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Paragraphs: 10.1 - 10.17
| 10.18 - 10.25 | 10.26 -
10.37 | 10.38 - 10.47 | 10.48
- 10.56 | 10.57 - 10.67 | 10.68
- 10.78 | 10.79 - 10.90 | 10.91
- 10.98 | 10.99 - 10.110 | 10.111
- 10.119 | 10.120 - 10.135 | 10.136
- 10.146 | 10.147 - 10.163
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10.1
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The North Middlesex University Hospital, previously the North Middlesex
Hospital, is situated in north east London. It forms part of what
was the Barnet, Enfield and Haringey Health Authority and is now
the North Central London Strategic Health Authority. It is sited
just inside the border of Enfield council. However, despite its
location, more than 70 per cent of the children treated in the hospital
live in Haringey, with the remainder living in Enfield. In 1999,
the approximate combined population of Barnet, Enfield and Haringey
councils was over 700,000. The current chief executive of the North
Central London Strategic Health Authority is Christine Outram.
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10.2
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Kouao took Victoria to the North Middlesex Hospital accident and
emergency department on Saturday 24 July 1999 at around 6.15pm.
Victoria was seen by a casualty officer who referred her to the
paediatric team.
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10.3
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The on-call paediatric registrar that evening was Dr Olutoyin Banjoko,
assisted by a paediatric senior house officer, Dr Simone Forlee.
The casualty officer told Dr Forlee over the telephone that a child
had been seen with scalds to the head, the explanation for which
was that she had poured hot water over herself to relieve the itching
caused by scabies.
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10.4
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Both Dr Banjoko and Dr Forlee thought that this history was unusual
and were immediately alert to the possibility that the injuries
might be non-accidental. Dr Banjoko decided that Dr Forlee should
go and see Victoria.
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10.5
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On her way there, Dr Forlee collected a set of the hospital's child
protection forms on which to record her findings. The individual
forms were designed to record specific sorts of information. Form
CP1 was for basic administrative data, CP2 was for the history of
the presenting complaint, and CP3 was designed to record the medical
examination. In addition, CP3 contained a section requiring the
doctor concerned to reach a conclusion as to whether the injuries
were accidental or non- accidental, or whether further information
was required before a conclusion could be reached. Finally, CP5
is an action checklist of things to do to assist with the diagnostic
process and with future management.
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10.6
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When Dr Forlee saw Victoria, she was "not really in pain" and was
"fairly passive". Her scalds were being attended to and, because
she did not require immediate medical attention, Dr Forlee concentrated
on finding out the details of what had happened from Kouao. During
the course of her conversation with Kouao, Dr Forlee made a number
of telling observations, the most significant of which are set out
below.
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10.7
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Dr Forlee found Kouao's account of how Victoria had come by her
injuries to be inconsistent and unconvincing. That Victoria would
pour hot water over herself to ease itching did not "ring true"
as far as Dr Forlee was concerned. Nor did she consider the pattern
of Victoria's burns to be consistent with her having poured water
on her own head in the manner described by Kouao. Furthermore, Kouao
seemed unable to provide a consistent account of when the incident
occurred - various times were mentioned, ranging from midday to
3pm.
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10.8
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Of greater concern than Kouao's inability to give a consistent
account of when the incident took place was the fact that, on any
version, there had been a significant delay before Victoria had
been brought to the hospital. Dr Forlee did not ask Kouao to provide
an explanation for this delay.
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10.9
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In addition to her reservations about Kouao's account of how Victoria
came by her injuries, Dr Forlee found a number of aspects of the
social history recounted by Kouao to be unconvincing. For example,
Dr Forlee found Kouao's account of having left a comfortable environment
in France to live in awful conditions in England "bizarre", and
she was understandably confused when Kouao gave her a date of birth
which would have meant that she was seven years old when her first
child had been born. Again, Dr Forlee would seem not to have challenged
Kouao on these aspects of her story.
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10.10
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As to her and Victoria's domestic circumstances, Kouao told Dr
Forlee that she had been involved with social services in respect
of housing, and gave the impression that the accommodation she and
Victoria were staying in was substandard. She also mentioned that
social workers had spoken about separating her from Victoria, but
she did not seem to want to elaborate on this issue. In addition,
and of particular concern to Dr Forlee, Kouao said that she was
not registered with a GP and indicated that she had no firm plans
to send Victoria to school.
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10.11
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At some point during the course of her discussion with Dr Forlee,
Kouao told Victoria in English to "tell the doctor what happened".
Dr Forlee recalled that Victoria responded by giving an account
of the incident, in broken English, which was broadly consistent
with Kouao's. Listening to Victoria give her account, Dr Forlee
formed the impression that she had been coached as to what to say.
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10.12
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Dr Forlee recalled that Victoria was unkempt and smelly and was
not wearing any underwear. In contrast, Kouao was immaculately presented.
She also observed that there did not seem to be particular warmth
between Kouao and Victoria.
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10.13
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Having listened to Kouao's account and watched the way in which
she interacted with Victoria, Dr Forlee felt that Victoria should
be spoken to on her own and with the aid of a French interpreter.
She said her plan in this regard was to ask a French- speaking member
of the nursing staff to obtain a full history from Victoria.
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10.14
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Unfortunately, however, neither of these entirely appropriate steps
was taken. At no point during her stay in the hospital did any doctor
speak to Victoria in a formal attempt to find out what had happened
to her, either with or without the assistance of an interpreter.
I consider this omission to amount to a major oversight in the care
with which she was provided by the hospital. I am in no doubt that
Victoria should have been spoken to as part of a comprehensive process
of gathering information about her condition and circumstances.
However, it would seem that the completion of this important task
was deferred on the assumption that someone else would do it, or
that it would be done at a later date.
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10.15
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Once she had obtained Kouao's account of how Victoria had come
to be injured, Dr Forlee moved on to carry out a brief physical
examination of Victoria. She charted the injuries to Victoria's
head and checked to see there were no other injuries on her body
that required immediate attention. She did not go any further because
she had decided that Victoria should be admitted and it would be
more appropriate to carry out a detailed examination once she was
on the ward under the supervision of a more senior paediatrician.
In addition, she was hampered by the poor lighting in the accident
and emergency department, together with the fact that much of Victoria's
skin was covered in white lotion.
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10.16
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Dr Forlee was not convinced, on the basis of what she had seen
and heard up to this point, that Victoria's injuries were non-accidental.
She therefore ticked the box on the CP3 form indicating that more
information was required before a firm view as to the nature of
the injuries could be taken.
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10.17
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Having done so, she proceeded to telephone Dr Mary Rossiter, the
North Middlesex Hospital's named doctor for child protection and
the on-call consultant at the time. She told her about Victoria's
injuries and the circumstances in which she had arrived at the hospital.
Dr Rossiter agreed with the plan to admit Victoria. In addition
to her burns needing attention, she felt that they "needed to get
to know her better". Dr Forlee then called Dr Banjoko to tell her
what had been decided.
