This is my response to Great Ormond Street’s rebuttal of my allegations. This will be copied to the Secretary of State for Health.
Chair Great Ormond Street Trust Board
Great Ormond Street Hospital
34 Great Ormond Street
London WC1N 3JH
2nd July, 2011
PLEASE CIRCULATE TO BOARD AND TRUSTEES
Dear Baroness Blackstone
Thank you for your response to my letter of 8th June. I am grateful to the Trust for their time in looking into these matters.
After fighting for over three years for justice for my constituent Kim Holt – the NHS whistleblower – who warned GOSH managers in writing before Baby Peter died that children were at risk in the clinic at St Ann’s – I am pleased to learn that you have finally apologised.
Too little and far, far too late. Kim has literally been persecuted by you – for speaking up for the safety of children.
The Sibert report makes clear how dangerous the situation was at St Ann’s. You have had this report on your desk for all this time and knew how dangerous the situation was and yet you rejected both Kim’s views and my representations on her behalf on all occasions.
It was not until I managed to get NHS London to commission an independent investigative report that Kim’s position was vindicated. Even then GOSH failed to re-instate her and that remains the situation to this day.
In this response to you, I lay out key points and then address your response to my letter point by point as you did in yours.
Firstly you say that ‘the Trust Board saw no justification for my decision to target Dr Collins so personally on this issue’. Very simply – it is Dr Collins’ name on the front cover of the addendum – as its author. It is Dr Collins who has explained and defended GOSH’s decisions at all times, and it is she who liaised with Sharon Shoesmith, when chair of the Haringey LSCB, ‘sharing’ some information with her. Dr Collins was central to GOSH’s approach to the 1st SCR.
The addendum that you submitted to the 1st Serious Case Review omits information including the expert conclusions that the situation at St Ann’s was ‘clinically risky’ and the authors’ ‘grave concerns’. Had the authors’ conclusions been given to the 1st Serious Case Review at that time, I believe that it would have resulted in GOSH being regarded in exactly the same light as Haringey Children’s Services.
Indeed, the author of the 1st Serious Case Review, Edi Carmi, said in a BBC interview that much of the material edited out of the report concerned issues fundamental to the inquiry. She claimed she was not given a full picture of the problems at the clinic.
“I’ve never been aware of any agency withholding this sort of information from a serious case review. I find it unbelievable this level of information was not provided”.
The basic argument you seem to be making is that – because recommendations were ultimately made and an action plan formulated and submitted – there was no requirement to reflect the conclusions of the authors in what was provided to the 1st SCR.
To understand the difference which would have been made if the information had not been with-held, please examine what Richard Horton, in a signed editorial in the Lancet suggests. As he says: When the highly critical Sibert/Hodes Report landed on the desks of GOSH’s managers, they clearly faced a difficult dilemma. If they made the findings public, the inevitable media scrutiny might have damaged their reputation and slowed the progress of their Foundation Trust application. If they edited out GOSH’s failings, they might leave themselves open to the claim of ‘cover up’.
Given you admit that the Sibert report authors’ conclusions were omitted, I think it reasonable to believe that Mr Horton has reached the same conclusion as me.
Timing was crucial. Whatever actions GOSH may have taken later to deal with the ‘clinically risky’ situation described in the conclusions of the Sibert report – had those conclusions been given to the 1st SCR and had the media scrutiny fallen on GOSH at that time the way it did on Haringey Children’s Services – then we might well have seen the GOSH CEO and the managers removed from post in the same way that Sharon Shoesmith and the managers at Haringey were sacked.
However, GOSH managers remain in post.
The allegations I have made are in bold. The Trust’s rebuttal of my allegations are in italic and my response to GOSH’s response are in normal text.
1. Allegation 1 (withholding vital information)
The Trust’s response to my allegation is that it is indeed the case that the full Sibert Report was not shared with the first SCR – but that this followed advice from lawyers and the police.
The Sibert report was commissioned during the serious case review process and specifically arising from it. To suggest otherwise is misleading. My understanding is that Dr Collins attended a serious case review meeting in January 2008 where a police officer made clear that there were serious issues for the doctor and the hospital revealed by the post-mortem into Peter Connelly.
Dr Collins was indeed forced to commission this further medical review (the Sibert Report) because the evidence supplied to the SCR up to that point was inadequate and had given St Ann’s a clean bill of health. That Dr Collins was – six months after a child’s death – only now investigating the practice of a GOSH doctor is a huge issue in itself which should be explored by the inquiry for which there is now unquestionably a need.
