Reading the Baby P Serious Case Review

Well, I read the full Serious Case Review into the death of Baby P at the end of the week. I was given sight of this document following the ho ha when Ed Balls appeared to use the Information Commissioner for cover, saying others could not be allowed sight of the review – and then the Information Commissioner went public clearly not happy with being used in this way. Net result – several MPs, myself included, were allowed to see the report.

Access was given on ‘privy council terms’ – political speak for promising to keep the contents confidential, so I can say nothing of what I have read. The reading was done on my own, in an empty room with one table and one one chair and one copy of said document marked ‘confidential’. I sat alone there for two hours. You are not allowed to make notes of its contents – but you are allowed to note your impressions.

What I can say is that having read the document I am even more of the opinion that it would be in the public interest for it to be published – obviously with some parts anonymized and with a tiny – very tiny – bit of editing of any personal information around the family.

Otherwise – how will all those who have an interest or experience or knowledge or expertise be able to judge Ed Balls action when the investigative report comes in on Monday? That report he has said he will publish – but surely the wider audience can only benefit from understanding how resonant the original document is and was.

To this end – I, David Laws (Liberal Democrat Shadow to Ed Balls) and Michael Gove (Conservative Shadow) wrote to Ed Balls at the end of last week asking him to publish the full Serious Case Review. He has since written back to say no.

Mr Balls’s key rationale for his refusal is that a Serious Case Review is for lessons to be learned. He says that if such documents were to be published – then those who contribute to them might feel nervous about doing so in the future and not talk or give their information freely. Utter bunkum!

Far from being a danger, the light of public scrutiny should be an essential safeguard to ensure that these reviews are carried out properly. Because – quite frankly – these reviews are barely ‘independent’ as they are commissioned by the Safeguarding Children board – in this case chaired by Sharon Shoesmith, one of the very people whose own actions are up for questioning. The ‘independent’ person commissioned on this one has already gone public on the fact that he wasn’t given any independent access to people or documents and that the report went to the sub-committee (chaired by Ms Shoesmith) something like five times for ‘correction’.

So public scrutiny should be welcomed, not feared. As we know already that public scrutiny doesn’t put people off saying what happened and their role in it. They did for Laming’s public inquiry and they did in court and as their jobs depend on it. So you should say goodbye to that old myth, ‘we can only find out the truth if we keep it secret’ Mr Balls.

I rate that old chestnut along with the ‘shhhhhhh don’t say anything brigade’ who keep wailing that this will put off decent social workers coming to Haringey. Nooooo – what will put decent, good, hard-working social workers off coming to Haringey is the constant poor management, cover ups, closing of ranks and appalling leadership – or lack of.

So – publish – and be damned. Whoops – that must be what they are afraid of!

0 thoughts on “Reading the Baby P Serious Case Review

  1. From what you write it does appear that Sharon Shoesmith has been overly protective about her role and her department. That is not healthy. She would have emerged from this with more credibility by allowing independent review and, perhaps more importantly, by disqualifying herself from presiding over the review on the grounds of conflict of interest.

  2. LynneWell said. The blocking of the publishing of this report is a disgrace and smacks of a government trying to hide something.There have clearly been a massive catalogue of errors in this case and to keep the report from being published will help no-one.Ed Balls, like Gordon Brown disgraces (and to be frank the Labour government generally) disgraces the position of MP, never mind cabinet minister.Dominic

  3. As daft Ed would say: “So What?”Well Ed, the ball’s in your court now, mate. (No pun intended…)

  4. Thanks for the update Lynne.There may be times when Ed Balls concerns (about publishing such a report) are justified, but one strongly suspects this occasion is not one of them.Most people recognize that the issues at stake are the most serious imaginable: life and death. Both the avoidable death(s) that have already happened and the overriding need to avoid another tragedy on the Child Protection Register.Many considerations have to give way to this, including the disruption of the vested interests of high-paying jobs and careers at Haringey. They are not delivering.If further Climbiés and Baby Ps can be averted then short-term upheaval in Childrens Services is justified and necessary.