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Paragraphs: 10.1 -
10.17 | 10.18 - 10.25 | 10.26
- 10.37 | 10.38 - 10.47 | 10.48
- 10.56 | 10.57 - 10.67 | 10.68
- 10.78 | 10.79 - 10.90 | 10.91
- 10.98 | 10.99 - 10.110 | 10.111
- 10.119 | 10.120 - 10.135 | 10.136
- 10.146 | 10.147 - 10.163
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10.18
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I have indicated above that Dr Rossiter was the 'named' doctor
for child protection. Before I go on to deal with Dr Forlee's referral
of Victoria's case to social services, it may help if I pause to
explain the nature and extent of the responsibilities of the named
and designated healthcare professionals.
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10.19
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The terms 'designated' and 'named' doctor and nurse for child protection
first appeared in the 1991 edition of Working Together
and were subject to further clarification in 1995 in Child Protection:
clarification of arrangements between the NHS and other agencies.
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10.20
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When commissioning child protection services, each health authority
must enlist the help of a senior doctor and nurse experienced in
child protection to advise on the content of contracts in relation
to the protection of children. This is the role of the designated
doctor and designated nurse.
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10.21
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In addition, each NHS organisation concerned with children should
have, or be able to call on the services of, a senior doctor and
a senior nurse with a high level of expertise in child protection,
to perform a number of functions, including identifying the child
protection training needs of medical and nursing staff. This ensures
that the proper child protection protocols are in place and acts
as a reference point for other agencies to ensure that child protection
advice is properly co-ordinated. In effect, the named doctor and
named nurse are the child protection experts and are expected to
lead their colleagues in all matters relating to the protection
of children.
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10.22
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Having decided upon a strategy to meet Victoria's immediate medical
needs, Dr Forlee contacted Haringey Social Services. The duty social
worker on call that evening was Luciana Frederick. Ms Frederick
was not immediately available and so Dr Forlee left a message for
her at around 8.30pm, their subsequent conversation taking place
"a lot later in the evening".
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10.23
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Dr Forlee's recollection of this conversation was patchy. However,
it was sufficient for her to dispute a number of aspects of the
note made by Ms Frederick on the Haringey council Out of Hours Social
Work Report form, which reads as follows:
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"1. Child admitted to hospital - concerns about injury caused
by hot water poured onto face causing facial burns. 2. It appeared
to be an accident, however mother may need support. 3. Advice given
- Doctor agreed to discuss case with hospital s/w the following
day. 4. NFA."
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10.24
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First, and most important, Dr Forlee denied telling Ms Frederick
that Victoria's burns appeared accidental. Second, she said that
she was told that further action on Victoria's case would have to
wait until "normal office hours", which meant that she could not
have agreed to talk to the hospital social worker "the following
day", because that was a Sunday. Finally, Dr Forlee was certain
that she never indicated that "NFA" (meaning no further action)
was necessary on the part of Haringey Social Services. As far as
Dr Forlee was concerned, it was her responsibility to inform social
services of Victoria's case. What they did about it was up to them.
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10.25
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Before leaving the accident and emergency department and picking
up the story of Victoria's treatment at the hospital with her transfer
to the ward, there are two aspects of Dr Forlee's involvement with
Victoria which require analysis. The first is the standard and contents
of her notes. The second is her failure to obtain a copy of the
records relating to Victoria's admission to the Central Middlesex
Hospital 10 days previously. I deal with each in turn.
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Paragraphs: 10.1 -
10.17 | 10.18 - 10.25 | 10.26
- 10.37 | 10.38 - 10.47 | 10.48
- 10.56 | 10.57 - 10.67 | 10.68
- 10.78 | 10.79 - 10.90 | 10.91
- 10.98 | 10.99 - 10.110 | 10.111
- 10.119 | 10.120 - 10.135 | 10.136
- 10.146 | 10.147 - 10.163
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10.26
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It is clear from the observations recorded above that, despite
the brevity of her physical examination of Victoria, Dr Forlee obtained
a large amount of telling information during the course of her interaction
with Kouao and Victoria. Even without the benefit of hindsight,
there was much that was plainly suspicious in Kouao's account and
the manner in which it was given. More importantly, Dr Forlee would
appear to have been very perceptive in her assessment of the relationship
between Kouao and Victoria.
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10.27
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Therefore, it is a matter of considerable regret that Dr Forlee
chose to record so little of the valuable information she gleaned
during the course of her contact with Kouao and Victoria on the
child protection forms. In particular, she failed to record the
following, vitally important observations that:
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•
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Victoria was living in inadequate and dirty accommodation.
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•
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She suspected that Victoria had been coached to give a consistent
account of the manner in which she came by her injuries.
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•
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There was very little warmth in the relationship between Victoria
and Kouao.
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•
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She regarded it as appropriate for Victoria to be spoken to alone
with the assistance of a French-speaking interpreter.
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•
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The pattern of burns to Victoria's head were inconsistent with
Kouao's account of the incident.
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10.28
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Dr Forlee explained the absence of these observations from her
notes by telling me that her role as an on-call senior house officer
was to gather information sufficient to ensure a child's safety,
before moving on to the next case. In her view, there was simply
not the time to produce a comprehensive account of all potentially
relevant information. She also explained that when filling in child
protection forms, doctors in her position are instructed merely
to record and not interpret what they are told, in case it is wrong.
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10.29
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While I appreciate the considerable burden placed on medical staff
in a busy hospital setting, and accept that inexperienced doctors
should not act outside their areas of competence, I remain troubled
by the fact that so many of Dr Forlee's important observations and
insights did not find their way into Victoria's notes. Had they
done so, they might have proved very useful in any subsequent child
protection investigation.
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10.30
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The central importance of a detailed history and a complete record
of the suspicions and observations of medical staff in the context
of a case of possible deliberate harm to a child is self-evident.
In many cases, such records can be the most valuable diagnostic
tool available to a clinician charged with forming a conclusion
as to whether injuries may be non-accidental. I wish doctors to
be in no doubt as to their obligations in this regard, and therefore
repeat the recommendation made in paragraph 9.72:
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Recommendation
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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.
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10.31
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From the outset of her involvement with Victoria, Dr Forlee had
what she described as a "vague idea" that she had recently been
treated at the Central Middlesex Hospital. It seems most likely
that she was given this information by a staff member in the accident
and emergency department when she arrived to examine Victoria. Despite
this knowledge, Dr Forlee made no attempt either to obtain the Central
Middlesex Hospital notes relating to Victoria's previous admission
or to telephone the Central Middlesex Hospital in order to speak
to a colleague with some knowledge of Victoria's previous problems.
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10.32
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Her explanation for not doing so seemed to be that sight of the
notes would not have made a material difference to her treatment
plan. Even without them, she had what she considered to be "sufficient
ground to make a reasonably accurate assessment that there was a
child at risk", and her decision to admit Victoria "would not have
been altered specifically by other information". She also reminded
me of the practical difficulties in obtaining notes from other hospitals
in the sort of on-call situation in which she was working at the
time.
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10.33
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I agree with Dr Forlee that obtaining the Central Middlesex Hospital
notes that evening, and speaking to a doctor who knew Victoria,
would not have altered her decision to admit. Furthermore, I appreciate
the difficulty associated with obtaining paper-based medical records
from other hospitals late in the evening and the constraints on
doctors' time in a busy on-call situation. However, I am firmly
of the view that, had the doctors at the North Middlesex Hospital
seen the Central Middlesex Hospital notes disclosing the possibility
of a previous serious assault on Victoria only 10 days previously,
the level of concern they felt about her scalding would inevitably
have been greater.
