Just got back from visiting Tottenham where Nick Clegg, Deputy Prime Minister, was visiting the devastated high road, meeting traders, families made homeless, community leaders and local police.

However much you see on the rolling 24 hour news – there is nothing as raw as seeing for yourself and meeting those whose lives have been so directly affected by the dreadful events in Tottenham and Wood Green.

After walking down the High Road talking to traders and local people, Nick Clegg, myself, David Lammy (local MP) met with community leaders including the police, Claire Kober (Leader of the Council), Nims Obunge (Haringey Peace Alliance and local pastor), Richard Wilson (Leader of the Liberal Democrats in Haringey), local safer neighbourhood officers from the area, Tottenham Traders, Tottenham carnival and many others. The Deputy Prime Minister wanted to hear what everyone had to say – and all the contributors raised issues of great importance from communications, to underlying factors to the role of the IPCC and the police.

The meeting was private – but it was quite clear that there is a great determination by all to rebuild Tottenham – which is a great place with a great community – and which has come a very long way since the days of Broadwater Farm. Everyone in Haringey, all the politicians (cross party), the community leaders, the local police and people – put a tremendous effort into all of this. And to see this terrible trashing of twenty years hard work is tragic. But it was clear in the room – that there is still a solid partnership base in Haringey that will overcome this terrible set back.

Having met the community leaders in Tottenham – I went on to Wood Green – which also came under attack on Saturday night – or more accurately the small hours of Sunday morning. There is much less media attention in Wood Green and although the wanton criminality that took place there may have been less shocking than what took place in Tottenham –  there are still many businesses that lost everything.

I met a group of traders in Wood Green Shopping City in that position – who had lost everything. Whilst I was there – shops began to close. It transpired that there were rumours running around that a gang was going to head down from Palmers Green to the Mall – and shopkeepers started shutting up shop. They are so frightened of a repeat of Saturday night. Even though the management of the Mall put out loud speaker announcements to say there was no threat, no danger – the shops just started closing.

The Big Green Bookshop has written an excellent account of what happened in Wood Green here.

As I write – Sky is covering the events in Lewisham Town Centre – as this mindless, wanton, criminality ricochets around our capital.

Here is my latest column for the Ham & High

 Men who are sexually abused as youngsters may not speak for twenty or more years of what happened. Sometimes their stories are never told.

In my role as Minister responsible for tackling violence against women and girls, I have seen the evidence that the overwhelming volume of domestic and sexual violence is perpetrated against women and girls. One in four women experience domestic violence during their lifetime. It has more repeat victims than any other crime (repeat victimisation accounts for 76% of all incidents of domestic violence) and in 2009/10, 21 men and 94 women were killed by a partner, ex-partner or lover.

These are shocking statistics.

The prevalence of domestic and sexual violence against women means, quite rightly, that the majority of services and funding is directed to eradicating this appalling crime. But men are also victims. Having talked to a survivor of male abuse recently, it is clear to me that because of male reticence over speaking out about their experiences – we may not know the numbers of men and boys who are victims of rape and sexual abuse.

He spoke of the possible link between male suicide in the fifty year age group and abuse during childhood. He spoke also about the connection between drugs and those referred to male help organisations. He spoke about the pain, buried for years, finding coping mechanisms – like blotting out the past through drugs or alcohol – which ultimately never truly ease that pain. He spoke of the difficulty of most of the advisers in this field being women and the difficulty men have, therefore, in bringing their situation into the light. He pointed out that the vast majority of health service workers being women. The inference was that men would not and could not talk to a woman. And that the fear of a woman’s potential view that any male who had suffered such abuse was somehow less of a man. And in our society expectations and stereotypes run very, very deep.

Most of male sexual abuse and violence is, according to my witness, perpetrated by men on boys. But he also referred to the percentage that raise what he called ‘the last taboo’ – women (yes mothers) who abuse their sons. How impossible it must be to bring that into the light.