Dr Collins says that it was only then that she knew the details of the post-mortem. However, this is no justification. As we now know, just an examination of Dr Al-Zayyat’s own notes reveals that her actions on the basis of what she did see were found to be flawed.
The Sibert report authors were not given the post-mortem by GOSH, but even without it, found a clearly risky absence of child protection skills in Dr Al-Zayyat – and not just in this case. Even now GOSH appears to have attempted to conceal the level of Dr Al-Zayyat’s competence and training. The version of the Sibert report released is redacted and I am informed that as a result the hospital is still publically hiding the fact that Dr Al-Zayyat had only seen four previous child protection cases while at the clinic – of which Sibert had concerns in at least three.
Why did GOSH believe it could still conceal and mislead people by claiming that this information is personal to the doctor? It goes fundamentally to GOSH’s decision to appoint this doctor and to leave her in such a vulnerable position.
You continue to rely on the explanation that you withheld the report because of advice from lawyers and police.
In a BBC London report last Friday the BBC say that the Metropolitan Police Service are completely refuting your suggestion – saying they would never interfere in what should or should not be given to an enquiry, a statutory process – and that it is not in their jurisdiction to do so.
Given the advice of your lawyers is still relied on, you really must explain what that advice is? How could I possibly withdraw my claims in such circumstances?
A further factor emerges which it is essential for an inquiry to investigate. You enclosed what you described as ‘an extract’ of the Sibert report and you claim you ‘shared’ it with Sharon Shoesmith?
How did you share this? Did you suggest to her that this was in fact the whole Sibert report?
Why did you change the title of the report in the version supplied to her, implying a narrower remit?
Why did you also remove two of the five bullet points from the Terms of Reference – specifically omitting the brief for the report’s authors to investigate whether “Dr Al-Zayyat had any additional training needs to enable her to fulfil her duties” and that the authors should “review the settings and systems where child protection cases are seen at St Ann’s”
Why did you not show her at this early opportunity the whole report? Were you misleading the chair of the LSCB?
I remain of the view that vital information never found its way to the 1st SCR, and this view has been endorsed in the BBC report that the author of the 1st SCR says it was information she should have had, and that she had never known a health agency with-holding such information.
As you know, recommendations drawn up in certain language are denied considerable meaning when the report conclusions and findings on which they are based have been removed.
The 1st SCR author says recommendations weren’t and wouldn’t have been accepted without clear ‘sourcing’, to enable them to understand what had led to them.
2. Allegation 2 (deliberate attempt to hide failings)
The Trust’s response is that there is no evidence to support this allegation.
You continue to be misleading about the issue. It is not relevant that you sent the document to others subsequently. The important fact, as you know, was that you failed to ensure all pertinent information went to a statutory enquiry.
I have no doubt that the information was ‘vital’ and revealing. Nor does the author of the 1ST SCR.
It is now for the Secretary of State to establish this.
The Lancet poses three questions: Have the events that led to the death of Peter Connelly been fully and transparently investigated? Have the right lessons been learned? And have those who managed (and continue to manage) children’s services at GOSH and its associated facilities been held properly responsible for the quality of care they delivered? The answers to theses three questions are the same – we don’t know. These uncertainties now rest with the Secretary of State for Health to resolve as a matter of urgency.
Secondly, there are a number of issues which arise from your apparent disclosure to others and what you may have been hiding. It is not yet clear publically whether the CQC received an unredacted report from GOSH. You claim that it went to the JAR. This is factually incorrect. It was sent to the Healthcare Commission while the JAR was being done and for some reason was not considered by the JAR – something that in itself raises further questions for the inquiry.
You also say you sent it to NHS London. However I am informed that they say you demanded that they shred the document after reading it? What were the legal reasons for trying to restrict its circulation so that not even the health service could assess the level of management failings for long? Why would you demand that such a report be shredded?
Your claim to have disclosed the report to the GMC raises another issue, which is that I have been told that you actually sent a copy of the Sibert report to the GMC which you changed without seeking the permission of or informing the authors. You altered a paragraph about my constituent Dr Kim Holt.
As you know a senior health official wrongly told Sibert that Holt was ‘on sick leave, unlikely to return’. As a result, Sibert did not interview her and was prevented from learning her important views on and experience of St Ann’s. Given it was Kim Holt worked there and had previously warned GOSH of the dangers – her evidence would have been important to Sibert. Did you inform Sibert of the letter signed by four senior consultants working at St Ann’s warning of dangers to children?
The Secretary of State will want to satisfy himself that GOSH’s subsequent amendation of the report was appropriate, and whether the authors of the report were content.