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10.34
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Dr Forlee said that the information contained in the Central Middlesex
Hospital notes would have been beneficial "at a later stage". I
disagree with her. In my view, the circumstances of Victoria's previous
admission was vital information which was relevant from the outset.
As it turned out, this step was never taken and the notes relating
to Victoria's treatment by the Central Middlesex Hospital were never
seen by those treating her at the North Middlesex Hospital.
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10.35
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In my view, the need to obtain details of other hospital admissions
at an early stage in the treatment and management of a child with
possible non-accidental injuries is not removed simply because a
decision to admit has already been made. Apart from the obvious
point that the significance of such further information that may
be available cannot be assessed until it has actually been obtained,
there may be numerous aspects of the management of the case that
may be affected by knowledge of what has happened to the child previously.
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10.36
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In cases involving possible deliberate harm to a child, it is vital
that doctors take their decisions in light of as much relevant information
about that child as may be available. The fact that Victoria had
been admitted to another hospital 10 days previously with another
set of suspected non-accidental injuries was plainly a relevant
piece of information in the context of her case. In an attempt to
ensure that doctors working in this difficult area have as much
relevant information available to them as possible, I make the following
recommendation:
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Recommendation
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When a child is admitted to hospital and deliberate harm is suspected,
the doctor or nurse admitting the child must inquire about previous
admissions to hospital. In the event of a positive response, information
concerning the previous admissions must be obtained from the other
hospitals. The consultant in charge of the case must review this
information when making decisions about the child's future care
and management. Hospital chief executives must introduce systems
to ensure compliance with this recommendation.
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10.37
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Despite her failure to secure the notes, there was one aspect of
Victoria's treatment at the Central Middlesex Hospital of which
Dr Forlee was aware. The North Middlesex Hospital casualty card
recorded that Victoria had taken "self-discharge" from the Central
Middlesex Hospital. I was interested to read this, as it provides
a possible explanation as to why there is no record of Victoria's
discharge in the Central Middlesex Hospital notes. The fact that
a seven-year-old child has discharged "herself" from hospital may
also be relevant when assessing whether that child might be the
victim of some form of deliberate harm.
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Paragraphs: 10.1 -
10.17 | 10.18 - 10.25 | 10.26
- 10.37 | 10.38 - 10.47 | 10.48
- 10.56 | 10.57 - 10.67 | 10.68
- 10.78 | 10.79 - 10.90 | 10.91
- 10.98 | 10.99 - 10.110 | 10.111
- 10.119 | 10.120 - 10.135 | 10.136
- 10.146 | 10.147 - 10.163
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10.38
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At around 10pm, Victoria, still accompanied by Kouao, was moved
to Rainbow ward. Shortly after their arrival, they were seen by
Dr Banjoko, who explained to Kouao that there was a need to further
investigate Victoria's injuries and provide her with appropriate
treatment. Dr Banjoko decided not to broach the subject of how Victoria
had come by her injuries at this stage.
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10.39
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Nor did Dr Banjoko consider it appropriate to carry out an examination
of Victoria that evening. She was aware from the child protection
forms that no proper examination of Victoria's body had yet been
carried out but, in view of the late hour, she considered that it
would not be "morally right" to conduct a full examination at this
stage and that this task was better left to Dr Rossiter who, as
she understood it, would be seeing Victoria the next morning.
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10.40
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In cases where a child presents with possible non-accidental injuries,
the importance of a full and thorough examination by a doctor experienced
in this area is self-evident. It was, in any event, an express requirement
of the hospital's child protection procedures. Therefore, I find
it staggering that throughout the two weeks she spent in the hospital,
this vital element of her care was overlooked by a succession of
doctors who, for the most part, seemed to assume either that it
had already been done, or that it could be left to someone else.
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10.41
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While I am prepared to accept that Victoria's age and her condition
at the time may have rendered it inappropriate to conduct a full
examination when she first arrived on the ward, I am in no doubt
that it should have been done as soon as possible thereafter. I
am anxious that doctors receive clear guidance on this important
issue, and therefore make the following recommendation:
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Recommendation
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Any child admitted to hospital about whom there are concerns about
deliberate harm must receive a full and fully-documented physical
examination within 24 hours of their admission, except when doing
so would, in the opinion of the examining doctor, compromise the
child's care or the child's physical and emotional well-being.
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10.42
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In fact, the first people to examine Victoria the following morning
were Nurse Millicent Graham and Nurse Regina Tsiagbe, who had been
specifically allocated to take care of her. Nurse Millicent Graham
was aware that Victoria had been admitted the previous evening with
general suspicions of non-accidental injury and so was on the lookout
for anything suspicious from the outset.
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10.43
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Victoria was the first patient that the two nurses went to see
that morning. They went into her cubicle, and Nurse Millicent Graham
remembered that Victoria was pretending to be asleep. Nurse Millicent
Graham recalled that Victoria had wet the bed overnight and needed
a bath, which she and Nurse Tsiagbe proceeded to give her.
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10.44
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The only entry made by these two nurses in the notes recording
what they saw that morning concerns the fact that Victoria had some
difficulty in walking to the bathroom and had bruises all over her
body. In their evidence before me, however, they were able to recall
some more detail. Nurse Millicent Graham, for example, remembered
that Victoria's fingernails seemed infected and that she thought
some of them might fall off. She also remembered seeing a mark on
Victoria's shoulder which looked as if something had been "heated
and pressed into her skin". As to the latter observation, she said
that although she made no note of it she did bring it to the attention
of one of the doctors on the ward at the time.
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10.45
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This will not be the last time that I remark upon an unfortunate
absence in the nursing notes of observations as to Victoria's condition
while she was on Rainbow ward that may well have proved to be significant.
The failure of the nursing staff to record their observations in
the notes, and the consequent discrepancy between the levels of
concern they expressed in their oral evidence and that reflected
in the records made at the time, was a matter which arose with depressing
regularity. In respect of this particular occasion, Nurse Millicent
Graham told me that she considered her note taking to have been
"absolutely disgusting".
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10.46
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In view of these discrepancies, each of the nurses who expressed
concerns in oral evidence, which they did not record at the time,
was asked whether or not their recollections had been coloured by
knowledge of what had subsequently happened to Victoria. Perhaps
unsurprisingly they all denied that this was the case and assured
me that I could confidently rely upon their oral evidence concerning
these matters.
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10.47
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While I do not believe that any of the nursing staff sought deliberately
to mislead me during the course of their oral evidence, I have taken
into account the fact that recollections can often be influenced
by knowledge of later events, particularly when those events are
as harrowing as those in Victoria's case. As a result, I have, as
far as possible, based the account of events that follows on the
documentation made at the time.
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Paragraphs: 10.1 -
10.17 | 10.18 - 10.25 | 10.26
- 10.37 | 10.38 - 10.47 | 10.48
- 10.56 | 10.57 - 10.67 | 10.68
- 10.78 | 10.79 - 10.90 | 10.91
- 10.98 | 10.99 - 10.110 | 10.111
- 10.119 | 10.120 - 10.135 | 10.136
- 10.146 | 10.147 - 10.163
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10.48
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Although no written records of it exist, both Dr Forlee and Dr
Rossiter clearly recalled conducting a ward round on the morning
of Sunday 25 July. Dr Rossiter clearly remembered seeing Victoria
during the course of this ward round but her memory of precisely
what transpired was "hazy".
