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Paragraphs: 12.30
- 12.44 | 12.45 - 12.57
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12.30
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In drafting this section of the Report, I have derived considerable
assistance from the closing submissions made by Counsel to the Inquiry.
They seem to me to accurately summarise the material evidence, and
I have drawn heavily on them in the paragraphs that follow.
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12.31
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The purpose of a health visitor in cases where there are concerns
of possible child abuse is, according to health visitor Rachel Crowe,
to provide "child surveillance" to make sure that the child in question
is developing properly and interacting appropriately within the
family. In order to carry out that role, regular visiting will be
required. She explained that referrals to a health visitor could
come from a variety of sources, including the medical and nursing
staff on the ward if a child happened to be an inpatient. However,
she confirmed that in the majority of cases involving children admitted
to hospital, the subsequent involvement of a health visitor will
be dependent upon a referral being made by a liaison health visitor.
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12.32
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Victoria had the misfortune to be admitted to the North Middlesex
Hospital at a time when the post of liaison health visitor with
responsibility for the accident and emergency department was vacant.
According to the Haringey Primary Care NHS Trust's senior child
protection nurse, Liz Fletcher, the post was eventually filled on
4 October 1999 (having been vacant for four months before that).
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12.33
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In the period during which the post was vacant, cover was provided
by health visitors covering the accident and emergency liaison role
on a two-week rota basis. This was in addition to their own caseloads,
for which they retained responsibility. Ms Crowe was providing cover
at the time Victoria was admitted to the North Middlesex Hospital.
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12.34
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Perhaps unsurprisingly, given the temporary nature of the arrangements,
Ms Crowe was unaware of the guidelines that were in force at the
time. In particular, she was unaware of the different procedure
that was to be followed in non-accidental injury cases, including
the requirement that four copies of the accident and emergency front
sheet be taken and distributed to the individuals specified.
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12.35
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She was also unaware of the procedure to be adopted in respect
of school-aged children admitted to hospital during the school holidays.
This was in spite of a memorandum, dated 22 July 1999, from Bridget
Inal, locality nurse manager for north Tottenham, setting out the
steps to be taken in such a case.
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12.36
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It was against this background that Ms Crowe read Victoria's accident
and emergency notes on or about 26 July 1999. The fact that she
did read them would appear to be indicated by the initials "RC"
marked on them, which Ms Crowe confirmed were written by her at
the time.
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12.37
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There are no notes or other records revealing what Ms Crowe did
next concerning this referral, and she relied in her evidence solely
on her independent recollection of events at what she accepted was
a "busy" time for her. However, her memory was helped by the fact
that Victoria's referral was something out of the ordinary for her
in that it was the only referral of a school-aged child that she
made during the period of her cover. Therefore, she told me that
she was confident in her recollection of the following sequence
of events.
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12.38
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She went to the accident and emergency department and picked up
Victoria's admission card together with her accident and emergency
notes. She agreed that there was nothing on Victoria's card that
indicated that she had been physically abused. However, it was the
accompanying notes made by Dr Forlee that made it clear to her there
was a possibility that non-accidental injury had occurred. She then
telephoned the ward to establish the current position and remembered
being told that Victoria would be on the ward for a while because
of the child protection concerns.
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12.39
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She next telephoned Ms Fletcher to find out what to do with the
referral because it concerned a school-aged child admitted during
the school holidays. She said that Ms Fletcher's advice was that
she should speak to the health visitor responsible for the area
in which Victoria lived.
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12.40
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In accordance with this advice, Ms Crowe telephoned the Lordship
Lane Clinic and said she was informed that Launa Brown was the health
visitor with responsibility for Victoria's area.
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12.41
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Ms Crowe said that the two of them then had a telephone conversation
during which she told Ms Brown about the child protection concerns
surrounding Victoria. She said she told her that Victoria was a
school-aged child in her area who would need to be followed up when
she was discharged from hospital. There were concerns that Victoria
had poured hot water over her face to relieve itching from scabies
and it was suspected that the burn injuries to Victoria's head might
be non- accidental. She said that Ms Brown indicated that she would
follow up the case after Victoria was discharged.
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12.42
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Again according to Ms Crowe, Ms Brown took down the relevant details
and asked for the relevant documentation to be sent to her. In response
to this request, Ms Crowe sent her a copy of Victoria's accident
and emergency card through the internal post system. She said that
she added some handwritten comments to the back of the card before
she sent it. Although she could not remember what she wrote, she
believed she would have mentioned the concerns that she and Ms Brown
had spoken about on the telephone.
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12.43
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The evidence of Ms Crowe on these matters was both clear and coherent.
It was also consistent with the evidence she gave in March 2000
to a locally conducted internal investigation into the Community
Nursing Service's involvement with Victoria's case. That investigation
concluded that Ms Crowe did make the referral but that "no record
can now be found of this action".
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12.44
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However, Ms Crowe's evidence was directly contradicted by that
of Ms Brown, who was equally confident in her recollection that
she never received a call from Ms Crowe about Victoria. She also
stated that she had no recollection of ever having seen Victoria's
accident and emergency card, and that subsequent checks had been
unable to find any record of it having arrived at the Lordship Lane
Clinic.