You rely again on private legal advice ‘reviewed’ by your Board members. It should now be for the inquiry to decide whether the documents you say have been considered, along with the advice given, was sufficient cause to with-holding information from a statutory enquiry.
It may set an important precedent that hospitals believe they can ‘self-select’ information for disclosure to a statutory process on the basis of ‘unspecified legal advice’.
Furthermore, it is patently clear both that there was nothing in the information with-held that could conceivably have prejudiced a criminal trial, and no reason to with-hold it anyway from a process which is confidential? The position here should surely have been to submit it in full and then make representations, explaining any sensitivities?
The Secretary of State will want to find out how GOSH’s failures of management could be ‘deemed’ to be information that might prejudice a trial?
The Secretary of State should also want to consider evidence from the NHS, CQC, SCR author and the former head of the LSCB – as well as the authors of the Sibert report, before reaching a conclusion that GOSH in any serious sense reflected the true nature of the problems at St Ann’s and why it should even have contemplated excising no less than half the original report.
The evidence does not show the Trust was trying to do the right thing. Far from it, there was one simple and transparent course – to aid the learning from a child death – which you failed to take.
As to ‘competing concerns in difficult circumstances’, I accept that this would have been of concern in terms of preserving the hospital’s reputation, and it was indeed a difficult situation for the Trust. However, learning from the tragedy should have been paramount.
3. Allegation 3 (removal of conclusions)
The Trust’s response agrees with my allegation and states that it is correct that the ‘Overall conclusions’ section of the Sibert report were not included in the Addendum. However, they say that ‘every critical point contained within this section had previously been communicated to the Chair of the LSCB in one or more other documents, including in the recommendations from the Sibert Report.
They agree that the words ‘clinically risky’ were not themselves replicated in any other document.
It is unacceptable to remove such a report’s overall conclusions and the intention seems clear – to hide the authors’ deep concerns. It is remarkable that the Trust claims every ‘critical’ point was included somewhere or other in other documents it may have ‘shared’ with the chair of the LSCB.
It should be for the inquiry to look into this and decide whether this ‘communication’ did happen and in an appropriate fashion, and for GOSH to explain why the authors of the report and the SCR panel were not given all this information. GOSH here accepts there are issues of transparency which should be resolved to help shape future reviews.
It is unacceptable to have failed to pass on the fact that any senior member of staff, let alone the head of the clinic itself, found it ‘clinically risky’.
This is in itself worthy of an inquiry, and the Secretary of State will want to establish how the information given here tallies with previous concerns expressed about ‘safety’ at the unit by consultants, and whether GOSH took appropriate action to eradicate the risk before Peter Connelly died.
As above, recommendations presented by the hospital itself, denied their context and the failures from which they are drawn, appear a disingenuous attempt to block the serious case review from getting the full picture. This should not happen.
I am not concerned, for these purposes, about what GOSH may have been forced to do urgently after receiving the Sibert report. What I am concerned about is what happened up to Peter’s death and why Sibert found what he did.
As I indicate above, the Secretary of State will want to establish why GOSH apparently failed to look closely at the actions of their own doctor after Peter’s death; apparently failed to check her previous child protection cases, and that when this was revealed nine months later – with Dr Al-Zayyat having remained in post during that time – the hospital then with-held the key issue from the 1st SCR: that they had appointed an under-qualified doctor.
4. Allegation 4 (removal of two key recommendations)
The Trust agrees that these recommendations were not in the list of recommendations included in the Addendum. They say they do not know the reason for this. They say that the full set of recommendations (including the recommendation to appoint a named doctor) was sent to the Chair of the LSCB and that it is not credible that there was any intention to deceive.
Again you confirm that I am right but do nothing to explain why two key recommendations were removed from the Addendum, and thus not attributed clearly as conclusions/recommendations made by Sibert.
What you may or may not have sent as recommendations to the LSCB Chair would have been misleading in purporting to be conclusions you had reached independently.
This is a very important distinction – and goes again to the crucial point that recommendations can be deliberately stripped of their importance when de-coupled from the raw material and the expert medical opinion on which they should be based.
It is an incomprehensible tampering with a report of two eminent paediatricians and raises serious questions.
One of the most serious issues here is GOSH’s approach to the post of named doctor – an utterly crucial role for safeguarding children. This post was cut a year before Peter’s death, despite opposition from all four consultants (as there were then).
The head of the unit subsequently claimed, in a published report of which GOSH and NHS London are fully aware, that the transfer of some of the responsibility of this post to her – already the ‘designated doctor’ – was ‘insidious’ and placed an unacceptable workload on her.