  5. LynneThanks.So I assume that what you are saying is:1. All Ministers told us “Procedures were correctly followed.”- This was their ENTIRE defence.2. the Report says “Procedures were not followed”In others words I assume the Report makes Ministers look: either wrong or liars.Note these are purely my assumptions. You obviously cannot comment…

  6. So – publish – and be damned. Whoops – that must be what they are afraid of!“Hmm. Unless the report says that Ed Balls and Gordon Brown personally murdered Baby P, which I doubt, then there’s pretty much nothing in there that could make the government less popular on their handling of the issue than they currently are.This strongly implies that they’re actually sticking to some kind of ‘principles over political advantage’ point on the report.I realise, given that you’ve been happy to make political capital over the whole tragedy both here and on LC, that you’ve no such qualms – but it’s a bit much to criticise others for not sharing your shameless opportunism…

  7. John – I don’t need to make political capital as you so sweetly put it. Labour did this to themselves. However, you have no idea what it was like last time, when I was Leader of the Opposition on Haringey when Victoria Climbie died. Then the Labour Leader, Lead Member and Social Services Director all walked away from it bearing no responsibility – only the social worker at the end of the food chain took the blame, despite all the criticisms from the Laming report about failures by others and other systems.They promised that lessons would be learned and that it would never happen again. And in my view it is not coincidence that it happened twice here in Haringey.There is a very cosy, rank closing fraternity who protect themselves rather than deal with the actual issues.Quite frankly, when I went personally to George Meehan (Labour Leader) and Ita O’Donovan (Chief Exec) to warn them that children were at risk because anyone who raises a concern over a child – including the whistle blower Nevres Kemal (amongst others), who lost her job for her trouble – they both did sweet FA as a response – and I went privately and confidentially so as not to make it political etc. However, you like others, would prefer that I say nothing and do nothing.My job is to keep holding Haringey’s feet to the fire until we have a department that is safe and leadership that leads. And yes – sticking my head above the parapet means that I put myself in the firing line from political enemies. And you know what – I don’t care!

  8. After reading reports and information “available” from various websites i am so shocked that this country a “democratic” governed country is allowing this to happen and to keep information like this the case of baby p private! They are doing this to cover there own backs and seems to be alot of cowardly professionals trying to pass the blame onto everyone else…The most pathetic comment i have heard is haringey’s officials saying “procedures were followed correctly” well no otherwise baby p would still be with us and with a loving and caring foster home which i have read one was found for him! That makes me really angry, the excuse of there not being enough foster homes doesnt cut it in this case because one was available. The reports from eye witnesses and social workers also say that the house smelt of urine and had faeces on the walls which we now know some of which was blood, Did maria ward miss this? Is a dirty health hazardous environment not enough to remove a child alone? I think we all know why this case wasnt taken as seriously though dont we? mainly because baby p diddnt come from a working class family and if he had it might be a different story, Unfortunately our governmernt and society expects a family on benefits and in council housing to be “more scruffy” it is expected that the house would be in a state and the children dirty, most will say i am being stereotypical but i am only saying what everyone else is thinking, It doesnt mean that i am judging people on benefits because i am on benefits but i have worked since i was 16 and only claim benefits because my baby is young and i do not want any other person bringing my child up at this young age but god knows i have paid my tax upto the birth of my daughter and so i am entitled to goverment benefits. I do not live in a council house and i rent privately because i refuse to have my child living on dangerous estates with drugs and unruly teenagers..I can say this because i was brought up in south London going from council estate to council estate going home from school and getting into the lift to get to my block of flats and having to step over needles and old condoms, until i was 15, i know what goes on and i promised i would give my daughter better.In my opinion the social workers in this case knew all along that procedures were not being followed but just couldent be bothered to do anything about it, About a week before baby p died maria ward visited the house she reports that he was sitting in a pram in the hallway with chocolate smeared round his face, why wasnt the mother asked to wipe the chocolate away? He had a broken back and broken ribs, why wasnt he taken out of the pram so he could be seen playing? or in this case even walking? why wasnt he checked over for bruises and marks? Even if the social workers believed that the incidents at hospital were all “accidental” then i think that alone should be questioned! If a child is turning up at hospital with bruises cuts and suspected broken legs then the mother is obviously unfit to have a child in her care! How could they allow this? I have seen pictures and with all the hospital evidence and reports why was this poor child abused for 8 months and not helped after 60 visits or reports? It is a complete sham, I cant believe i am part of a country called “Great Britain” we only seem to get rights when we do something wrong! or commit a crime. I hear that they will only be sentenced for causing or allowing a child to die, that is shocking, What kind of message does this give to the monsters in society that are abusing children right now! We have a right to see the report and i believe we have a right to know what is going on! Haringey council and the Doctor involved allowed a child to be abused over 8 months of being under there care, How are they still allowed to work in this field of work!? Ed Balls wants to protect everyone who failed and cover up the incompetance of the people involved.Baby p is only a fraction of how social services and the goverment is failing us on a daily basis, When is it going to stop? I am shocked that sharon shoesmith and the other pathetic officials involved in this catastrophic case have not resigned! They are obviously unable to protect the children of Haringey, Oh then she would lose her 100K salary! silly me…. Chantelle

  9. I note several retirements and a firing.How can that be?We were assured by Mr Brown “all procedures were followed”.I am shocked. Is a gross injustice being done? or are we going to receive an apology for misleading statements?or do pigs fly?

