to be further investigation of Victoria's case by social services, and that she was likely to have role to play in that investigation. I am unable to discern how she could have felt equipped to provide social services with a coherent view of Victoria's circumstances and physical condition without having made her own notes at the time of her interview with Kouao and examination of Victoria. In an effort to avoid the repetition of such a mistake, I make the following recommendation:

Recommendation

When concerns about the deliberate harm of a child have been raised, doctors must ensure that comprehensive and contemporaneous notes are made of these concerns. If doctors are unable to make their own notes, they must be clear about what it is they wish to have recorded on their behalf.

Paragraphs: 9.1 - 9.10 | 9.11 - 9.26 | 9.27 - 9.35 | 9.36 - 9.43 | 9.44 - 9.60 | 9.61 - 9.72 | 9.73 - 9.83 | 9.84 - 9.95 | 9.96 - 9.105

Further investigations

9.73

Also included in Dr Modi's note were instructions that a skin swab be performed and a dermatology opinion obtained. Dr Modi told me that she considered it to be the responsibility of junior doctors on the ward to ensure that these instructions were carried out and that she delegated this responsibility when she handed over to another junior doctor on the morning of 15 July 1999. Nurse Gobin also recorded "refer to dermatologist and other multidisciplinary team" on the nursing care plan. He said he would have told the nurse in the morning during handover to pass this information on to doctors to ensure it was done.

9.74

The senior house officer on the ward during the morning of 15 July was Dr Charlotte Dempster, a locum. When questioned about the further investigations ordered by Dr Schwartz and recorded in the notes by Dr Modi, she said that she would have expected the skin swab to have been done by a nurse and sent to the laboratory, and that she did not remember whether or not she spoke to a dermatologist in order to seek an opinion. However, what does seem to be clear is that in the event, no skin swab was taken and no dermatology opinion was obtained.

9.75

As to how these unfortunate omissions could have occurred, Dr Schwartz said: "There are many requests that, in this case and in other cases, we ask for that do not appear to occur, and I do not know, in a system where there are so many people, how we can actually prevent these sorts of things from occurring.

9.76

I do not accept Dr Schwartz's assertion that oversights of this nature cannot be prevented. On the contrary, the more people that are involved, the more important it is to devise a system that ensures that requests are followed up. I refuse to accept that failures to follow through important medical requests are somehow either inevitable or excusable. The fact that there would appear to have been no system operating on the ward designed to ensure that requests of this nature were followed up is one, therefore, that causes me considerable concern. I return to the issue of systematic care later in this Report in paragraphs 11.35 and 11.36.

The day after admission

9.77

Dr Dempster first met Victoria and Kouao on the morning ward round on 15 July. She would normally expect to carry out such ward rounds in the company of a consultant or registrar but, on this occasion, she was on her own. This is particularly surprising given that Dr Dempster was a locum working only a single shift in the hospital.

9.78

Dr Dempster based her understanding of Victoria's situation on Dr Modi's notes written the evening before and the information that she was given at the handover when she arrived on the ward. She described that understanding as: "It had been passed over to me that the concerns about non-accidental injury were not a problem any more, so the diagnosis with her was she had scabies.

9.79

Following her ward round, Dr Dempster considered that the priority as far as Victoria was concerned was to contact social services and arrange for them to come and see Victoria. It would normally be the job of a registrar to seek the involvement of social services in cases such as Victoria's but, as she was the only doctor on the ward, Dr Dempster assumed the responsibility for ensuring that this was done.

Dr Dempster's contact with social services

9.80

She rang the number that had been written in the notes on the previous evening but could not remember to whom she spoke or in which department they worked. She refuted the suggestion, made by Ms Hines, that she told social services that the hospital "would like the child protection withdrawn and treat as a child in need, because the family needs urgent housing". Her recollection was that she told social services, "Dr Schwartz's diagnosis from the ward round the night before and ... what the concerns were - the problems with the housing and other issues."

