GOSH continued………

This is the letter I wrote to GOSH following the interview I did with BBC London. The program did not appear until later the following week. BBC London had succeeded in getting a full copy of the Sibert Report under Freedom of Information. The evidence is all in the report and the altered addendum. The addendum which was supplied to the 1st Serious Case Review into Peter Connelly’s death.

GOSH have responded to the letter below  and I will post their response to my allegations over the weekend. It is on their website currently as well.
Chair Great Ormond Street Trust Board
Great Ormond Street Hospital
34 Great Ormond Street
London WC1N 3JH

8th June, 2011


Dear Baroness Blackstone

Re: Call for investigation into Dr Jane Collins’ actions in withholding of information by GOSH from the original Serious Case review into the death of Peter Connelly (Baby P).

I am writing to you on a matter of grave concern.

From information I have now received it appears that the Chief Executive of Great Ormond Children’s Hospital (GOSH),Dr Jane Collins, withheld vital information from the 1st Serious Case Review (SCR) into the death of Peter Connelly (Baby P).

In January 2008 a report (the Sibert Report) was commissioned by Dr Collins. It has recently been released to the BBC in response to an FOI request. It is entitled ‘Review of Child Protection Practice of Dr Sabah Al-Zayyat’ and was written by Professor Jo Sibert and Dr Deborah Hodes ( Sibert report), two renowned paediatricians.

The report highlights the serious problems and failings in the management at St Ann’s child development clinic in Haringey, where Great Ormond Street Hospital employed the consultants and clinical staff. The report goes to the heart of what went wrong in the NHS’s care for Peter Connelly.

Much of the most important information was deliberately withheld from the Serious Case Review. Instead of submitting the full report as an addendum to GOSH/Haringey PCT’s Individual Management Review (IMR), Dr Collins passed over a partial and selective version.

The information that was expunged would have helped to show the dangerous conditions operating within the Child Health Safety Team for which GOSH had responsibility.

The report examines the actions of Dr Al Zayyat – the doctor who examined Peter Connelly – but also ‘The settings and system for child protection cases referred to Community Child Health at St Ann’s Hospital’. This service was run jointly at the time by Haringey PCT and GOSH, and GOSH subsequently took over the whole service in May 2008.

This report was kept secret and has only been released in response to an FOI request from the BBC.

In the overall conclusions section of the report ‘Settings and Systems’ for child protection cases referred to Community Child Health at St Ann’s’ – which does not appear in the addendum supplied to the first Serious Case Review – Sibert and Hodes state:

‘We were concerned that Dr Al Zayyat was appointed to a substantive post when she did not meet some of the core requirements in the job description’

‘‘Dr Banergee told us that the state of affairs at St Ann’s was a ‘clinically risky situation’. We agree with her and we believe the present arrangements for seeing child protection cases at St Ann’s cause grave concern. In particular the lack of consultant staff and the problems linking with the North Middlesex and Great Ormond Street make it very difficult. There is no named doctor for child protection at St Ann’s. We were surprised that the report of the Designed Doctor and Nurse made little mention of the staffing problems at Consultant level at St Ann’s.

Also there was no nurse to help in the clinic and the doctors have to weigh and height the patients. Haringey has a large multi-ethnic deprived child population. There were no details of the previous admissions in the St Ann’s notes. All these things made it hard for Dr Al-Zayyat’.

A litany of criticism – most serious in nature – is expunged from the addendum edited by Dr Collins and submitted to the Serious Case Review. It appears that Dr Collins has attempted to cover-up the fact that the situation was ‘clinically risky’. Moreover, the key criticisms in the report of GOSH management have been removed as have two key recommendations that address serious GOSH failures.

– there needs to be an urgent appointment of a named doctor in child protection at St Ann’s.

– Doctors should not be appointed unless they meet the core requirements set out in the job description. If they do not meet them, then a programme should be implemented and the appointment reviewed.

The depth of the deception that has been perpetrated is unbelievable. For example, the table showing the immediate actions taken has been written in such as way as to make it unclear that there wasn’t a named doctor in post at the time of Child P (i.e. they say it was included in the JD for the new post which was being advertised, and that the Designated doctor was covering a vacancy). They do not make clear that the post was not covered at all when Peter C.onnelly presented. This is clearly why the recommendation to appoint a named doctor was omitted from the list of recommendations.

This can be nothing other than a deliberate attempt to hide the management failings highlighted in the Sibert Report – for which Dr Collins bears a share of responsibility.

There can be no more serious charge for the person in whom responsibility is vested for sharing lessons learned from the deaths of children.

Dr Collins claimed in defence of her action removing material from the report (in an interview with the BBC last summer) that she removed certain parts of the report only to protect Dr Al-Zayyat, staff and other children. All personal references are redacted from the report – so her argument does not hold water. Moreover, Serious Case Reviews themselves redact personal details.