  10. Well done Lynne. It’s a cover-up all right. Until we realise, however that this sort of “management” stitch-up is endemic in ALL Public Sector organisations, we won’t be applying sufficient joined-up thinking to get to the root of the problems. “Separate” thinking enables, for example the continuation of disgraceful episodes such as Victoria Climbie (obviously), “Deepcut”, Child and Sexual Abuse in children’s homes, etc., etc..The reason thease problems are never cured, is that there is a cult of “unquestionnable management” in this country. A ridiculous belief that any manager can run anything, as long as they are ” leaders” and “managers”. The result of this is that, at ground level and just above ( ie local workplaces) the internal promotion systems often engineer “jobs for the boys” ( and girls). It is a regular occurrence that “line-managers” know next to nothing of the job, and frequently NOTHING WHATSOEVER. Surreally, and most insultingly, many front line (non-manager)experts have to learn to accept appraisals and criticism of their efforts and results from complete rookies, but obviously rookies with amazing egos that allow them to carry out such nonsense. What do they care ? They can quote various modern managenent manuals extolling the virtues of their “leadership” qualities, and revelling in the tripe that “experience” is not necessary !Many an end of year “appraisal” speech is delivered to an expert practitioner by a rookie, in which the recipient spends the entire interview attempting to conceal the fact that their wide-open eyes and mouths are permanently stuck in the “gobsmacked position.Keep up the good work Lynne. This stuff cannot be kept hidden.


    Why are we so soft on dodgy doctors? There are thousands of complaints about them in a single year – yet just ELEVEN are struck off
    By Jane Feinmann
    Last updated at 2:56 PM on 9th February 2012
    • Comments (92)
    Doreen Williams had a chest infection — it wasn’t serious but her GP thought it best to admit the 71-year-old to hospital so that she could have stronger, intravenous antibiotics.
    Seven days later, Mrs Williams was dead as a result of a pulmonary embolism — a blood clot on the lungs which had developed while she was in hospital.
    Her death was entirely needless, says her daughter Karen Rutland.

    Karen Rutland’s mother Doreen Williams was admitted to hospital for a chest infection. Neither the doctors nor nurses intervened to save her life
    ‘My mother was a busy retired teacher who had visited Wales and Cornwall in the two months before her death,’ she explains.
    ‘She had chronic obstructive pulmonary disease, a long-term lung condition, but it never seriously affected her daily life.
    ‘It just meant she had to be careful to get proper treatment for chest infections.’
    Mrs Rutland, 56, has no doubt what was to blame for her mother’s untimely death.
    ‘She was not given the intravenous antibiotics or standard blood tests until five days after she was admitted to hospital.
    ‘And although she was at high risk of a blood clot because of her age and her lung condition, she was never given the blood-thinning medication that would have prevented it.’
    The doctor in charge also issued a ‘do not resuscitate’ order — without discussing it with the family.
    So, as Mrs Williams lay dying, neither the doctors nor nurses intervened to save her life.
    Shocked and distressed by this betrayal of her mother, Mrs Rutland, a former management consultant from Cornwall, did what most people would do. She tried to complain. She got nowhere.
    The doctor denied any responsibility for her mother’s death. And Luton and Dunstable Hospital Trust, where Mrs Williams spent her last days, refused to accept any wrongdoing.