9.81

Having listened to Dr Dempster's evidence, I conclude that her recollection of this conversation is to be preferred to that of Ms Hines. The uncertainty she displayed as to the difference between a "child in need of protection" and "a child in need", together with her lack of experience of dealing with social services, causes me to doubt that she expressed herself in the precise and technical way suggested by Ms Hines. As to the lifting of child protection, this was again a matter of which Dr Dempster had little experience. She told me that she would not have known how to go about removing a child from police protection and would not have considered this to be a matter within the authority of a senior house officer. Given her lack of familiarity with the issues involved, I consider that Dr Dempster did little more than relay the conclusion expressed in the notes that there were no longer any "child protection issues".

9.82

Whatever the precise form of words she used, Dr Dempster had some difficulty in securing a satisfactory response from social services. She recalled that she ended up having at least two or three lengthy conversations with social services due to the fact that she was having trouble ascertaining who was going to take responsibility for seeing Victoria. Her impression was that the change in diagnosis from non-accidental injury to scabies meant that a different person was now to take responsibility for the case. She said, "Whoever I talked to made it a lot more complicated, actually, because I thought that whoever I talked to would come in and see her and it would be very straightforward. But it was not."

9.83

In fact, there would appear to have been considerable confusion, not merely as to the identity of the social worker who was to visit Victoria, but whether there was going to be a visit at all.

Paragraphs: 9.1 - 9.10 | 9.11 - 9.26 | 9.27 - 9.35 | 9.36 - 9.43 | 9.44 - 9.60 | 9.61 - 9.72 | 9.73 - 9.83 | 9.84 - 9.95 | 9.96 - 9.105

Dr Dempster's letter

9.84

At some stage during her conversations with social services, Dr Dempster was asked to put the hospital's concerns in writing. In response to this request, she wrote and faxed a letter to the "Duty Social Worker". She expected the letter to be passed to one of the social workers with whom she had been dealing thus far. The letter read as follows:

"Thank you for dealing with the social issues of Anna Kouao. She was admitted to the ward last night with concerns re: possible NAI [non- accidental injuries]. She has however been assessed by the consultant Dr Schwartz and it has been decided that her scratch marks are all due to scabies. Thus it is no longer a child protection issue. There are however several issues that need to be sorted out urgently: 1) Anna and her mother are homeless. They moved out of their B & B accommodation 3 days ago. 2) Anna does not attend school. Anna and her mother recently arrived from France and do not have a social network in this country. Thank you for your help."

9.85

Dr Dempster said that her intention in writing the letter was to prompt a visit to the hospital by a social worker, rather than to set out every relevant piece of information in the hospital's possession. However, her letter did not contain any such invitation and Dr Dempster explained that it was through the conversations that she had with social workers that she expected someone to come to the ward. She admitted that she could not remember being told outright that a social worker would come to the ward to see Victoria, and agreed that the origin of her understanding was possibly the entry in the hospital notes from the night before that stated: "Michelle Hines will visit ward tomorrow".

9.86

Dr Dempster agreed that, taken at face value, her letter alone was inadequate to ensure a visit, and that it would have been sensible to make explicit her wish that social services come in and see Victoria on the ward before she was discharged. She also accepted not only that she omitted to mention many of the important markers of neglect that were recorded in the hospital notes, but also that she failed to mention these markers verbally to the social workers to whom she spoke. The inevitable result was that social services gained an incomplete picture of the hospital's concerns. As explained above, Dr Dempster thought that these gaps could be filled when the social worker responsible for Victoria's case came to visit the ward. No such visit ever took place.

9.87

Dr Schwartz said that the writing of this letter should not have been left to a locum doctor with little knowledge of the case and that, had she written it herself, its contents and emphasis would have been very different. In particular, she regarded Dr Dempster's letter as constituting only a very "superficial" account of the complex discussion which had taken place the previous evening.

9.88

It is plainly a matter of considerable regret that Dr Dempster's letter did not contain a more thorough account of the information held by the hospital - which was potentially indicative of abuse. However, it is easy to see how Dr Dempster's letter came to be worded in the way that it was. There was little, if anything, in Dr Modi's note of the previous day's ward round which would have indicated to Dr Dempster that Victoria's case was one of particular concern and, by the time that she came onto the ward on the morning of 15 July, the strong suspicions held by Dr Beynon and Dr Ajayi-Obe less than a day earlier had effectively fallen below the horizon.