Dr Al-Zayyat’s practice was certainly considered to be lacking but all the factors listed below were actually mitigating of Dr Zayyat’s position but damning of the management; i.e. most crucially she was put in a job that she was not qualified to do and given inadequate support. Dr Al-Zayyat has clearly been held to account for her part in this tragedy – but as can be seen in the content of the information that was removed – the fault was not hers alone.

a) GOSH appointed Sabah Al-Zayyat to a post that she was not qualified to carry out.
b) GOSH failed to appraise her capabilities in child protection, or to give her any supplementary training in this, despite clear deficits in her previous experience and training
c) There was no ‘named doctor’ for child protection. The ‘named doctor’ is a critically essential post in all paediatric units, with ‘on the ground’ responsibility for ensuring that the Trust meets its obligations in safeguarding children. The lack of such a person in the very place where Victoria Climbie had died a few years previously is indefensible.
d) GOSH were running a service with inadequate numbers of consultants
e) Communication between GOSH, North Middlesex and St Ann’s was poor
f) The arrangements for assessments of children under 2 did not meet national guidelines
g) Doctors frequently had to see patients without access to medical records
Although GOSH was only responsible for the doctors, not the rest of the service, all of the above issues would still fall within their responsibility either directly (a. – f.) or indirectly (g.) as a governance issue that they should have addressed with Haringey.

Also, although not stated in the Hodes -Sibert report, the shortfalls in consultants were not primarily a funding issue. They had had 4 doctors in post previously but had lost staff for the reasons that first brought me into this case. (One of my constituents is one of the four paediatric consultants who signed a letter to the management warning that children were in danger and that consultants’ concerns were being ignored). Key staff had resigned, become ill or had to go on special leave because they could not stomach what was going on.

Hodes & Sibert state in the report that they were surprised that the Designated Doctor did not comment on the staffing shortfalls. However, since the Designated Doctor was also the Clinical Director responsible for the running of the service, and worked half-time at GOSH, this is not as surprising as it might appear.

I have a further concern. Last summer, when the two serious case reviews were published
(the first one, incidentally, without the GOSH ‘addendum’) the chairman of Haringey’s LSCB at the time of the second SCR – Graham Badman – told the BBC that he had not seen the Sibert report, this crucial document dealing with issues at the heart of the Baby Peter case.

I met relatively recently with Graham Badman to ask if he had any more information about the systemic failings within the GOSH management team. Mr Badman told me that, knowing I was seeking a copy of the Sibert Report, he had contacted Great Ormond Street to see if he could have a copy. He was told by its legal team that anything he needed to know about Peter Connelly was in the addendum that had been supplied to the second Serious Case Review. He asked if he could see it on Privy terms. He was refused.

Contrary to what Great Ormond Street has said publically, Mr Badman had never had sight of the Sibert Report and never had access to the information that was in that report. That is what he told me directly.

Shortly after the Sibert report (with redactions) was released under FOI, Dr Collins contacted me by email. She said she had always wanted to release the report but legal advice was that she could not. She does not explain what this legal advice is, nor how it over-rides the duty of transparency to a statutory serious case review process. Did the legal team advise her to remove any criticisms of GOSH?

Moreover, I must dispute what Ms Collins says in her email to me where she states that the ‘whole report was provided for the second SCR after the trial’. That totally contradicts Mr Badman (Chair of the 2nd Serious Case Review) who says he never had sight of the full report not at the time he chaired the 2nd Serious Case Review nor when he requested he be given sight of it before his recent meeting with me .

I am concerned that while we must, as a general rule, attempt to move forward and put the problems of the past behind us, there is clear evidence here of actions which subverted the serious case review process in the case of Baby Peter. It is not possible to learn the right lessons unless all relevant and important information has been disclosed, whatever the potential impact on the hospitals and health trusts involved.

There are two key issues: the actions of Dr Collins in withholding vital information from a statutory process (the Serious Case Review) and the fact that those managers who presided over this ‘clinically risky’ situation are still in post because none of these facts came to light and their roles and culpability never faced proper scrutiny.

The key person in charge in Haringey was dismissed from post. The key managers also lost their jobs as a result of the Serious Case Reviews. There has been no such equivalence at Great Ormond Street Hospital.

It is not a difficult task to see what was and was not passed on by Great Ormond Street. I trust that you will investigate this immediately and I look forward to hearing from you as a matter of urgency.

Yours sincerely

Lynne Featherstone, MP
Member of Parliament for Hornsey & Wood Green

Note: this letter has also been sent (addressed to each) to Jo Williams, Chair Care Quality Commission, Baroness Blackstone Chair of GOSH Board (with a request to circulate to all Board Members and Trustees), Secretary of State for Education, Michael Gove and Secretary of State for Health, Andrew Lansley

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