This is clearly counter to guidance in Working Together to Safeguard Children 2006 which as you point out was the relevant guidance at that time. This makes it clear that these roles should always be explicitly defined in professionals’ job descriptions and that they should be allowed sufficient time to fulfill their child protection responsibilities effectively. Moreover, the Trust must surely have been fully aware that the Designated and the Named role should not be undertaken by the same doctor since there are inherent conflicts of interest.
The Secretary of State will want to consider how clear Sibert was about the importance of the named doctor, and what GOSH had in mind when removing this from the version of the Sibert report passed on.
Perhaps, given GOSH have not been able to find out from Dr Jane Collins what the reason was for this, the Secretary of State will better be able to do so.
You do not explain why Dr Collins failed to pass on the most important recommendation of all (and the most damaging to GOSH) about doctors meeting job descriptions. This failure alone warrants an inquiry. The Secretary of State will want to establish why GOSH actively ensured that the 1st SCR did not know that it had allowed a sub-standard doctor, failing to meet a core job description, first in to a locum post; then not ensured she was adequately trained, before then appointing her to a substantial post and leaving in her in post – with access to further child protection cases – for a further 9 months after Peter’s death.
5. Allegation 5 (Dr Collins’ BBC interview)
The Trust’s response says that the Trust Board reviewed the transcript of Dr Collins’ interview last summer and claims that my summary of what she said is incorrect.
Your response here is inadequate. A full transcript of the BBC London interview is available, and it should be for the Secretary of State to decide whether or not your public assurances were fair or misleading. He will want to establish whether, in making these remarks, Dr Collins believed that a copy of the Sibert report would ever be released, against which her claims could be tested?
Suffice it to say, Great Ormond Street’s appointment of an under-qualified doctor is not information with-held to protect the doctor so much as information with-held to protect the hospital. This is the same for other omissions too.
6. Allegation 6 (issues found at St Ann’s clinic)
The Trust’s response claims that all of the points raised have been discussed extensively in the media over the past three years.
The issues have been discussed in the media – in spite of GOSH – not because of it.
It is only down to the media and a few others that GOSH’s approach here has been revealed. This is why an inquiry is so necessary – to ensure that agencies are aware of their duties in future.
These issues have NOT been discussed in the media for three years. Given the time you took to deal with Kim Holt’s concerns and the fact that you with-held this information from the SCR in 2008, some of this information only emerged from May 2009 – long after social workers had been blamed for the problems and social care management had been dismissed.
If the failures of GOSH had been known at the time that the SCR was completed, it is inconceivable to me that the CEO of GOSH would not have been required to resign alongside Sharon Shoesmith.
It may be part of the inquiry’s remit to establish whether GOSH and the other agencies have done a suitable assessment of whether disciplinary matters should have been – or should be – pursued with any of its managers involved here.
For the reasons given in earlier allegations, it is not correct that ‘issues within the clinic’ as reported by Sibert were sent to the Chair of LSCB. Alarmingly, given GOSH’s duties to the SCR process, they were not sent within the full context of the Sibert report to the SCR overview authors themselves.
7. Allegation 7 (Consultant absences)
The Trust’s response states that the allegations (including the lack of consultants) made by one individual Haringey Consultant (Kim Holt) have already been extensively aired in public. ‘As you know, an independent review commissioned by NHS London concluded that the concerns raised by this individual were genuine and taken seriously by GOSH. The Report also found that the Trust’s management made genuine attempts to address these concerns.’
It is of the utmost seriousness that the SCR authors were not made aware of the serious consultant shortages at St Ann’s and consequently signed off an overview report and produced an executive summary without knowing this crucial context.
These issues went fundamentally to resources and GOSH management. It was only the NHS London report many, many months later which allowed some of Dr Holt’s concerns into the public domain. If these concerns had been known at the time, GOSH would have faced inevitable major criticism in the SCR.
Moreover, the independent report commissioned by NHS London only happened because I responded to the inaction regarding Kim Holt’s concerns by appealing directly to the Secretary of State, Ed Balls’ office. He then got NHS London to meet with me. I presented the evidence to Trish Morris Thompson – who on the back of our meeting agreed to commission this independent report.
The ‘genuine attempts’ to address concerns happened long after Baby Peter died and they did not happen when they should have. Had those concerns been addressed in timely fashion, Peter Connelly might not have died.
8. Allegation 8 (Designated Doctor comments)
The Trust say that they do not consider it appropriate to comment on any statement made by the Designated Doctor. This role was (and is) a PCT role, and this individual is no longer a GOSH employee.
I find it extraordinary that GOSH are failing to answer this accusation – that its existing and past staff did not explain the consultant shortages to Sibert.