    There were 7,000 complaints to the General Medical Council (GMC) last year. Only 17 per cent of those by patients were investigated
    Perhaps most frustrating, however, was the response of the General Medical Council.
    This is the only medical regulatory body in the UK with the power to suspend or strike off doctors in the interests of patient safety.
    Initially, the GMC’s senior investigating team recommended the doctor in charge of Mrs Williams’s care should face a Fitness to Practise hearing.
    But the hearing was cancelled — twice — because the GMC’s medical advisors said there was ‘an insufficient case to answer’.
    However, the coroner who later examined the case said he found it ‘inconceivable that vital steps were not taken to follow up’ particular warning signs that something was seriously wrong.
    ‘There was every reason to believe that after a short stay in hospital, Mrs Williams should have been well enough to return home,’ he said.
    So why didn’t the GMC take action? It is a question being asked in an increasing number of cases of alleged medical negligence.
    The concern is that the GMC, which is funded by the doctors it regulates, is biased in their favour and shields those it is supposed to discipline.
    Furthermore, it is accused of treating whistleblowers who try to expose malpractice as pariahs.
    Five years ago Sir Liam Donaldson, who was then the government’s Chief Medical Officer, described the GMC as ‘secretive, tolerant of sub-standard practice and dominated by professional interest rather than that of the patient’.
    It’s a criticism that won’t go away.
    Last year, the Parliamentary Health Select Committee described the GMC in a highly critical report as ‘overly lenient’ to doctors — while just a few months ago, the chair of the Patients’ Association, Dr Mike Smith, accused the organisation of ‘clearly under-investigating complaints submitted by patients’.
    The statistics speak for themselves. There were 7,000 complaints to the GMC last year. Only 17 per cent of those by patients were investigated — with only 11 doctors struck off as a result of these patient complaints. It is worth noting that once the GMC makes a decision, there is no right of appeal from the complainant.
    Even when decisions do go against doctors, the criticism is that the disciplinary process takes far too long, allowing incompetent doctors to continue putting the public at risk.

    It took 12 years after the first complaints were made about Dr Jane Barton for the GMC to initiate the investigation
    In January 2010, Dr Jane Barton was found guilty of serious misconduct after a GMC investigation found she’d given painkillers at six times the recommended dose to 12 elderly patients, causing their death at two wards she ran at the Gosport War Memorial Hospital in Hampshire.
    Yet it took 12 years after the first complaints were made for the GMC to initiate the investigation.
    ‘If Dr Barton had been suspended by the GMC in 1998 when her actions were first questioned, then many of these patients would have been saved, including my mother,’ says Ann Reeves, 57, whose mother Elsie Devine died aged 88 of a ‘substantial overdose’ of opiates administered by Dr Barton in 1999.
    Incredibly, despite finally finding Dr Barton guilty of serious misconduct, a Fitness to Practise panel — who are appointed by the GMC — still allowed her to continue working as a GP (she has since retired).
    Indeed, in 2010, 39 other doctors were permitted by panels to remain on the medical register even though the GMC’s own investigators recommended they be struck off.
    One of these was general surgeon Gideon Lauffer, who was found guilty of serious misconduct after a series of botched operations that caused the death of two patients and injured 18 more.
    Yet a Fitness to Practise panel ignored the advice and imposed a six-month suspension allowing him to return to work ‘under supervision’. By November 2011, he was back at work.
    Karen Rutland had little idea of the failings of the GMC when she decided to complain to the organisation about her mother’s death in 2006. While Doreen Williams was in hospital, her husband Ralph had become increasingly worried.
    Mrs Rutland recalls: ‘He told me the consultant in charge of my mother, Dr Tariq Mirza Rehman, hadn’t started her on the intravenous antibiotics.’
    So, the next day, the concerned father and daughter spoke to Dr Rehman. ‘He told us in a reassuring voice how very seriously he was taking our mother’s care.’
    But after her mother’s death, Mrs Rutland learned that from the moment Mrs Williams was admitted, Dr Rehman was responsible for a series of glaring omissions in her care. The full extent of neglect was revealed at an inquest in January 2011 — five years after Mrs Williams’s death.
    The inquest heard that not only did Dr Rehman fail to prescribe Mrs Williams antibiotics, but he didn’t give her medication routinely prescribed to hospital patients of her age and health background to prevent the blood clot.
    There were other more serious failings too. The level of oxygen in Mrs Williams’s blood dropped — a warning sign of a pulmonary embolism — and fell further on the day of her death, which should have resulted in her emergency transfer to intensive care.
    At 3pm on Mrs Williams’s final day, Dr Rehman issued a ‘do not resuscitate’ order, a step that is supposed to be taken by doctors at the end of a terminally ill person’s life to stop resuscitation in the event of a cardiac arrest — thereby preventing unnecessary suffering.
    Such a step was ‘entirely inappropriate and unwarranted’, according to Dr Vincent Mak, a respiratory medicine and intensive care consultant at Central Middlesex Hospital, North West London, and an independent expert witness at the inquest.
    He noted Mrs Williams’s health prior to admission was ‘of reasonable quality’, adding that ‘she had recently had an echocardiogram that showed her heart was working well’.
    By issuing the ‘do not resuscitate’ order, Dr Rehman breached two sets of legally binding guidelines, including failing to record the reason for taking this drastic step — which is mandatory.
    Nor did he consult with Mrs Williams, later insisting that she did not have mental capacity — another claim denounced as untrue by the coroner.
    It is also mandatory for doctors to notify a coroner if a death is unexpected —Dr Rehman did not do this. Instead, he allowed Mrs Williams’s death certificate to carry the cause of death as septicaemia and pneumonia.
    Dr Mak said Dr Rehman presided over a regime of ‘suboptimal care that led to (Mrs Williams’s) death’.
    The coroner summed up his concerns as Dr Rehman stood in the witness box as: ‘You failed to pay attention and treat the patient in front of you’.
    Despite these findings, the hospital trust supported Dr Rehman and denied any wrongdoing.
    So Mrs Rutland turned to the GMC for help.
    ‘We saw it as our duty to ensure no other family would suffer as we have,’ she says.