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10.49
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The notes provide some assistance. For example, the fact that Dr
Rossiter's signature appears on the CP3 form, and is dated 25 July,
would seem to confirm her recollection of having gone through the
CP forms with Dr Forlee. In addition, the CP5 form would appear
to indicate that Dr Rossiter was correct in her assertion that she
directed a skeletal survey to be carried out and a set of photographs
of Victoria's injuries to be taken.
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10.50
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The nature and extent of Dr Rossiter's examination of Victoria
on this occasion remains unclear. She thought that she "looked at"
Victoria after her bath and noted then that she had injuries that
needed to be documented and drawn properly. She remembered considering
what may have caused the marks and identified looped wire as a possibility.
Unfortunately, no notes were made either of the marks she saw or
of her theory as to their possible cause - an omission she regretted
but was unable to explain.
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10.51
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Dr Rossiter's recollection was that she delegated the task of carrying
out a full examination of Victoria's body and recording of any marks
discovered to Dr David Reynders, the senior house officer who was
due to take over from Dr Forlee. Dr Rossiter was confident that
Dr Reynders had sufficient experience and ability to be able to
perform this task on her behalf.
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10.52
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If this was indeed Dr Rossiter's plan, there were two problems
with it. First, Dr Reynders was not on duty on 25 July and did not
arrive on the ward until the following day. Second, Dr Rossiter
left no clear instructions in the notes and made no arrangements
to ensure that the doctor to whom she had delegated the task had
a clear understanding of what was expected of him.
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10.53
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Dr Rossiter accepted that the arrangements she put in place to
ensure that a full examination of Victoria was carried out were
"clearly inadequate". In addition to agreeing with her assessment,
I would add that her failure to check whether her instructions had
been carried out meant that she did not find out until after Victoria's
death that no thorough examination of her was ever carried out during
the two weeks she was an inpatient at the North Middlesex Hospital.
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10.54
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Finally, with regard to Dr Rossiter's ward round on 25 July, a
note by Nurse Tsiagbe indicates that Dr Rossiter had a conversation
with Kouao that morning. Unsurprisingly, the notes record neither
the questions put to Kouao by Dr Rossiter nor her responses. Dr
Rossiter was unable to assist me any further from her independent
recollection. Therefore, I will simply restrict myself to observing
that a further opportunity to record potentially useful information
for the benefit of those who came later to deal with Victoria's
case was squandered.
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10.55
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The last significant event of 25 July was a visit from Kouao, who
arrived on the ward accompanied by a man. Nurse Millicent Graham
recalled Kouao behaving towards Victoria in a manner she considered
inappropriate, a view apparently shared by Nurse Grace Pereira,
who made the following entry in the ward's critical incident log:
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"Mum visited with a gentleman at 10.30pm. Woke Anna up from
her sleep. They sat on the chairs whilst Anna stood up in front
of mum as they talked. Master servant attitude observed and mum
kept pointing a finger at her. They left the room after about 10
mins. Mum went back to the room again to ask her what she needs
after a suggestion from nurse and as soon as she entered although
Anna had got into bed she got out and stood in front of mum to talk
to her."
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10.56
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The critical incident log was kept in a folder in the ward office
and did not form part of the main hospital notes of the child concerned.
Its purpose was to record concerns of a child protection nature
felt by nurses and, as such, took the place of form CP6, which had
been designed for that purpose but was found to be inadequate. The
fact that Nurse Pereira chose to record her observations on the
critical incident log is an indication that she regarded the interaction
between Victoria and Kouao to be relevant in a child protection
context.
|
|
Paragraphs: 10.1 -
10.17 | 10.18 - 10.25 | 10.26
- 10.37 | 10.38 - 10.47 | 10.48
- 10.56 | 10.57 - 10.67 | 10.68
- 10.78 | 10.79 - 10.90 | 10.91
- 10.98 | 10.99 - 10.110 | 10.111
- 10.119 | 10.120 - 10.135 | 10.136
- 10.146 | 10.147 - 10.163
|
|
|
|
|
|
10.57
|
The morning ward round on Rainbow ward usually took place between
8.30am and 9.30am. On 26 July 1999, it was conducted by a paediatric
registrar, Dr Justin Richardson, who was accompanied by Dr Forlee.
|
|
10.58
|
Dr Richardson recalled being brought up to date with Victoria's
case, probably by Dr Forlee. In particular, he remembered being
told that there were child protection concerns surrounding Victoria
and that marks had been noticed on her body which, it was thought,
were attributable to "inappropriate chastisement". Despite being
aware of these concerns, Dr Richardson did not look at the child
protection forms contained in Victoria's notes to ensure that the
concerns and suspicions reported to him were adequately recorded.
Nor did he examine the marks on Victoria for himself.
|
|
10.59
|
While I regard a careful review of the notes as one of the key
responsibilities of the senior doctor conducting a ward round, I
realise that Dr Richardson would probably have been aware that,
by the time he saw her, Victoria had been seen by Dr Rossiter, and
a plan for her future management had been put into action. In those
circumstances, it is perhaps understandable that Dr Richardson should
have limited himself to ensuring that Victoria was comfortable rather
than taking the child protection issues forward.
|
|
10.60
|
Dr Forlee wrote up the notes at the end of the ward round. In addition
to some physical findings she recorded the following: "X-rays; discuss
at psychosocial meeting today. Dermatologist. Photographs." As to
whose responsibility it was to ensure that these further steps were
carried out, Dr Forlee told me that this would have fallen to one
of the senior house officers on the ward at the time. However, she
did not think that she was responsible on this particular occasion.
|
|
10.61
|
Later the same morning, Nurse Clare Watling and Noelle O'Boyce,
the play specialist on Rainbow ward, gave Victoria a bath. At approximately
10.30am, they called over Nurse Beatrice Norman, the lead paediatric
nurse at the North Middlesex Hospital, to show her what they had
found. Nurse Norman said that, when she looked, she saw a number
of injuries to Victoria's body. She told me that she instructed
the nurses to make a note of all they had seen once they had finished
bathing Victoria. If that is right then she was disobeyed - the
nurses restricted themselves to recording only the fact of Victoria's
bath, not what it had revealed.
|
|
10.62
|
The fact that no record was made of Victoria's injuries at this
point was quickly rectified, at least in part by Dr Reynders who,
at some point during the morning of 26 July, completed a set of
body maps upon which he made a detailed record of the marks visible
on Victoria's body.
|
|
10.63
|
Dr Reynders would appear to have restricted himself simply to recording
the marks on Victoria's body. Despite the fact that he concluded
that the shape and distribution of the marks was strongly suggestive
of deliberate injury, he did not think that he should be the one
to investigate further how they had been caused. That was a task
which, in his view, was better left to a more senior clinician working
in a controlled environment where any information could be properly
recorded.
|
|
|
|
10.64
|
In the afternoon, a routine psychosocial meeting was held. These
meetings provided a forum in which any child with possible social
or psychological problems could be discussed. Notes of these meetings
were recorded in a book stored in the hospital's child psychology
department.
|
|
10.65
|
Dr Richardson was at the meeting on 26 July, and Dr Rossiter thought
it very probable that she was also there. Neither of them had anything
but the vaguest recollection of what was discussed. However, the
notes provide some assistance and indicate that Victoria's case
was raised. It was recorded that child protection concerns remained
and that Dr Rossiter was to carry out an examination of Victoria's
injuries.
|
|
10.66
|
When it was put to her, Dr Rossiter was somewhat confused by the
note which indicated that she was to carry out an examination. Her
recollection was that she was extremely busy that week and could
not recall having taken on this responsibility herself. However,
whether or not she agreed to do so at the psychosocial meeting,
Dr Rossiter agreed that she should have examined Victoria at some
point during the days that followed.
|
|
10.67
|
A number of explanations were offered for her failure to do so.
