11 Health analysis

Paragraphs: 11.40 - 11.48 | 11.49 - 11.53

Status of child protection

11.40

I turn now to the other issue with which I am particularly concerned, namely the status and priority afforded to child protection within paediatric medicine.

11.41

In the fourth seminar in Phase Two of this Inquiry, Dr Chris Hobbs, a consultant community paediatrician from Leeds, told me that he considers maltreatment to be the single biggest cause of morbidity in children. If he is correct in his assessment (and I am unaware of any statistics which prove or disprove his assertion), then this is a staggering state of affairs. It seems clear that when considering the issue of deliberate harm to children, one must keep in mind that one is dealing not simply with the extreme cases which occasionally prompt Public Inquiries such as this one, but an enormous number of instances in which the health and development of children is impaired by maltreatment.

11.42

Having heard the evidence of a large number of expert practitioners and academics who work in this field, I have no difficulty in accepting the proposition that the scale of this problem is greater than that of what are generally recognised as common health problems in children, such as diabetes or asthma.

11.43

That being so, Dr Hobbs's further statement - that it is difficult to find doctors who wish to work in the field of child protection - is all the more surprising and disturbing. One might have expected that the scale of the problem would act as an inducement to those doctors who wished to make a significant impact on the health and well-being of the child population to enter the field. In such circumstances it is vitally important that those practitioners who do work in the field are adequately equipped to do so effectively.

11.44

The two consultant paediatricians primarily responsible for Victoria's care while she was in hospital, Dr Schwartz at the Central Middlesex Hospital and Dr Rossiter at the North Middlesex Hospital, were both vastly experienced in the child protection field. They were both the named doctor for child protection in their respective hospitals, and Dr Rossiter also filled the role of designated doctor for her health authority, as a result of which she sat on her local Area Child Protection Committee. They both conducted child protection training sessions for the benefit of their junior staff and were used to the multi-disciplinary aspects of the investigation of possible deliberate harm to children.

11.45

In view of their experience and expertise in the field, I was interested to know how they viewed the deliberate harm of a child in comparison with other ailments with which they have to deal as paediatricians. I put it to both doctors that there may be merit in approaching the diagnosis and treatment of deliberate harm in much the same way as one would approach the diagnosis and treatment of any other disease.

11.46

In essence, this would mean taking a history, conducting a thorough examination, carrying out investigations and tests, reaching a differential diagnosis and then determining treatment and management. This sort of systematic and rigorous approach, commonly applied to the treatment of physical disease, contrasts sharply with the rather haphazard manner in which Victoria's case was managed by both hospitals and, I suspect, the manner in which cases of possible deliberate harm are managed in hospitals across the country.

11.47

Dr Schwartz told me that she had never before viewed deliberate harm as a disease process or entity, and thus had never approached its management in the same manner as other childhood ailments with which she would commonly have to deal. However, she thought that there was merit in such an approach, and that it was instructive to compare the management of a case of deliberate harm with the management of a physical disease. Dr Rossiter agreed.

11.48

I was grateful for the evidence of these two experienced clinicians on this matter. It helped reinforce my conclusion that there is no good reason why the rigorous and systematic approach commonly applied by paediatricians to the diagnosis and treatment of physical disease in children, should not be applied to cases of possible deliberate harm. Deliberate harm is a serious and potentially fatal condition. There is no reason, in my view, why it should be approached in any less thorough a manner than physical diseases of equal seriousness.

Paragraphs: 11.40 - 11.48 | 11.49 - 11.53

11.49

It is tempting to question whether Victoria's case would have received the same level of medical concern, and consequently the same level of evaluation and intervention, had she been admitted to either hospital with a presumptive diagnosis of a potentially fatal disease. Nothing I heard in evidence persuaded me that the majority of doctors involved in Victoria's care - including Dr Schwartz and Dr Rossiter - gave anything like the same level of attention to Victoria's condition as they might have done had she been admitted to hospital with, say, a possible brain tumour or a potentially fatal heart condition.

11.50

My firm conviction is that children presenting to doctors with an actual or a presumptive diagnosis of deliberate harm require the rigorous application of the medical model to their evaluation, and that anything less than this is neglectful of their needs and potentially dangerous.

11.51

However, it is not enough to simply state that paediatricians should adopt a more sophisticated and thorough approach to the treatment of deliberate harm to children. It is also necessary that they have the skills to enable them to do so.

11.52

The lead in making sure that paediatricians in a given hospital are adequately trained and instructed in this area must come, in my view, from the named and designated doctors for child protection. These doctors wield a very significant degree of influence within both the hospital and the multi-disciplinary child protection teams. I have recorded numerous instances during the course of Victoria's case where great regard has been shown to the views of the consultant paediatricians concerned, and it will often be the case that their diagnoses determine whether further investigation takes place or not. In those circumstances, it is vital that they have a level of expertise and training equal to their responsibilities. As Victoria's case shows, the proper management of a case of possible deliberate harm to a child can be a very challenging job, even for an experienced paediatrician.

11.53

In order to make sure that cases of possible deliberate harm to children are properly managed by well-qualified paediatricians, I make the following recommendations:

Recommendation

The investigation and management of a case of possible deliberate harm to a child must be approached in the same systematic and rigorous manner as would be appropriate to the investigation and management of any other potentially fatal disease.

Recommendation

All designated and named doctors in child protection and all consultant paediatricians must be revalidated in the diagnosis and treatment of deliberate harm and in the multi-disciplinary aspects of a child protection investigation.

Recommendation

The Department of Health should invite the Royal College of Paediatrics and Child Health to develop models of continuing education in the diagnosis and treatment of the deliberate harm of children, and in the multi-disciplinary aspects of a child protection investigation, to support the revalidation of doctors described in the preceding recommendation.

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