He also pointed to the common view that this is a ‘gay’ issue. No it is not. Any boy who is sexually abused is the victim of a crime. Sexual orientation is no part of this and no excuse whatsoever.

The Home Office has ringfenced £28million of stable funding to provide local services such as Independent Sexual Violence Adviser posts, Independent Domestic Violence Advisers and MARAC coordinator posts. We have provided £900,000 to sustain national helplines. One of these helplines is the Mens Advice line which provides advice and support to male victims of domestic violence. Over £10million is being provided by the Ministry of Justice for Rape Support Centres throughout the UK over the next three years. Some of these services provide help for men too.

I feel that the gendered pattern of violence against women and girls also needs to be better understood and acknowledged. We recognise that men and boys can be victims of violence and that it can affect whole families, including children. Men also have a key role in challenging violence and helping to change the attitudes and actions of their peers. We want to work with them to achieve this and I will raise these issues at the next Inter-Ministerial Group on Violence Against Women and Girls.

There are a number of places where male survivors of sexual abuse can get help – amongst which these three (amongst others) are in receipt of funding from the Government: First Step (Leicester area), helpline 0116 254 8535; Survivors UK on 0845 122 1201 and Mankind 01823 334244. Male victims of domestic violence can get advice and support from the Mens Advice Line 0808 801 0327.

On Saturday I had the pleasure and honour of opening the 7th Sparkle in the Park in Manchester. Sparkle is the biggest event of its kind for the transgender community.

The transgender community as a group suffer a great deal of discrimination. It is a community that is small and little understood by the population at large. That most basic of questions when a child is born – is it a boy or is it a girl – is something that most of us never question or even have to think about.

But for those to whom the answer to that question is less clear as they grow – a lifetime of trying to exist in a binary gender system when those descriptions conflict with feelings – is what is born.

But things are changing.  Sparkle, which as I said is in its 7th year, is a public statement from the community that they are standing out there and standing proud.

The Equality Act gives protection to the transgender community from discrimination in the same way as it gives  protection for gender, sexual orientation, disability, race and other protected characteristics. But protection under the law is one thing. Hearts and minds need to follow – and whilst much has been achieved – there is still a hugely long way to go.

The trangender community suffer from a great deal of hate crime, discrimination at work, access to public services and generally a lack of understanding about what it means to be transgender. Whilst it is often joined to the LGB agenda as LGB&T – there is a world of difference between sexual orientation LGB (lesbian, gay, bisexual) and T (transgender) which is about gender identity and quite separate from sexual orientation.

Currently we (the government) has a consultation going on all the issues for the transgender community because we recognise that there are issues that need addressing separately from those that are addressed by our LGB&T workplan. We have had over 1200 responses so far – making this the largest ever in the UK.

These responses will form the basis on which we can make informed decisions about what changes are needed. I can’t promise that every aspect can be met – but we will use the information to do as much as is possible.

When I left Sparkle, having given the opening speech and met a number of those taking part and organising the day, the sun had come out – and Sparkle was sparkling. The turnout for this event in the park was huge. And it was striking that in a park where only a few years ago the transgender community wouldn’t have even dared to walk – now they were holding a party in that same park.

A huge thank you to Bella and her team for all the organisation – and a thank you for inviting me to share the day.

This is my response to Great Ormond Street’s rebuttal of my allegations. This will be copied to the Secretary of State for Health.

Baroness Blackstone
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.

Summary Allegations

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.

Yours sincerely

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

Cc Andrew Lansley, Jo Williams, Michael Gove

Great Ormond Street Hospital sent me their rebuttal of my allegations on the 21st June – which I post below. It is on their website too.

Needless to say – I disagree!  My response follows shortly.

21st June 2011

Dear Ms Featherstone,

I am replying on behalf of Great Ormond Street Trust Board to your letter of 8th June 2011 (which was received by the Trust on 10th June). In this letter, you called for an investigation into Dr Jane Collins’ actions, based on an allegation that the Trust withheld vital information from the original Serious Case Review into the death of Peter Connelly.