First, she speculated that she may have forgotten, and the notes
of the psychosocial meeting did not come to the attention of those
who might have been in a position to remind her. Second, it was
possible that she thought that there was no need to examine Victoria,
as this had already been delegated by her to another member of her
team. Finally, and to my mind most plausibly, she thought that she
may simply have failed to get round to it due to pressure of work
and the fact that she was "juggling a lot of cases and trying to
prioritise".
|
|
Paragraphs: 10.1 -
10.17 | 10.18 - 10.25 | 10.26
- 10.37 | 10.38 - 10.47 | 10.48
- 10.56 | 10.57 - 10.67 | 10.68
- 10.78 | 10.79 - 10.90 | 10.91
- 10.98 | 10.99 - 10.110 | 10.111
- 10.119 | 10.120 - 10.135 | 10.136
- 10.146 | 10.147 - 10.163
|
|
|
|
10.68
|
It is instructive to pause at this point to consider what, if any,
conclusion the hospital had reached as to the cause of Victoria's
injuries at this stage. Despite the fact that she had been seen
in the bath by five nurses, examined by two doctors and observed
by several of the ward staff interacting with her 'mother', no firm
view would seem to have been taken as to whether the injuries discovered
were likely to be non-accidental.
|
|
10.69
|
This is illustrated by the referral made on the afternoon of 26
July by Nurse Sharon Jones to Karen Johns, a social worker employed
by Enfield Social Services. At the time there was an agreement between
Enfield and Haringey under which hospital social workers employed
by Enfield Social Services would carry out an initial assessment
of Haringey children admitted to the North Middlesex Hospital with
child protection concerns, and then pass on the case to Haringey
Social Services for action.
|
|
10.70
|
Following receipt of the referral, Ms Johns telephoned the ward
and spoke to Nurse Jones. Her note of the conversation indicates
that she was told by Nurse Jones that the child protection forms
did not state that Victoria's injuries were thought to be non-accidental.
Nurse Jones's note of the conversation, made in the critical incident
log, reads as follows: "S.W. referral made. Spoke with Karen Johns
(Hospital Social Worker). Drs and nurses to contact SW dept. again
if it is thought that injuries are non-accidental and CP forms have
been completed stating this.
|
|
10.71
|
It would seem clear, therefore, that the various suspicions chronicled
above were not communicated to Ms Johns on 26 July. As far as she
was concerned, the hospital had yet to reach the view that Victoria's
injuries were likely to be non-accidental. It would also appear
from the note in the critical incident log that she was waiting
for such a view to be expressed by the hospital before taking any
further action.
|
|
10.72
|
Continuing with Victoria's story, later the same evening, Kouao
returned to the ward to visit Victoria. Dr Reynders spoke to her
and obtained her consent for the skeletal survey to be carried out
and the photographs of Victoria's injuries to be taken.
|
|
10.73
|
There is one aspect of this conversation which causes me some concern.
Dr Reynders did not tell Kouao the real reason why the hospital
wished to take photographs of Victoria's injuries. Instead of telling
her that there were child protection concerns, he said that the
photographs were necessary to monitor the healing of the burns.
While I understand the reluctance of a junior doctor in Dr Reynders's
position to confront a parent about matters of this nature, I regard
it as undesirable that an inexperienced clinician be placed in a
position where he or she is forced to resort to subterfuge in this
way. It is preferable, where possible, to be honest with the parents
or carers of a child about whom there are child protection concerns.
If that means that difficult conversations are necessary then they
should be handled by a senior and experienced doctor. In order to
encourage the development of this practice, I make the following
recommendation:
|
|
|
Recommendation
|
|
|
In a case of possible deliberate harm to a child in hospital,
when permission is required from the child's carer for the investigation
of such possible deliberate harm, or for the treatment of a child's
injuries, the permission must be sought by a doctor above the grade
of senior house officer.
|
|
|
|
10.74
|
The nurse in charge of the night shift on 26 July was Nurse Isobel
Quinn. She allocated Victoria's care to Nurse Pereira. Before settling
Victoria down for the night, Nurse Pereira gave her another bath.
As she bathed her, Nurse Pereira saw a large number of scars on
her body, many of which she considered to be indicative of non-accidental
injuries, such as bites and blows with a belt buckle.
|
|
10.75
|
Disturbed by what she had seen, Nurse Pereira called Nurse Quinn
to come and look. Nurse Quinn told me that she also saw marks, which
she thought may have been caused by a belt buckle. She also noticed
that Victoria's arm was bruised and swollen.
|
|
10.76
|
I should state that the first time that either of these two nurses
recorded what they saw that evening was in their written evidence
to this Inquiry. The only indication in the notes that this incident
ever took place was a comment written by Nurse Pereira that, when
she bathed Victoria, she found her to be "sore all over her body".
There is no mention of the bite marks, the belt buckle mark or the
injuries to the arm.
|
|
10.77
|
I have found it very difficult to understand why important observations
of this nature were not recorded in the notes. Both Nurse Pereira
and Nurse Quinn were aware that Victoria was a child about whom
there were child protection concerns, and Nurse Pereira had seen
fit the previous evening to make a note in the critical incident
log concerning the master-servant relationship between Kouao and
Victoria. Nurse Pereira was frank enough to accept that she should
have made a note of her observations that night. Nurse Quinn simply
told me that she could not account for why she chose not to do so.
|
|
10.78
|
I consider the issue of recording information in more detail in
section 11. For present purposes, I wish simply to make the point
that this is precisely the sort of information that nurses should
record in the notes. They are a vital source of information in the
discovery and investigation of child abuse and it should be made
clear to anyone who may be in doubt that the recording of suspicious
injuries on a child is a fundamental responsibility.
|
|
Paragraphs: 10.1 -
10.17 | 10.18 - 10.25 | 10.26
- 10.37 | 10.38 - 10.47 | 10.48
- 10.56 | 10.57 - 10.67 | 10.68
- 10.78 | 10.79 - 10.90 | 10.91
- 10.98 | 10.99 - 10.110 | 10.111
- 10.119 | 10.120 - 10.135 | 10.136
- 10.146 | 10.147 - 10.163
|
|
|
|
|
|
10.79
|
Dr Maud Meates, a consultant paediatrician, conducted the morning
ward round on 27 July accompanied by Dr Saji Alexander, a registrar.