It is equally remarkable that GOSH fail to mention that Dr David Elliman, its senior paediatric consultant, who is still employed by GOSH, signed off a health IMR without mentioning consultant problems (along with many other problems). The role of Dr Elliman in supplying evidence to the 1st SCR as well as deciding that Dr Al-Zayyat should stay working at St Ann’s after Peter’s death, should also be part of the inquiry.
9. Allegation 9 (not giving information to Graham Badman – Chair of the 2nd Serious Case Review)
The Trust say that they reviewed the documentation and it is clear that GOSH did share the full Sibert Report with the IMR writers for the 2nd SCR. They say they do not know how the IMR team subsequently chose to share their Report. They say they do have correspondence with Mr Badman which implies that he did have a copy of the report and they are writing to Mr Badman to clarify this.
A number of questions arise from your answer to Allegation 9.
Firstly – as you know – Mr Badman made it crystal clear to me that he had never had sight of the Sibert Report. I understand that for some time GOSH has been saying that it intended to write to Mr Badman for clarification? When did this happen, and what did you write to him?
It is clear also from reading the 2nd SCR that health is barely looked at or mentioned individually as an agency, and GOSH gets only one or two direct mentions. The 2nd SCR ordered by Ed Balls lays an emphasis heavily weighted on Haringey Children’s Services.
There are important questions which arise here which the inquiry must explore:
– who were the health IMR writers for the 2nd SCR?
– Does GOSH allege that the IMR writers failed to pass on key information to the 2nd SCR?
– why did they not pass on important information.
– were they completely independent?
– had they previously had any contract work from GOSH?
– were they familiar consultants to GOSH? Might further work to GOSH have been jeopardised if their IMR exposed damaging information about GOSH’s management failings?
10. Allegation 10 (refusing information to Graham Badman when he asked for the Sibert Report)
The Trust acknowledge that Mr Badman did recently ask for the report but that GOSH missed the opportunity to clarify their understanding that Mr Badman had already seen the whole report because the Trust solicitor who he spoke to was not aware of the opportunity when she spoke to Mr Badman.
I can only repeat the Allegation 10 itself. I met 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.
Now you are claiming that you thought he had had it and you have apologised for any miscommunication between yourselves and Mr Badman.
Words fail me.
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 Trust response says they see no justification for my decision to target Dr Collins so personally on this issue.
As I explained earlier, very simply – it is Dr Collins’ name on the front cover of the addendum – as its author. Dr Collins led at all times, contacting the chair of the LSCB during the process and defending the hospital’s actions subsequently in public.
The Trust says there was no intention by GOSH management to hide anything
The Trust is acknowledging that information was hidden – we need to know why this happened.
The Trust says that reasonable decisions were made about the information sent to the first SCR.
The purpose of Serious Case Reviews is to look at all the evidence and then it is for the LCSB to decide what to publish, not for Great Ormond Street. Dr Collins claims to act on legal advice but is unable to produce it. Dr Collins is therefore making an untested claim, without any supporting evidence. The Trust believes the decision to with-hold the most serious criticisms of GOSH management from the SCR was reasonable. Whether it was reasonable can only be judged by an inquiry.
The Trust says that the full Sibert report was shared with the second SCR but
Graham Badman, chair of the 2nd SCR, says he never had it.
Lastly the Trust says I am wrong in suggesting that managers did not face proper scrutiny and that it is patently untrue that they were unscrutinised and that the facts about the situation in Haringey did not come to light. You state as evidence of this the existence of:
– the recommendations sent to Sharon Shoesmith in May 2008
– the Action Plan sent to the SCR Panel in May 2008
– The Care Quality Commission report published in May 2009
– All the monitoring documents of action plans as part of the Joint Area Review
– A variety of critical media coverage
None of the above justify with-holding the overall conclusions, let alone about half of the report from the 1st Serious Case Review. They are all partial and subsequent. That is the point.
The conditions in Haringey that led to the dismissal of social workers were no worse than what was allowed to go on in community paediatrics in Haringey, despite warnings, under GOSH management.
The differential treatment and outcomes in terms of accountability appear to have resulted solely from critical information failing to get to the 1st SCR.
It is not right that there should be one rule for social workers and Haringey managers and another for GOSH. As Richard Horton put it in the Lancet ‘Perhaps GOSH is just too important to be seen to fail. Even when a child dies.’
I thank you and the Trust Board for your response but sadly we do not see eye to eye.
Lynne Featherstone, MP
Member of Parliament for Hornsey & Wood Green
Cc Andrew Lansley, Jo Williams, Michael Gove