All members of the Trust Board have reviewed the documentary evidence in response to each of your individual claims. Our conclusions are that your allegations about the Trust’s failure to share information are incorrect and unsubstantiated by the evidence.

The Trust Board found that:

–  There was no intention by Great Ormond Street Hospital management to hide anything.
– Reasonable decisions were made about the information sent to the first Serious Case Review.
– The full Sibert report was shared with the second Serious Case Review.

We firmly reject any call for an investigation into Dr Collins’ actions and, as you will see from our specific responses to your allegations below, much of what you allege is factually incorrect. Attached to this letter are copies of specific documents which clearly show what you have got wrong. These documents have been scrutinised by an external legal advisor.

It is highly regrettable that you did not give the Trust the opportunity to provide you with this evidence to answer your allegations before you made them in public on BBC London on 9th June 2011. To clarify, you made your allegations public the day before I had received a copy of your letter.

The Trust has always accepted its failings in the care of Peter Connelly and said that it did not get everything right. However, to claim that the Trust deliberately sought to mislead any inquiry into his death is a very grave allegation which we refute.

I will deal with your particular allegations in turn:

1. Allegation 1 (withholding vital information)

I assume that you are referring here to the Sibert Report. The Sibert Report, as we assume you know since you have read it, was commissioned by Dr Collins. She commissioned the report specifically to examine the practice of the clinician involved in the case, once the nature of Peter Connelly’s injuries were revealed by the Police, (who had access to the coroner’s post mortem report). The Sibert Report was not commissioned as part of the SCR process and it was completed a matter of weeks before the original date of the criminal trial.

It is correct that the full Sibert Report was not shared with the first SCR, however this followed advice from lawyers and the police.

The following documents were shared with the Chair of the Local Safeguarding Children’s Board (who also chaired the Serious Case Review) and they contain the “vital information” about the service:
– An extract of the Sibert Report (see document 1 as sent)
– Draft updated recommendations arising from the Sibert Report (see
   document 1 in yellow highlight)
– Action plan as at 12th May 2008 (see document 2)
– A summarised version of the Sibert Report, (known as the Addendum), with
  an updated Action Plan as at 25th May 2008 (see document 3 – already in
   public domain)

The Trust Board carefully reviewed the information that was passed to the first SCR, and we do not agree that “vital information” was withheld. We believe that we provided all the information that was needed to the SCR from the Sibert Report.

2. Allegation 2 (deliberate attempt to hide failings)

The second part of this allegation concerns the motivation behind the decisions made as to what information should or should not be shared. i.e.

There is no evidence to support this allegation.

The whole Sibert Report was sent to the Metropolitan Police, the Crown Prosecution Service, the Joint Area Review (involving the Healthcare Commission), the Care Quality Commission, NHS London and the General Medical Council.

The Trust Board has reviewed the evidence, which includes documented discussions with lawyers and Police, and which provides the clear rationale for not sharing the whole document with the first SCR. The Trust took advice from lawyers at the time.

We are not able to discuss this because it is legally privileged. However, the advice we took from the Police concerned our duty not to prejudice the criminal trial. We told the Police we wished to co-operate fully with the SCR but did not want to prejudice the criminal process, and would therefore not send the full Sibert report to the SCR Chair unless they instructed us to do so, which they did not.

We reviewed Section 8.32 of Working Together to Safeguard Children 2006 (the guidance in place at the time) and noted its comment : “constraints on public information-sharing when criminal proceedings are outstanding, in that
providing access to information may not be within the control of the LSCB”.

This guidance was particularly pertinent given the imminent planned June date of the criminal trial in this case.

Failings within the service were clearly identified in several different documents (including the draft updated recommendations from the Sibert report) which were sent to the Chair of the LSCB as listed above, and thus could not and cannot be described as being ‘hidden’.