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Paragraphs: 12.30
- 12.44 | 12.45 - 12.57
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12.45
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As to this last point, there would seem to have been very little
in the way of a system for logging referrals when they arrived at
the clinic. If a referral arrived for a health visitor who was not
in the office at the time, it would be placed on that health visitor's
desk. No record was made of the referral's arrival at the clinic,
or of the identity of the health visitor to whom it had been allocated.
As a result, Ms Brown accepted that the relevant piece of paper
could have gone missing without anyone knowing.
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12.46
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The absence of any system for the logging of referrals is also
relevant to the assertion made by Ms Brown in her statement to the
effect that she "checked all the records held at the clinic" and
"checked with the other health visitors within the clinic" and could
find no reference to Victoria's case.
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12.47
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Given that there was no logbook or filing system that would have
enabled those checking to have identified where the referral should
have been, the fact that nobody at the clinic remembered the referral
being made amounts to no more than those staff who were questioned
being unable to recall what happened to a specific piece of paper
some two years after the event. Therefore, the fact that there was
no record of the referral having arrived at the clinic and that
nobody remembered having seen it, provides me with little help.
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12.48
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The question of whether or not the referral of Victoria's case
was ever made by Ms Crowe to Ms Brown is not an easy one to resolve.
Unfortunately, Ms Fletcher was unable to shed any light on the matter
as she could not recall having spoken to Ms Crowe about the case
and could not say whether or not Ms Crowe had called her to ask
how she should deal with Victoria's referral.
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12.49
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Having carefully considered all the evidence, I have reached the
same view as the internal investigation carried out in March 2000.
I conclude that Ms Crowe did refer Victoria to Ms Brown.
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12.50
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In reaching this conclusion I derived considerable assistance from
the only piece of documentary evidence available to me - the initialled
copy of Victoria's accident and emergency notes. It is clear to
me from this that Ms Crowe was indeed aware of Victoria's accident
and emergency attendance and I consider it unlikely that, having
noted it, the process of onward referral would have stopped at this
point. Therefore, I conclude that when Ms Crowe became aware of
Victoria, and of the possibility that she had suffered a non-accidental
injury, she did indeed take the action she claimed and telephoned
the Lordship Lane Clinic to speak to Ms Brown. However, I would
emphasise that the lack of reliable evidence on this issue has left
me far from confident as to what really happened.
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12.51
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More important than whether Ms Crowe or Ms Brown is correct in
their recollection, is the fact that it was impossible, even in
the immediate aftermath of Victoria's death, to say with any certainty
whether or not the referral was made. This points, in my view, to
the absence of a reliable system for the recording and tracking
of important referrals concerning vulnerable children.
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12.52
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The assertions of Ms Crowe, and of all the other parties involved
in the community nursing aspects of Victoria's care, were unsupported
by documentary evidence other than the initialled accident and emergency
notes. Neither was there any form of system for recording actions
and the onward transmission of information. It is this, and what
it represents for the care of vulnerable children, that is a matter
of great concern to me.
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12.53
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A further indication of the unsystematic manner in which referrals
of this nature were being handled at the time is given by Ms Crowe's
lack of awareness of the procedures that she was supposed to follow
when dealing with cases like Victoria's. While I have considerable
sympathy for Ms Crowe's individual situation as a busy health visitor
having to cover a role with which she was unfamiliar, the fact that
she was in this position reinforces, in my view, the need for clear
and accessible procedures for her to follow.
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12.54
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The importance of the role of the liaison health visitor is illustrated
by the description given by Ms Brown of the appropriate steps to
be taken in response to a referral concerning a child in Victoria's
situation. She said that she would have first made inquiries to
see whether the child was registered with a GP and was attending
school. She would then have sought to find out where he or she lived
and whether there were any siblings. Depending upon the result of
those inquiries, it would be decided whether a home visit was necessary.
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12.55
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Given what we now know to have been Victoria's circumstances at
the time and Ms Crowe's claims to have referred her case to Ms Brown,
there seems little doubt that, had Ms Brown conducted the inquiries
described above, she would have decided that a visit was necessary.
One can only speculate as to what she may have discovered during
the course of such a visit, but there seems little doubt that the
supervision of a health visitor can only have increased the chances
of Victoria's abuse being discovered and addressed.
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12.56
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It is clear, therefore, that the precise circumstances surrounding
the alleged referral are of considerably less importance than the
fact that no action was taken by the health visiting service in
Victoria's case. Her admission to hospital and Ms Crowe's apparent
discovery of the concerns of the medical staff provided a valuable
opportunity to include Victoria within the provision of primary
health services of a type that may well have prevented her death.
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12.57
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Nothing could illustrate more clearly the need for an efficient
and effective referral system for children discharged from hospital
about whom there are child protection concerns. In an effort to
encourage the development of such systems, I make the following
recommendation:
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Recommendation
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Liaison between hospitals and community health services plays
an important part in protecting children from deliberate harm. The
Department of Health must ensure that those working in such liaison
roles receive child protection training. Compliance with child protection
policies and procedures must be subject to regular audit by primary
care trusts.
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