    Dr Kim Holt was suspended by Great Ormond Street Hospital after blowing the whistle on staff shortages and a ‘chaotic’ appointment system at the clinic
    Yet in 2008, the Fitness to Practise panel, a group of medical and non-medical volunteers, appointed to investigate Dr Rehman’s behaviour, was cancelled — because an independent medical expert claimed ‘none of the points in respect of medical management reflect either incompetence or malpractice’.
    Astonishingly, the same thing happened a year later when a second hearing was set up following a complaint from the Rutlands.
    Despite the coroner’s unusually critical verdict last January, the GMC insists its own rules prevent it from ‘reviewing a decision to cancel a hearing’.
    Chief executive Niall Dickson recently defended the organisation’s record, claiming problems often lie with flawed perceptions of the GMC’s responsibilities.
    ‘Our job is not to punish doctors but to protect patients by taking action against a failing doctor,’ he said.
    ‘We look closely at every complaint to see if the doctor’s fitness to practise could be impaired but will only take a case forward if the complaint indicates serious concerns about the doctor. In the majority of cases where a doctor has made a single mistake, this is not indicative of a bad doctor, however catastrophic the consequences.’
    So what exactly does a doctor have to do in order to provoke ‘serious concerns’ by the GMC? The worrying answer may be to tell the truth — there is growing concern that doctors who try to blow the whistle on unsafe practice could can end up facing disciplinary action themselves.
    Two weeks ago, the GMC issued new guidance reminding doctors they have a duty to raise concerns about poor patient care.
    Yet it’s an empty warning for Dr Kim Holt, a consultant community paediatrician at Haringey Primary Care Trust.
    In 2006, Dr Holt was excluded by Great Ormond Street Hospital, the trust that then employed her, after blowing the whistle on staff shortages and a ‘chaotic’ appointment system at the clinic where, months later, Baby P (Peter Connelly) was treated days before his death.
    ‘It didn’t ever get to the stage of a complaint to the GMC. But there was an attempt to discredit me, to force me out of medicine as a damage limitation exercise,’ she recalls.
    ‘I was lucky in that I’ve now been reinstated in my job. But I’ve met several doctors who have been reported to the GMC by their trusts after they became whistleblowers, and a handful who have even been struck off the medical register.
    ‘Hospitals use threats of referral and actual referral to the GMC as a means of ensuring silence from medical staff.’
    Brian Jarman, professor of primary health care at Imperial College, London, agrees changes are needed.
    ‘There is precious little evidence the GMC supports doctors who speak out when they see failing practice. Why doesn’t the GMC have a confidential helpline for people who see problems at their hospitals? That would be a start.’
    Later this year, the GMC will supervise the launch of a revalidation scheme under which doctors’ performances will be evaluated every five years.
    Katherine Murphy, of The Patients’ Association, is not impressed.
    ‘Unfortunately the GMC’s record on managing complaints makes you wonder how revalidation will work — and whether it’s going to be friends revalidating friends,’ she says.
    ‘We have many experiences of good care and unsung heroes in the NHS,’ adds Mrs Rutland.
    ‘But there has to be a way of taking action against the bad ones — otherwise standards slipping and people dying unnecessarily becomes acceptable.’