There is no evidence of any motivation to hide management failings. On the contrary, evidence reveals individuals at the Trust trying to do the right thing, and having to balance competing concerns in difficult circumstances.

3. Allegation 3 (removal of conclusions)

It is correct that the “Overall conclusions” section was not included in the Addendum. However, every critical point contained within this section had been previously communicated to the Chair of the LSCB in one or more other documents, including in the recommendations from the Sibert report (see document 4).

The words “clinically risky” which were contained within the “Overall Conclusions” section, were not themselves replicated in any other document. However, the fact that the Trust sent a list of 14 recommendations (including: increasing the numbers of doctors; appointing a named doctor; and developing a clinical pathway) does not
suggest an organisation seeking to hide failings, but rather to present a picture of a service needing significant improvement.

Turning to the specific issue of the arrangement at St Ann’s, GOSH management agreed with the view in the Sibert Report that the arrangements current at that time were unsatisfactory. The Trust took over the full running of the service in April 2008 and upon receiving the Sibert Report in May 2008, the child protection service was moved to the North Middlesex Hospital within weeks.
4. Allegation 4 (removal of two key recommendations)

It is correct that these recommendations were not in the list of recommendations included within the Addendum. We do not know the reason for this. However, given that the same individual had previously sent the full set of recommendations (including the recommendation to appoint a named doctor) to the Chair of the LSCB, it is not credible that there was any intention to deceive.

There is simply no evidence for your allegation of deception.

5. Allegation 5 (Dr Collins’ BBC interview)

The Trust Board reviewed the transcript of Dr Collins’s BBC interview last summer. Your summary of what she said is incorrect. The relevant passages are actually as follows:

 [What was shared by GOSH with the Chair of the LSCB]

“What we shared were the issues around the doctor. We shared information about what was happening at St Ann’s. We pointed out the issue about the named doctor”.

[Why the whole Report wasn’t shared]

“The Report included a review, which is what I had requested, about some other children. It wouldn’t be appropriate for their confidentiality to pass that information on……because they were children who were being seen for other reasons. Because I wanted a review of the whole practice, not just the child protection practice.”

Having reviewed the documents that were shared with the Chair of the LSCB the Trust Board supports Dr Collins’ statements.

6. Allegation 6 (issues found at St Ann’s clinic)

All of the above points have been discussed extensively in the media over the past three years. Points c) to g) formed the basis of the action plan which was included as part of the first SCR and over the last three years has been monitored as part of the multi-agency working.

With regards to points a) and b), the Trust continues to ensure – as it did in the substantive appointment of Dr Al-Zayyat – that all consultant appointment panels are properly convened. They must all include an external, independent Royal College representative (whose role is to ensure that candidates are not appointed unless they
are properly qualified) as well as local specialist clinicians.

In summary, these issues within the clinic at St Ann’s were sent to the Chair of the LSCB in May 2008 ( see documents 1,2 and 3). GOSH took over full running of this service in April 2008 and over the next three years these issues formed the basis of an action plan to improve the service, which the Trust succeeded in doing.

7. Allegation 7 (Consultant absences)

As the CQC Report acknowledged, Haringey is a challenging borough in which to provide healthcare, which makes it a challenging borough in which to try to retain staff.

The allegations made by one individual Haringey Consultant 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 were taken seriously by GOSH. The Report also found that the Trust’s management made genuine attempts to address these concerns.

Turning to the two individuals who left, neither raised any issues with the Trust before they left, despite having the opportunity to do so.

In summary, this is not a new allegation, it has been fully investigated previously by the independent review commissioned by NHS London, the results of which were accepted by GOSH and NHS London.

8. Allegation 8 (Designated Doctor comments)

The Trust Board do not consider that it is 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.

9. Allegation 9 (not giving information to Graham Badman)

Firstly, it should be noted that the Addendum was an Addendum to the first IMR not to the SCR, therefore it was entirely appropriate that it was not published alongside the first SCR.