Both doctors said that they were aware of the fact that there were
suspicions that Victoria may have been physically abused. Dr Meates
added that discussions she had with other medical staff during the
course of her ward round alerted her to possible issues of emotional
abuse and neglect as well. At the time, she said the accumulating
evidence was "making us much more certain that this was an abusive
situation".
|
|
10.80
|
Neither Dr Meates nor Dr Alexander carried out a full examination
of Victoria during the course of the ward round. Both doctors apparently
assumed that this had already been done. Neither of them sought
to confirm this assumption by reading through the notes.
|
|
10.81
|
At the end of the ward round, Dr Alexander recorded an action plan
that included referral to the hospital social worker, a request
for an opinion about Victoria's right eye that had become swollen,
and a further request for photographs and a skeletal survey.
|
|
10.82
|
As to the referral to the hospital social worker, Dr Alexander
said that he was "probably" unaware of the fact that Ms Johns had
already been informed about Victoria and that she was awaiting a
definitive medical opinion as to whether Victoria's injuries were
thought to be non-accidental. Dr Meates, it would seem, was similarly
ignorant of the current position.
|
|
|
|
10.83
|
Dr Meates's ward round appears to have prompted a further call
to be made from the ward to Ms Johns. Her records indicate that
she received a call from Nurse Sue Jennings concerning Victoria
on 27 July. Although Nurse Jennings had no recollection of the conversation,
Ms Johns's notes suggest that Ms Johns was asked what action she
proposed to take. Ms Johns replied that she intended to take no
action until there was a clear diagnosis of non-accidental injury
and Victoria's parents had been informed of social services' involvement.
|
|
10.84
|
To reinforce the message, Ms Johns wrote a memo to the "Sister
in charge of Rainbow ward", in which she clarified the child protection
referral procedures. She explained that, unless and until a paediatrician
confirmed that a child was likely to be suffering from non-accidental
injury and informed the child's "parents" of that suspicion, social
services could do no more than carry out routine checks. Finally,
she wrote in the memo that she understood that it had not yet been
suggested that Victoria was suffering from non-accidental injury,
but that she would retain the papers and await further information.
|
|
10.85
|
Unfortunately, neither Dr Meates nor Dr Rossiter ever saw Ms Johns's
memo and so did not take steps to correct her misunderstanding that
non-accidental injury had yet to be "suggested". However, even without
their intervention, matters started to inch painfully towards the
point where Ms Johns felt she had sufficient information to make
a child protection referral.
|
|
10.86
|
Although Dr Forlee could not recall doing so, Ms Johns's notes
record that Dr Forlee called her on 27 July and explained that fresh
concerns had arisen since the child protection forms had originally
been completed, and that suspicion was growing that Victoria was
the victim of abuse. Ms Johns recorded that she explained to Dr
Forlee that the child protection forms would have to be amended
to reflect these heightened suspicions and that Victoria's "parents"
should be informed.
|
|
10.87
|
Assuming that Ms Johns's note made at the time of her conversation
with Dr Forlee is accurate (and I have no reason to doubt it), then
Dr Forlee failed to do as she was asked. She made no amendment to
the child protection forms herself and could not recall whether
or not she reported Ms Johns's request to anyone else. During the
course of her oral evidence, Dr Forlee drew my attention to the
ad hoc manner in which responsibility for matters of this nature
was assumed by doctors on the ward. She told me that "areas that
we covered, areas that we had responsibility for changed every day"
and that "things happen[ed] fairly haphazardly rather than in an
organised, co-ordinated way".
|
|
10.88
|
This is a woeful state of affairs. It combines what appears to
me to be an institutionalised lack of any system on the ward for
responding to requests and for ensuring the comprehensive and coherent
gathering and passing on of information, with a discontinuity of
medical care that blurred areas of personal responsibility.
|
|
10.89
|
It is abundantly clear that Ms Johns needed a straightforward,
documented statement from ward staff about Victoria's injuries and
whether or not these were thought to be non-accidental. She had
made a request for this four times: in a conversation with Nurse
Jones on 26 July and recorded by her in the critical incident log,
in a conversation with Nurse Jennings the following day, in a memorandum
to the ward, and in a conversation with Dr Forlee. On each occasion
she was clear in her request and in her reasons for it.
|
|
10.90
|
Despite the number and clarity of her requests, she received no
satisfactory response from the ward staff. Furthermore, there did
not seem to be any system in place on the ward designed to ensure
that requests for information from other agencies were dealt with
promptly and efficiently. As Dr Rossiter put it, "I think we were
in trouble of having a lot of links in the chain most of which are
able to break."
|
|
Paragraphs: 10.1 -
10.17 | 10.18 - 10.25 | 10.26
- 10.37 | 10.38 - 10.47 | 10.48
- 10.56 | 10.57 - 10.67 | 10.68
- 10.78 | 10.79 - 10.90 | 10.91
- 10.98 | 10.99 - 10.110 | 10.111
- 10.119 | 10.120 - 10.135 | 10.136
- 10.146 | 10.147 - 10.163
|
|
|
|
|
|
10.91
|
It would appear that Ms Johns eventually decided to take Victoria's
case forward, despite the absence of the unambiguous diagnosis she
had asked for. Her notes indicate that she spoke to Dr Alexander
on 28 July and told him that the referral had been passed on to
Haringey Social Services. He told her that the hospital staff would
pass on this information to Kouao when they saw her later that day,
and a note made by Dr Richardson indicates that this was indeed
done.
|
|
10.92
|
Ms Johns's notes further state that she spoke to Nurse Jennings
and asked, yet again, if she could remind the doctors either to
complete a new CP3 form or amend the existing one to show that non-accidental
injury was suspected. Nurse Jennings could not recall what, if anything,
she did in response to this request. Whatever it may have been,
it certainly did not result either in the amendment of the CP3 form
or in the completion of a new version.
|
|
10.93
|
However, it is possible that Ms Johns's call prompted Nurse Jennings
to speak to Dr Rossiter concerning Victoria's case and Ms Johns's
outstanding queries. This may explain why Dr Rossiter spoke to Ms
Johns later the same day. At the end of this conversation, Ms Johns
made the following entry in her notes: "Anxious attachment? At least
neglect; probable emotional abuse; possible physical abuse.
|
|
10.94
|
Dr Rossiter did not make her own note of the contents of her conversation
with Ms Johns and had insufficient recollection of it to enable
her to dispute the accuracy of Ms Johns's record. Assuming that
the note is an accurate reflection of what Dr Rossiter said, then,
in my view, she gave Ms Johns a substantially more equivocal impression
of the level of the hospital's concerns regarding physical abuse
than the available evidence would have warranted. Nonetheless, Ms
Johns considered by this stage that she had sufficient grounds to
refer Victoria's case on to Haringey Social Services.
|
|
|
|
10.95
|
Having received the referral from Ms Johns, Haringey Social Services
arranged a strategy meeting for 2.30pm on 28 July at Haringey's
offices. No one from the hospital attended. Dr Rossiter said that
she was probably aware that the meeting was taking place and would
have gone had it been held in the hospital at a time compatible
with her other commitments, but that she would not have had time
to travel to Haringey's offices on the afternoon in question. Nurse
Norman was unaware that the meeting was taking place and none of
the ward staff would seem to have been invited.
|
|
10.96
|
Following the strategy meeting, Ms Johns sent a memo to the ward.