Victoria's discharge

9.89

How Victoria came to be discharged from Barnaby Bear ward remains a mystery. While Dr Dempster was able to provide me with some assistance as to the discharge procedure that should have been followed, she had no recollection whatsoever of the circumstances of Victoria's departure.

9.90

The decision to discharge, she told me, is normally taken by a senior doctor, following which a discharge letter is written. One copy of the discharge letter should go in the notes, one should go to the patient, and one should go to the GP. The fact that no discharge letter appears in Victoria's notes led Dr Dempster to conclude that she cannot have been involved in the actual discharge itself. In any event, she said that she would not have authorised Victoria's discharge herself, but would have contacted whichever senior doctor was responsible for the ward that day.

9.91

As there was no registrar on duty on 15 July, Dr Dempster thought it likely that she spoke to Dr Schwartz. For her part, Dr Schwartz remembers being paged by Dr Dempster on the morning of 15 July and being told by her that social services were not investigating further.

9.92

Having received this news, Dr Schwartz was "almost positive" that she spoke to someone in social services seeking an assurance that Victoria would not go home without being satisfied that the "significant worries" she felt about her would be addressed. These included, as far as Dr Schwartz was concerned, the concerns about housing and schooling identified in Dr Dempster's letter.

9.93

Unfortunately, there is no note of any conversation between Dr Schwartz and social services in the hospital records and, therefore, no way of knowing if a call took place, to whom Dr Schwartz spoke, or what assurances she received. Nor is there any record of a conversation with Dr Schwartz on the Brent Social Services' case file. Ms Hines was firm in her denial that she spoke to Dr Schwartz and equally firm in her belief that she recorded faithfully in her contact notes details of the doctors she spoke to, together with a brief summary of their conversation.

9.94

In the absence of any objective at evidence from that time that a conversation between Dr Schwartz and social services took place on 15 July, or any convincing explanation of why no record of it was made in either the hospital or social services records, I am driven to conclude that it is unlikely such a conversation occurred. The result of this conclusion is that I reject Dr Schwartz's evidence that she received any assurance, either from Ms Hines or any other Brent social worker, that her concerns regarding Victoria would be addressed before she was discharged.

9.95

The problems caused by such imprecision of recollection are clear. It is understandable that busy professionals dealing with a large number of cases on a daily basis can forget precisely what conversations they may have had about which cases. The result is that cases can proceed on the basis of mistaken assumptions as to what has been done or said. The only solution to this problem lies in the keeping of better notes. I therefore make the following recommendation:

Recommendation

When concerns about the deliberate harm of a child have been raised, a record must be kept in the case notes of all discussions about the child, including telephone conversations. When doctors and nurses are working in circumstances in which case notes are not available to them, a record of all discussions must be entered in the case notes at the earliest opportunity so that this becomes part of the child's permanent health record.

Paragraphs: 9.1 - 9.10 | 9.11 - 9.26 | 9.27 - 9.35 | 9.36 - 9.43 | 9.44 - 9.60 | 9.61 - 9.72 | 9.73 - 9.83 | 9.84 - 9.95 | 9.96 - 9.105

9.96

Regardless of what her expectations of social services may have been, Dr Schwartz did accept that she should have arranged some form of medical follow-up for Victoria prior to her discharge. She blamed her failure to do so on pressure of time and the fact that there was no "failsafe" mechanism in operation to ensure that children were not discharged before appropriate arrangements had been made for their continuing care.

9.97

Nurse Johnson agreed that appropriate medical follow-up should have been arranged for Victoria and that, as the named child protection nurse, she should have taken responsibility for ensuring that it was. However, the position was complicated by the fact that Victoria was under the care of neither a GP nor a school nurse, who would ordinarily be the hospital's first points of contact. Therefore, once Victoria had left the ward, Nurse Johnson felt that there was nobody she could speak to who was in a position to ensure that Victoria's medical needs were monitored and addressed. In addition, having seen from the notes that Dr Dempster had been in both written and verbal contact with social services, she took the view that 'they' would ensure that Victoria's needs were met. However, she accepted that she should have at least made a telephone call to ascertain why no social worker had ever visited the ward to see Victoria.