However, with reference to the substantive allegation, we have reviewed the documentation and it is clear that GOSH did share the full Sibert Report with the IMR writers for this second SCR. This is the normal and appropriate means by which agencies in an SCR process share information.

We do not know how the IMR team subsequently chose to share our Report. However we do have correspondence with Mr Badman which implies that he did have a copy of the report, and we are writing to Mr Badman to clarify this.

10. Allegation 10 (refusing information to Graham Badman)

Graham Badman did recently ask the Trust for a copy of the Sibert Report, which he mistakenly believed had been commissioned as part of the SCR process. On 22 December 2010 he spoke to the new Trust Solicitor who clarified that:

1. The Sibert Report was about the whole practice of Dr Al-Zayyat;
2. It was not only a report about Peter Connelly (Baby P);
3. The Report had been independently commissioned by the Trust;
4. It had not been commissioned for the IMR or SCR processes;
5. The sections of the Report about Baby P were shared with the SCR as an Addendum to the IMR.

The opportunity was missed to clarify our understanding that Mr Badman had already seen the whole report because the Trust Solicitor was not aware of that when she spoke to him.

We have been in communication with Mr Badman on this issue already, have apologised for any miscommunication between us and enquired whether there is any further information he requires from us.

Summary Allegations

You conclude your letter by highlighting the following:

Firstly, the Trust Board saw no justification for your decision to target Dr Collins so personally on this issue.

As I state at the beginning of my letter, each member of the Trust Board has reviewed the evidence, which has also been scrutinised by an QC. The conclusion of the Trust Board is that:

– There was no intention by Great Ormond Street Hospital management to hide anything.
– Reasonable decisions were made about the information sent to the first Serious Case Review.
– The full Sibert report was shared with the second Serious Case Review.

You suggest that managers did not face proper scrutiny. It is patently untrue that they were unscrutinised and that the facts about the situation in Haringey did not come to light.

Documents / reports that highlighted the situation in Haringey include:

– The 14 recommendations sent to Sharon Shoesmith in May 2008 (see document 1)
– The Action Plan sent to the SCR Panel in May 2008
– The Care Quality Commission report published in May 2009 (publicly available, see particularly pages 16, 19 and     20)
– All the monitoring documents of action plans as part of the Joint Area Review
– A variety of critical media coverage

As I said at the beginning of this letter, the Trust has never hidden our role in the tragic death of Peter Connelly. We have apologised for our failings on several occasions and alongside all the other agencies involved, tried to learn lessons. Since we took over the service in April 2008, we have implemented many changes that have been favourably reviewed by the CQC and others.

Your allegation that the Trust deliberately sought to mislead any inquiry into his death is serious and not supported by the evidence we have shared with you. On the basis of this, we ask you to withdraw it.

Yours sincerely,

Baroness Blackstone

Chair, Great Ormond Street Hospital for Children NHS Trust

Cc:

Dame Jo Williams, Chair, Care Quality Commission

The Rt Hon Michael Gove MP, Secretary of State for Education

The Rt Hon Andrew Lansley, MP, Secretary of State for Health

Following my letter to Baroness Blackstone, Chair of GOSH Board in which I call for an investigation – in a signed editorial, Richard Horton (editor of the Lancet) arrives (pretty much) at the same conclusions that I did over the with-holding of information by Great Ormond Street from the Serious Case Review into the death of Baby Peter. I paste his editorial at the bottom

Interestingly he links the ‘cover up’ with GOSH’s application for Foundation Status and the dilemma that the Sibert report posed with its damning conclusions about the dangerous conditions at St Ann’s – where Baby Peter was seen.