The memo stated that social services would contact Dr Meates to
clarify the medical position and discuss a timetable for intervention
(it would seem as though Haringey had yet to realise that Dr Rossiter
had assumed responsibility for the child protection aspects of Victoria's
case).
|
|
10.97
|
The memorandum ended by asking ward staff to "kindly assist" in
the following respects:
|
|
"-
|
To provide a brief summary of the observed interactions between
Anna and her mother, which led to staff members feeling concerned
|
|
-
|
Could staff continue to closely monitor the interaction between
mother and daughter and record this
|
|
-
|
Should Ms Kovao [sic] attempt to remove Anna from the ward, prior
to discharge being agreed jointly by the hospital and Haringey Social
Services, the police to be alerted immediately and asked to prevent
this."
|
|
10.98
|
The final significant event of 28 July was a visit to the ward
by Dr Thomas Mann, a consultant dermatologist. He examined Victoria
at around 4.30pm at which point he found no evidence of scabies
burrows and concluded that Victoria had been successfully treated
and no longer posed a risk of infection. However, he did consider
that Victoria's skin may have been irritated by over-treatment with
the Derbac lotion that had been prescribed by the Central Middlesex
Hospital to treat Victoria's scabies.
|
|
Paragraphs: 10.1 -
10.17 | 10.18 - 10.25 | 10.26
- 10.37 | 10.38 - 10.47 | 10.48
- 10.56 | 10.57 - 10.67 | 10.68
- 10.78 | 10.79 - 10.90 | 10.91
- 10.98 | 10.99 - 10.110 | 10.111
- 10.119 | 10.120 - 10.135 | 10.136
- 10.146 | 10.147 - 10.163
|
|
|
|
10.99
|
The days immediately following the strategy meeting passed uneventfully
as far as Victoria was concerned. She would seem to have been well
cared for on the ward and her injuries continued to heal. By 2 August,
Dr Reynders felt able to write in her notes that Victoria was "much
better" and "able for discharge".
|
|
10.100
|
At Dr Rossiter's suggestion, Victoria was befriended by a French-speaking
nurse named Lucienne Taub. Nurse Taub would spend some time with
Victoria virtually every day and would often take her on little
excursions around the hospital, including visits to the neo-natal
wards, which Victoria particularly enjoyed.
|
|
10.101
|
While unremarkable from Victoria's perspective, this period witnessed
a number of incidents of potential significance to the future management
of her case.
|
|
|
|
10.102
|
The first was the visit of the hospital's photographer, Ian Abernethy,
on 29 July. Mr Abernethy took a series of photographs of Victoria's
injuries, several of which were shown during the course of the Inquiry's
hearings. They constitute a clear and helpful record of the marks
visible on Victoria's body at the time.
|
|
10.103
|
Therefore, it is a matter of great concern that they were not seen
by anyone until after Victoria's death. Part of the explanation
for this unfortunate omission may lie in the fact that the photographs,
once developed, were sent to Dr Meates's office rather than Dr Rossiter's
office. This was because they had originally been requested in Dr
Meates's name. Dr Meates had no recollection of ever having received
the photographs. She explained that, if she had received them she
would have passed them to Dr Rossiter who, in turn, was clear in
her recollection that they never reached her.
|
|
10.104
|
The lack of any adequate system for the proper distribution of
the photographs is illustrated by the manner in which Dr Meates
dealt with the request, contained in a memo written by Ms Johns
on 29 July, for the police to be provided with copies. Dr Meates
was prepared to agree to the request, annotated the memo to this
effect and sent it back to Ms Johns. Thereafter, nothing was done.
|
|
10.105
|
It is unfortunate that Dr Meates did not share the contents of
the memo of 29 July with Dr Rossiter. Given that Dr Rossiter was
responsible for the child protection aspects of Victoria's care,
her ignorance of it was regrettable. Victoria's case would seem
to demonstrate that, unless it is clear to all those concerned exactly
which consultant is responsible for the child protection aspects
of a particular case, there is the possibility that important information
is missed. In order to address this problem, I make the following
recommendation:
|
|
|
Recommendation
|
|
|
When a child is admitted to hospital with concerns about deliberate
harm, a clear decision must be taken as to which consultant is to
be responsible for the child protection aspects of the child's care.
The identity of that consultant must be clearly marked in the child's
notes so that all those involved in the child's care are left in
no doubt as to who is responsible for the case.
|
|
|
|
10.106
|
The second incident of significance happened on 1 August 1999,
when Dr Rossiter finally got round to amending the CP3 form originally
completed by Dr Forlee over a week earlier. The amendment consisted
of an arrow pointing from the conclusion originally ticked by Dr
Forlee, "I wish to await further information before committing myself",
to the one above which read "I consider the incident is likely to
be non-accidental". Next to the arrow Dr Rossiter wrote: "What is
uncertain is the category."
|
|
10.107
|
Dr Rossiter explained that the intention of the arrow was to show
that her view had changed and that the note beside it was intended
to convey that she considered Victoria to be a victim not just of
physical abuse but, perhaps just as seriously, emotional abuse and
neglect. As to the physical abuse, her view was based not on the
scalding injuries to Victoria's head but on the other injuries which
had been discovered since her admission. This is significant because
Dr Rossiter chose not to amend the 'description of injuries' section
on the CP3 form, which continued to refer only to the scalds to
Victoria's face.
|
|
10.108
|
In fact, the long-awaited amendment of the CP3 form did little
to improve the position as far as social services were concerned.
The annotated CP3 form still fell well short of an accurate reflection
of the hospital's concerns. In particular, there was no reference
to the various marks on Victoria's body which were thought to be
indicative of abuse, including those Dr Rossiter thought may have
been caused by looped wire. Similarly, there was nothing to indicate
that the overall picture of Victoria's circumstances was leading
Dr Rossiter to have serious concerns about emotional abuse and neglect.
|
|
|
|
10.109
|
The third incident of significance was when Dr Rossiter decided,
during the course of her ward round on 1 August, that Victoria should
be subject to a psychiatric assessment. She took the view that a
psychiatrist might be able to gain a clearer insight into the difficulties
Victoria was facing. Dr Reynders wrote up the notes of that ward
round and recorded that the assessment should be done urgently.
He also noted that Victoria's case would be discussed at the psychosocial
meeting to be held the following day.
|
|
10.110
|
Dr Rossiter attended the psychosocial meeting on 2 August and repeated
her instruction that a psychiatric assessment of Victoria should
be carried out. In the event, the psychiatrist concerned refused
to carry out an assessment until more background information about
Victoria's circumstances was available and she had been assessed
by social services. Instead of taking steps to provide the psychiatrist
with what he needed, matters would seem to have been left there
by those responsible for Victoria's care. The result was that no
psychiatric assessment was ever carried out and the opportunity
it may have provided to gain a valuable insight into Victoria's
circumstances was lost.
|
|
Paragraphs: 10.1 -
10.17 | 10.18 - 10.25 | 10.26
- 10.37 | 10.38 - 10.47 | 10.48
- 10.56 | 10.57 - 10.67 | 10.68
- 10.78 | 10.79 - 10.90 | 10.91
- 10.98 | 10.99 - 10.110 | 10.111
- 10.119 | 10.120 - 10.135 | 10.136
- 10.146 | 10.147 - 10.163
|
|
|
|
|
|
10.111
|
The ward round on the morning of 3 August was carried out by Dr
Alexander. He noted that Victoria was "better" and "medically fit
for discharge". However, he was concerned that she had yet to provide
a satisfactory account of what had happened to her and considered
that a proper history was still required.
|
|
10.112
|
In my view, Dr Alexander was undoubtedly right in his assessment
of the situation - a proper history was plainly necessary. Unfortunately,
this proved to be another example of a member of the hospital staff
deciding on an appropriate course of action but failing to follow
it through. Dr Alexander did not take the history himself, apparently
because he thought that Nurse Taub would do so. However, Nurse Taub
said that nobody ever asked her to take a history from Victoria.
