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Paragraphs: 12.1 - 12.16
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12.1
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The diagnosis and management of deliberate harm to children is
not the exclusive province of those health professionals who work
in hospitals. Others, such as GPs and health visitors have an equally
vital role to play in protecting children. During her life in this
country, Victoria's case came briefly and sporadically to the attention
of a number of such professionals. This section records those occasions
and considers ways in which the working practices of GPs and health
visitors might be improved in order to provide children with more
effective protection against deliberate harm.
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12.2
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On 8 June 1999, Victoria was registered with Dr Indravadan Patel,
a single-handed GP whose surgery was situated close to the Nicoll
Road hostel in which Victoria and Kouao had been living since the
end of April 1999. Dr Patel told me that his practice covered an
area of considerable economic and social deprivation and that he
was kept extremely busy. He also had to contend with a high patient
turnover and many temporary residents.
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12.3
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Dr Patel's knowledge of and experience in child protection matters
was limited at the time Victoria came to be registered with him.
Although he made efforts to keep up-to-date with paediatric medicine
in general, he had received no training in the medical aspects of
child protection or joint working with other agencies. Nor, he told
me, had he ever received any child protection policies or guidelines
from his local medical committee, or elsewhere.
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12.4
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Despite this lack of training or guidance, Dr Patel was clear that,
were he to consider that a child was or might be in need of protection,
he would contact social services and pass on the relevant information.
He had never had occasion to do so during the 30 years he had spent
in general practice.
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12.5
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The practice nurse, Grace Moore, undertook Victoria's registration.
Nurse Moore was an experienced nurse of 15 years, although she too
had had no child protection training.
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12.6
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Nurse Moore followed the computerised registration protocol used
by the practice. The protocol covered such matters as general health,
past operations and family history of major diseases. In addition,
Victoria was weighed and measured as part of the registration process.
Her height and weight were found, according to Dr Patel, to be "within
normal guidelines".
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12.7
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Nurse Moore had no independent recollection of Victoria, basing
her evidence on her standard practice and Victoria's patient summary,
which consisted of a printout of the computerised registration protocol.
However, there was nothing to suggest that the registration process
went beyond the basic steps described above. No examination of Victoria
was carried out and it would not appear as though Nurse Moore sought
to question either Kouao or Victoria about their social circumstances
or living conditions.
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12.8
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Therefore, it is perhaps unsurprising that Nurse Moore did not
feel there were any concerns of a child protection nature arising
out of her contact with Kouao and Victoria that required any follow-up
or report to another agency. Furthermore, as she was told that Victoria
had no current health problems, she considered that there was no
need to make any further appointment for Victoria to see either
her or Dr Patel.
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12.9
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Dr Patel told me that there was a part-time health visitor attached
to his practice. He also indicated he was aware of a 'school contact'
to whom he could refer cases involving school-aged children where
there might be a problem. Neither the health visitor nor the school
contact was informed about Victoria by Nurse Moore.
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12.10
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Therefore, Victoria's contact with Dr Patel's practice started
and ended with the registration appointment on 8 June 1999. The
sum total of the information that would appear to have been obtained
on this occasion was that Victoria was of unexceptional height and
weight, and that she had no current health problems.
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12.11
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On 30 June 1999, Kouao registered with Dr Gurdas Israni of the
Greenhill Park Medical Centre, which is also located close to the
hostel address in Nicoll Road. Dr Israni saw Kouao just once for
a routine health check on the occasion of her registration. Kouao
wrote on the new patient information card that she had five children
aged 23, 20, 18, 16 and seven, but did not give their names. She
told Dr Israni that all her children were living in France.
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12.12
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On 20 July 1999, Kouao registered with Dr Martin Lindsay at the
Somerset Gardens practice. The practice was situated a matter of
yards from Manning's flat, which Kouao gave as her address when
she registered. Kouao made several visits to this surgery over the
course of the next seven months. However, her records contain no
family history or mention of any child.
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12.13
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On 24 November 1999, Victoria was registered with another doctor
at the same practice, Dr Wasantha Gooneratne. Information about
Victoria was provided in a registration form and a health questionnaire,
completed on Victoria's behalf (presumably by Kouao). This information
was subsequently entered on the practice computer.
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12.14
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The registration was completed without anyone at the practice ever
actually seeing Victoria. According to Dr Gooneratne, this was not
unusual for children over the age of five with no disclosed medical
problems. Unsurprisingly, given that Victoria was never seen by
anyone at the practice, no child protection concerns were felt and
no action was taken.
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12.15
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Victoria's GP records amount, in total, to two registration cards
- one from Dr Patel's practice, the other from Dr Lindsay's practice.
Neither contains anything other than the most basic information.
In particular, no mention is made of the two occasions on which
Victoria was hospitalised, despite the fact that she was registered
with Dr Patel at the relevant times.
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12.16
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Similarly, no reference is made in Victoria's hospital notes to
the fact that Dr Patel was her GP. However, there is a reference
to the Somerset Gardens practice in Victoria's North Middlesex Hospital
notes, which is somewhat surprising given that she was not registered
there until four months later.
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Paragraphs: 12.1 -
12.16 | 12.17 - 12.29
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12.17
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In my view, there are three issues arising out of the limited contact
that Victoria had with GPs, which require particular attention.
These are:
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The manner in which new child patients are registered with general
practitioners
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The information that should be gathered during the registration
process and the manner in which that information should be shared
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Training in child protection and knowledge of local policies and
procedures.
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I deal with each in turn.