Long ago on this blog – Friday November 21st, 2008 to be precise – I said:

I did go personally to see the Chair of Haringey PCT with all these concerns. I was told – this is no longer the concern or business of the PCT. They had ‘outsourced’ their health team to Great Ormond Street Hospital. So – in my limited research as to why such an important local service would be outsourced – this is what I have been told thus far. Great Ormond Street want to become a Foundation Trust Hospital. In order to do so it has to demonstrate ‘community outreach’. Great Ormond Street had none and no experience in that area. Hence it negotiated with Haringey to take on that department. Well – if that’s all the case, is that what should have happened?

So in the Lancet article (pasted below) Richard Horton sitesthe role of GOSH’s quest for Foundation Status as a potential reason why the information was with-held from the Serious Case Review.

CommentI mentioned a few weeks ago that a scandal might soon erupt at a leading London teaching hospital. It has now done so. The Home Office Equalities Minister, Lynne Featherstone, has called on the Chief Executive of Great Ormond Street Hospital for Children (GOSH), Dr Jane Collins, to resign. In a letter sent to the Secretary of State for Health, Andrew Lansley, as well as to the Chairs of the Care Quality Commission and the GOSH Board, Ms Featherstone writes that Dr Collins “appears [to have]…withheld vital information” from a serious case review into the death of Peter Connelly (also known as Baby P). On BBC television news, Featherstone said that Dr Collins “has to resign. I can think of no more serious charge”.

*

Peter Connelly was born on March 1, 2006. He died on Aug 3, 2007. According to a January, 2008, report by Prof Jonathan Sibert and Dr Deborah Hodes, commissioned by Dr Collins, doctors who saw Baby P at North Middlesex Hospital found injuries, bruises, skin breakdown, and deep tissue damage on his body at the time of death. Prof Sibert and Dr Hodes agreed with the view of one witness they consulted that St Ann’s Hospital, where Baby P was seen just prior to his death and whose clinical staff were employed and managed by GOSH, was a “clinically risky situation”. The arrangements for child protection at St Ann’s “cause grave concern”, they wrote. When a serious case review of the events surrounding the care of Baby P took place, it might have been expected that Dr Collins would submit the full Sibert/Hodes report as evidence. But only “a partial and selective version” (Ms Featherstone’s words) was passed on: “important information was deliberately withheld.” In particular, because GOSH was responsible for “the dangerous conditions” under which Baby P was seen and eventually died, and since “it appears that Dr Collins has attempted to cover-up the fact that the situation was ‘clinically risky’”, Featherstone concluded in her letter to Lansley that “the depth of the deception that has been perpetrated is unbelievable”. “Dr Collins bears a share of responsibility”, the Member of Parliament writes, for what looks like “a deliberate attempt to hide the management failings highlighted in the Sibert Report.” BBC news says that GOSH denies a cover up. The hospital’s Board, chaired by Baroness Tessa Blackstone, has complete confidence in Dr Collins. But there are unanswered 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 these 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.

*

There remains one additional and very puzzling question. Why did an alleged “cover-up” take place at all? The reasons given are, first, that GOSH submitted a partial report based on legal advice and, second, that the hospital had employment obligations to staff mentioned in the report. There is a third reason that ought to be considered. GOSH is seeking Foundation Trust status, an objective it hopes to achieve by autumn, 2011. The hospital’s perfectly legitimate quest for greater independence, which brings more freedom to manage its affairs, has been ongoing over several years and has not always been a happy journey. But this prestigious repositioning is now within reach. What GOSH did not need at this late stage was a public debate about the integrity of its leadership or the quality of its management of services that failed Baby P. 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”. An unkind observer might conclude that GOSH’s board is still trying to reduce its exposure to public criticism. I have no evidence to prove that this was (or is) the calculus of GOSH’s managers. But as one person close to these events put it to me, if GOSH’s management team had been in Wigan they would almost certainly have departed by now. Perhaps GOSH is just too important to be seen to fail. Even when a child dies.

Richard Horton

http://www.thelancet.com Vol 377 June 18, 2011

Offline: “The depth of the deception”?