It would appear, therefore, that Dr Alexander not only failed to
take the step that he rightly identified as being necessary, but
also omitted to delegate it to someone else.
|
|
10.113
|
Although Dr Alexander considered that Victoria was medically fit
for discharge when he saw her on 3 August, he considered that it
was still necessary to ensure that it was safe for her to return
home. This would have required, in his view, some form of formal
investigation or case conference at which the "specific details
of further care are discussed". Again, Dr Alexander was plainly
correct in his assessment of the situation. It is, therefore, a
matter of regret that he did not take the trouble to contact social
services to ensure that his expectations in this regard would be
met.
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|
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10.114
|
Later that morning, at around 11.20am, Lisa Arthurworrey, the social
worker from Haringey who was responsible for Victoria's case, telephoned
the hospital and spoke to Nurse Quinn. Their respective accounts
of this conversation differed in a number of critical respects.
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10.115
|
Nurse Quinn said that her conversation with Ms Arthurworrey lasted
about 10 minutes, during the course of which she told her about
all the concerns the medical staff felt regarding Victoria. These
included suspicions that Kouao was not Victoria's real mother and
that the scalds to Victoria's head were non- accidental. In addition,
Nurse Quinn said that she told Ms Arthurworrey about the inappropriate
interaction between Kouao and Victoria that had been observed on
the ward.
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10.116
|
According to Nurse Quinn, Ms Arthurworrey appeared to appreciate
the hospital's concerns and asked her to fax "details of the nurses'
concerns about Victoria's behaviour and interactions with Kouao".
Nurse Quinn said that, in response to this request, she faxed to
Haringey Social Services a handwritten note along with form CP1
and possibly also forms CP2 and CP3. The fax amounted to six pages
in total.
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10.117
|
There is a copy of the note written by Nurse Quinn in the hospital
records. It takes the form of a chronology of what Nurse Quinn would
seem to have regarded as significant incidents during Victoria's
stay on the ward. The following matters were included:
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|
•
|
The 'master and servant' relationship between Kouao and Victoria
observed by Nurse Pereira
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•
|
The fact that Kouao made no effort to assist Victoria when she
wet herself during the course of one of Kouao's visits
|
|
•
|
The fact that Kouao never brought any clothes or treats into the
hospital for Victoria
|
|
•
|
The evidence of 'emotional abuse' recorded by Dr Rossiter during
the course of her ward round on 1 August
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|
•
|
The fact that Victoria seemed to simulate crying when Kouao left
after a visit on 3 August
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|
•
|
Victoria's large appetite, including the fact that she once ate
five bowls of cereal during the course of a single evening.
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10.118
|
There is no indication in the note as to whether it was intended
to constitute a comprehensive account of the hospital's concerns,
whether the matters included were additional to those discussed
over the telephone, or whether they represented a selection of the
concerns already discussed. What is clear, however, is that no mention
was made of any of the hospital's suspicions about physical abuse.
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10.119
|
For my part, I find it extremely difficult to know what to make
of Nurse Quinn's note. Numerous witnesses from the hospital came
before me and gave disturbing accounts of the injuries they saw
on Victoria's body. I heard a variety of nurses say that they thought
Victoria had been bitten, branded and beaten with a belt buckle.
Dr Rossiter said that she suspected that some of the marks on Victoria
had been caused by chastisement with a looped wire and there were
suspicions regarding the serious scalds with which Victoria had
originally been admitted. Even if Nurse Quinn is right to say that
all the hospital's concerns were covered in her conversation with
Ms Arthurworrey prior to the writing of this note, this does not
explain why she should have chosen to leave these matters out in
favour of a description of how much cereal Victoria ate one morning.
|
|
Paragraphs: 10.1 -
10.17 | 10.18 - 10.25 | 10.26
- 10.37 | 10.38 - 10.47 | 10.48
- 10.56 | 10.57 - 10.67 | 10.68
- 10.78 | 10.79 - 10.90 | 10.91
- 10.98 | 10.99 - 10.110 | 10.111
- 10.119 | 10.120 - 10.135 | 10.136
- 10.146 | 10.147 - 10.163
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10.120
|
In addition, the note Nurse Quinn made of her conversation with
Ms Arthurworrey in the critical incident log would suggest that
she had no justification for being deliberately selective in terms
of the concerns she included in her note. Nurse Quinn made a note
of the conversation in the critical incident log. The relevant section
of the note reads: "She has requested that I fax the CP1 form to
her and any [my emphasis] concerns we may have."
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10.121
|
The explanation for Nurse Quinn's note may lie in the alternative
account of Ms Arthurworrey, whose evidence as to her conversation
with Nurse Quinn was bolstered by the fact that she made a detailed
note at the time about what was said.
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10.122
|
Critically, Ms Arthurworrey's note contains the following entry:
"Hospital are satisfied with the explanation given by Anna's mother
re her burns. Explanation was that Anna, who had been suffering
from scabies, had poured hot water from a kettle over her head.
She did this to relieve the itching.
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10.123
|
Nurse Quinn was adamant that this note was incorrect and said that
she told Ms Arthurworrey precisely the opposite. Ms Arthurworrey
was equally confident that her note was an accurate reflection of
what she was told. The point is plainly one of considerable importance.
Deliberately scalding a seven-year-old girl to the extent that she
needs two weeks in hospital is a matter of enormous seriousness.
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10.124
|
If the hospital really did suspect that Kouao had injured Victoria
in this manner I find it impossible to understand why Nurse Quinn
would have chosen not to say so in her note to Ms Arthurworrey which,
according to her own record, was supposed to contain "any concerns
we may have". The suggestion that one might simply forget to mention
the concern that Victoria's mother had deliberately poured boiling
water over her head is, to my mind, utterly implausible.
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10.125
|
I find it equally difficult to accept that Ms Arthurworrey could
have so disastrously misinterpreted what she was told by Nurse Quinn
such that she failed to appreciate that she was being told that
the hospital suspected that Kouao had deliberately inflicted very
serious injury to Victoria. Ms Arthurworrey's note is detailed and
was made at the time. It indicates to me that she was paying close
attention to what she was being told by Nurse Quinn.
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10.126
|
Finally, I note that in the letter written by Nurse Quinn to Ms
Arthurworrey, the following is included in the list of matters thought
by Dr Rossiter to indicate emotional abuse: "self-treatment - boiling
water prior to admission and whilst in hospital put Hibisrub on
her head". This would seem to indicate that the hospital's concern
regarding Victoria's scalds was n |