9.98

The circumstances of Victoria's discharge illustrate clearly one of the principal concerns I have as to the way that Victoria's case was managed by the Central Middlesex Hospital, namely the marked lack of adequate notes of the important decisions made regarding Victoria's care and the material on which those decisions were based. There is no record of the various conversations that apparently took place between medical staff and social services, or about what was discussed in them. Nor are there any notes which throw any light whatsoever on how Victoria came to be discharged and who took the final decision to let her leave.

9.99

As to this last point, I was very concerned to hear that it was not considered normal practice in the hospital at the time to record the identity of the person who took the decision to discharge a child. I would agree entirely with Dr Schwartz's assessment that this constituted a "worrying state of affairs".

9.100

This lack of adequate record-keeping is indicative, it seems to me, of the amateurish and haphazard manner in which the crucially important decision to discharge Victoria was made. Dr Dempster, a locum working a single shift, was alone on the ward on the morning of 15 July with only Dr Schwartz on the end of a telephone to advise on Victoria's management. Although Dr Dempster had a broad understanding of the role of social services in the protection of children, she was unfamiliar either with the relevant terminology or with the particulars of local child protection arrangements and quickly became confused as to who in social services was dealing with the case and what he or she was proposing to do. In the event, neither she nor any of the other witnesses who appeared before me were able to say how it was that Victoria actually came to leave the ward.

9.101

The unsurprising result of this obviously inadequate approach to Victoria's discharge was that she left hospital without any record of her departure, without a discharge letter, without having been seen by a social worker, and without any arrangements whatsoever being made for any form of medical or nursing follow- up. In the context of her case, these were disastrous omissions. In an effort to ensure that they are not repeated, I make the following recommendations:

Recommendation

Hospital trust chief executives must introduce systems to ensure that no child about whom there are child protection concerns is discharged from hospital without the permission of either the consultant in charge of the child's care or of a paediatrician above the grade of senior house officer. Hospital chief executives must introduce systems to monitor compliance with this recommendation.

Recommendation

Hospital trust chief executives must introduce systems to ensure that no child about whom there are child protection concerns is discharged from hospital without a documented plan for the future care of the child. The plan must include follow-up arrangements. Hospital chief executives must introduce systems to monitor compliance with this recommendation.

9.102

I wish to make one further comment concerning Victoria's discharge from hospital that applies equally to the Central Middlesex Hospital and the North Middlesex Hospital, and that is the failure to record a GP for her.

9.103

The uncritical acceptance that Victoria was not registered with a GP, or that her GP was unknown, ensured that no effort was made to identify a GP for Victoria at either the Central Middlesex Hospital or the North Middlesex Hospital. Inevitably, any attempt to follow up Victoria after discharge from hospital, or any attempt to pass on to her GP the very serious concerns that had been identified about her, were severely compromised by this gap in information.

9.104

Registration with a GP is the bedrock of continuity of care in the National Health Service. It is stating the obvious to note the importance of registration with a GP for every child, let alone one in whom there are concerns about deliberate harm. In reality there will be very few children who are not registered with a GP, which is why failure to establish the identity of a GP for Victoria was such a major oversight.

9.105

The discharge of a child from hospital back into the community is as much a transfer of responsibility for a child's care, as is a referral from the community to a hospital consultant. I consider that the importance of continuity of care for all children is such that there needs to be clear responsibility placed on a hospital consultant under whose care a child has been admitted, to ensure that every child is discharged with a registered GP, whether this involves diligently tracking down the GP during admission or, in the rare event of a real lack of a registered GP, registering the child with an appropriate one before discharge. Therefore, I make the following recommendation:

Recommendation

No child about whom there are concerns about deliberate harm should be discharged from hospital back into the community without an identified GP. Responsibility for ensuring this happens rests with the hospital consultant under whose care the child has been admitted.

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