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

PLEASE CIRCULATE TO BOARD AND TRUSTEES

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

My column from this week’s Ham & High:

Tacking Violence against Women and Girls internationally

I visited a rural village outside of Patna in the northern state of Bihar in India last week. Everyone was gathered around. We sat under a tree where an acting troupe put on a show about the violence women in India experience as part of their everyday lives.

The women of the village all sat in a circle – joined by myself and UK Department for International Development (DFID) aid workers with the men of the village watching on.

The ‘play’ showed a young woman who was just married and now living with her new family of in-laws. Daughters when they marry go to the family of the groom to live. The whole family treated her like a slave – the mother-in-law, sisters, brothers, father. They hit her for the most minor transgression (like putting down food for her husband slightly in the wrong position). She is four months pregnant. It gets worse and worse and one day the husband uses such violence that she dies. Never mind. He marries a new wife straight away. No problem there.

Afterwards I got to talk to the women of this village who are taking part in the state government and DFID program of setting up female Self Help Groups (SHGs). These SHGs are based on financial empowerment where women put in a few rupees to save. A bank account is opened – and then collectively they can loan the money to members for investment in small micro-finance projects (growing tomatoes and selling them was one) or to lend to a woman who needs medical treatment. The loans are paid back. From this ‘empowerment’ for the first time women are talking to each other about their circumstances.

I asked the women whether they recognised the situations portrayed in the play. Yes. I asked if any of them had experienced violence. Yes. I asked their assurance that when they became mothers-in-law – they would not treat their daughters-in-law that way. They say they would not. They also said that they would make sure their daughters were not forced into early marriage before they were eighteen and that they would make sure their daughters were educated.

They also said that since the formation of the SHG the violence had reduced by 75%.

Violence against women and girls in India is a very private matter. It is kept behind closed doors – silence surrounds the victim – and no one is there to help. But even here things are changing. There is a law now against Domestic Violence – but access to justice is very, very limited. Girls are now mandated primary education – but enrolment is better than attendance. The law now states that it is illegal to marry under 18 – but under age marriage is still common (70% of women in Bihar marry before 18). It is illegal to demand a dowry – but dowries are still common, and ‘dowry deaths’ are still regularly featured in the news – with young women either being driven to suicide – or actively helped. Forced marriage is not uncommon. 5000 women a year are murdered. Millions are victims of violence. Girl fetuses are often aborted. Trafficking is still common.

With recent attacks on the coalition for ring-fencing the overseas aid budget – I want to say how proud I am that even in this time of great hardship for people in our own country – we continue to recognise the depth of need and levels of poverty of others in the world and do not turn our backs on our international responsibilities.

I have just come back from two days in Nepal and three days in India in my role of overseas champion for tackling violence against women and girls internationally. Yes – we have a huge enough problem with domestic violence in this country which we are tackling at a number of levels and for which we are ring-fencing central government funding – but the scale and scandal of such violence in developing countries is beyond imagination. Our commitment to overseas aid and our work through DFID is a hugely important part of our commitment to international human rights.

Whilst violence against women runs at around 37% in India generally – in Bihar – a northern state of around 100 million people – it runs at 59%. The village I describe was in Bihar. Of course, in a column I only have space to relate one tiny piece of what I saw in India and Nepal. Bihar is one of three states in which DFID is concentrating UK aid efforts.

But in that village – what I saw with the SHG – was the beginning of change. It will take years – no doubt. Violence against women and girls happens right across the world in every country – but as women find a voice and group together – strength grows.

DFID is working on the ground in Bihar on health, on urban development, on governance and on violence against women. They work with the state government (many members of which I had meetings with) and my mission was to raise the issue and share information.

There is no doubt that this work, this partnership, will deliver huge change and huge benefits for the people of Bihar and we should be proud of our contribution.

What makes me sad is the single comment on the YouTube video which shows the village play. The sole comment is ‘who cares’?

Well – I do. And the British Government does. And despite our economic challenges – I have some faith that the majority of the British people do too.