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12.18
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Dr Patel and Dr Gooneratne followed two different registration
procedures. Victoria's registration with Dr Patel required her to
have a face-to-face screening interview with Dr Patel's practice
nurse. Victoria's registration with Dr Gooneratne was by way of
a registration form and health questionnaire, completed on her behalf.
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12.19
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When Victoria was registered with Dr Patel in June 1999, signs
of physical abuse and neglect may not have been of a nature or severity
to have been apparent at a screening interview of the type conducted
by Nurse Moore. While a child's height and weight may cause concern
in some cases, there is nothing to suggest that Victoria's development
had been significantly impaired at this stage. Even if Victoria
had been subject to a more extensive examination by Nurse Moore,
I heard no evidence to indicate that she would have found obvious
signs of physical abuse on Victoria's body.
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12.20
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The same cannot be said about the later registration at the Somerset
Gardens practice. This took place three months before Victoria's
death and, according to Manning, approximately two months after
she had started to spend her nights in the bath. She was also being
regularly beaten. If Victoria been seen by a practice nurse on this
occasion, it is possible (but by no means certain) that signs of
the treatment she was being subjected to may have been apparent.
However, as it was, no member of the Somerset Gardens practice staff
ever saw Victoria.
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12.21
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Even the slightly more rigorous approach to registration adopted
by Dr Patel's practice would have been unlikely to detect anything
but the most glaringly apparent signs of ill-treatment. Nurse Moore
was required to do no more than complete the basic registration
protocol. Once that had revealed that there were no immediate health
concerns, nothing more was required - other than for Dr Patel to
include Victoria on his large and rapidly changing list of patients.
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12.22
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Dr Patel agreed that "it would be nice" to offer a more comprehensive
initial screening process, perhaps involving a more thorough examination
and a wider questioning of the child and his or her carer, but pointed
out that the practice he operated at the time followed the standard
health authority protocol, and to do any more than this would take
increased resources.
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12.23
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I understand these practical limitations. However, I regard the
skills and experience of GPs as a vital component in any effective
scheme of child protection. The registration of child patients with
a GP should provide an opportunity to consider their needs over
and above their immediate health status.
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12.24
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I appreciate that in a busy inner-city practice of the type described
by Dr Patel, overwhelming workload may make the operation of anything
more than a basic registration protocol impractical. However, it
is the welfare of children that is at stake, and the occasion of
a child patient registration is an opportunity to consider not only
factors such as family history of heart disease, but also the wider
social and developmental needs of the children concerned.
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12.25
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Of particular relevance in this regard will be information such
as whether the child concerned is attending school, how he or she
is cared for, and the nature of the accommodation in which the family
is living. Had such questions been asked at the time that Victoria
registered with Dr Patel (and assuming that they were truthfully
answered), he would have learned that Victoria was not attending
a school, was living in a potentially unsuitable hostel and that
Kouao was about to start a job which would reduce her capacity to
look after Victoria during the day.
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12.26
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It seems to me that there must be a distinct possibility that Dr
Patel, if apprised of this information, would have considered that
Victoria was a child who needed careful monitoring. In this regard,
I do not seek to suggest that GPs should be required to fill the
role of social workers - they have neither the time nor the training
to do so. However, I do believe that they have a role to play in
the distribution of information which might be important in determining
whether a child is in need of protection. The health visitor and
the 'school contact' to which Dr Patel made reference are examples
of the sort of resources available to GPs when they obtain information
about a child who causes them concern.
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12.27
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I was surprised to hear that an experienced GP such as Dr Patel
had never received any training or guidance in child protection
matters, particularly in the recognition of possible deliberate
harm. As is apparent from the preceding sections, these are difficult
and sensitive matters and present a considerable challenge to even
the most experienced practitioners. My view is that, in dealing
with cases of deliberate harm to children, professionals must have
more to rely on than simple common sense. They require training
and regularly updated guidelines, and they must be clear as to what
constitutes best practice in such situations.
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12.28
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I appreciate that in a busy general practice environment - particularly
a single- handed one - making time to attend training courses is
a challenge. With the many educational opportunities available in
post-graduate medical centres, choosing how most profitably to spend
one's time in training is equally difficult. However, I consider
training in child protection not just desirable for GPs, but an
essential part of their initial and continuing professional training.
Furthermore, I consider that this principle applies with respect
to the training of other members of general practice staff where
direct contact with children is a routine part of their work.
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12.29
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I repeat my view that GPs are an extremely important element of
the child protection framework. It is crucial that the optimum possible
use is made of their skills and experience. With this aim in mind,
I make the following recommendations:
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Recommendation
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The Department of Health should invite the Royal College of General
Practitioners to explore the feasibility of extending the process
of new child patient registration to include gathering information
on wider social and developmental issues likely to affect the welfare
of the child, for example their living conditions and their school
attendance.
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Recommendation
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The Department of Health should seek to ensure that all GPs receive
training in the recognition of deliberate harm to children, and
in the multi-disciplinary aspects of a child protection investigation,
as part of their initial vocational training in general practice,
and at regular intervals of no less than three years thereafter.
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Recommendation
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The Department of Health should examine the feasibility of introducing
training in the recognition of deliberate harm to children as part
of the professional education of all general practice staff and
for all those working in primary healthcare services for whom contact
with children is a regular feature of their work.
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Recommendation
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All GPs must devise and maintain procedures to ensure that they,
and all members of their practice staff, are aware of whom to contact
in the local health agencies, social services and the police in
the event of child protection concerns in relation to any of their
patients.
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