Great Ormond Street kept report into Baby Peter secret?

Tim Donovan of BBC London has done a brilliant piece of investigative journalism on the role that Great Ormond Street Hospital played in the Baby Peter tragedy. Read the full report here.

For months I banged on about the role of the health protection team and its management  – on this blog and on the floor of the House of Commons. Everyone leaped (quite rightly) to criticising the Doctor who failed to recognise broken ribs and abuse injuries – but she was a locum.

I, meanwhile, questioned why there was a locum there in the first place. And when I dug  – I found that there was a locum because four senior consultant paediatricians in the child protection health team which was now run by Great Ormond Street had either resigned, gone off sick or had been put on special leave. Dr Kim Holt – was the one put on ‘special leave’ because she was a whistle-blower on the dangerous practises going on in that department – more on Dr Holt’s dreadful treatment follows.

It emerged that the four senior consultant paediatricians (including Dr Holt) had jointly signed a letter to Great Ormond Street Hospital (GOSH) management saying that they were so worried about bad processes in the department that children were being put in danger. Sadly – a year later – they were proved right.

Now Tim Donovan of BBC London has discovered that Great Ormond Street Hospital commissioned an Independent Report on the role of the paediatric health team run by GOSH – and its finding were damning. Whilst we all heard about the Doctor who saw Baby Peter and failed to recognise the abuse and injuries – the report found that the conditions she was working under were unsafe. So whilst she may have been inadequately qualified – it was GOSH that had hired an underqualified doctor for such a senior post. Dr Al Zayat was under extreme pressure of work as the department was understaffed. Apart from the four consultants who for different reasons were not there -there was a lack of nurses. There was no information available about children coming to the department. No proper IT system. No Support. And, there was no ‘named’ doctor in the department – a vital role in child protection. Now – I (like everyone else) haven’t seen the report – so this is what I have been told.

But that over-used phrase ‘lessons must be learned’ is useless if facts are kept hidden.

This report never seems to have seen light of day. GOSH are now saying that it was made available to key agencies. But Tim Donovan has discovered that if anything at all was handed over to any investigating authority or agency – it was a summary only.

In the Joint Area Review – the report commissioned by Ed Balls that so damned and led to the sacking of Ms Shoesmith – there was barely a word about the role the health team played. I’ve read it – and we are literally talking about two lines about GOSH.

Given the importance of the role in Baby Peter’s death that the health team (or lack of one) played – you cannot help but come to the conclusion that the role of Great Ormond Street in all of this was suppressed.

I have raised the role of GOSH and the child health team in Haringey on the floor of the House. It is in Hansard. And yet – until now – there has been a deafening silence on this part of the Baby Peter tragedy.  I could not understand why such an important part of the jigsaw had no traction or even real interest from the powers that be. Was Great Ormond Street being protected?

I remember phoning Ed Ball’s office and threatening to raise hell if the treatment by GOSH of the whistle-blower Dr Kim Holt (the paediatric consultant who was and is still on special leave from the health team) was not put right. Ed Balls commissioned an investigation by NHS London (to his credit) but the findings of that investigation are also astonishing.

Whilst the report finds Dr Holt to have a spotless record and to be an excellent paediatrician and recommends that she is gotten back to work – the report also finds a whole series of faults with the management processes and some personnel in GOSH. Not a single recommendation pertains to that part of the findings.

GOSH has failed to re-instate Dr Holt now some five or six months since the findings of that report came out.

Haringey Council, of course,  rightly were first in the firing line as they were the lead agency and Ms Sharon Shoesmith the Executive Director of Children’s Services and the person under the 2004 Children’s Act in the accountable position.

However, the focus of the spotlight on Haringey Council does not mean that other agencies – GOSH, Haringey PCT (who commissioned GOSH) and OFSTED to name but three – should not come under the same scrutiny as Haringey.

The secrecy, the cover ups, the lack of transparency, the refusal to publish the Serious Case Review, the appalling treatment of whistle blowers Nevres Kamal (Haringey Social Worker) and Dr Kim Holt (Senior Paediatric Consultant) and now this vital Independent Report – all mean that we cannot be confident that lessons have been learned at all.

We need a public inquiry!

Ed Balls and Arsene Wenger come to Treehouse

Arsene Wenger, Lynne Featherstone and Ed Balls at TreehouseIt may have been raining – but the sun was shining in every one’s heart – for the opening of the splendid new building for Treehouse. Treehouse is the wonderful charity that set up an exemplar school for autistic children in Muswell Hill.

It is the most wonderful, spectacular building – with the most wonderful and spectacular people involved in its teachings, its running and its work right across the country to advance the cause and understanding of autism. Brilliantly – this super-school only takes children who are state funded – so that all autistic children can come here. Getting local authorities to fund individual children, however, is still the main battle. But once they are here – these children and their parents join a family whose support and care is unparallelled.

Ed Balls, Secretary of State for Education, came to do the honours – and gave a really great speech. He seemed to have a real understanding of the needs of children with autism – and their parents. We heard too, from Arsene Wenger, (yes – Arsenal Arsene) who last year made Treehouse Arsenal’s Charity of the Year and donated huge amounts to it. Trevor Pears of the Pears Foundation also spoke – and it was interesting to hear him thank Treehouse. It must be rewarding to be a key donor to something as wonderful as Treehouse – which was the point he made. And then, very , we heard poignantly from Claire Coombe-Tennant, a parent and a Trustee whose youngest son (of four sons) is at Treehouse. That was the clincher speech – to recognise the anguish, agony and exhaustion of the parents of an autistic child – and what Treehouse means in terms of relief, reassurance, rescue, hope and love to those families.

And yes – I had a word too. I simply spoke about the way Treehouse has become part of the Muswell Hill community – reaching out with the children going to three local schools each week to mix with other children and once a week the children from Muswell Hill Primary School come in and play with the children at Treehouse. The benefit to both sets of children is wonderful – and says we are all members of society and the more we know and understand and include each other the better our world.

We had all brought gifts to put in a time capsule – and two of the Treehouse children, Kaiser and Bilal, came onto the stage with their gifts too.

All in all – a terrific celebration of what can be done with passion and commitment. Congratulations to all at Treehouse.

Child protection: my conference speech

Here’s my speech in the child protection debate at the Lib Dem conference in Bournemouth:

I was leader of the opposition on Haringey Council when Victoria Climbie died.

We were promised that lessons would be learned. That it would never happen again.

But lessons were not learned.

And it did happen again – with the tragic death of Baby Peter.

And it happened because the rotten culture of Haringey didn’t change, the secrecy didn’t change, the unwillingness to listen to outsiders didn’t change, the instinct to close ranks and turn backs on warnings of problems didn’t change and key senior people didn’t change.

After Victoria Climbie’s death, the only person who had to carry the can for all the failings right up and down the management chain was Lisa Artherworry – the most junior social worker at the end of the food chain. She took all the blame – and it’s the memory of that buck-shifting and failure to change that drove me and my colleagues to campaign so hard to say that this time, after the death of Baby Peter, there had to be a real clearout of those who had failed – however senior.

But my deep-seated fear is that it was only the outpouring of public grief and anger , the focus of national media coverage and – yes, to his credit – the intervention of Ed Balls – that forced change – and so when that attention moves on, will the old ways return once more to Haringey?

That is why we need to attract the brightest and the best social workers and managers to Haringey and give them the support and the resources they need to do the job.

We need to get rid of the tick box culture that takes away all personal responsibility. We need to enable professionals to use their brains and their instincts and their critical faculties. We need a performance regime that doesn’t give gold stars based on rubbish inspections which, the moment things go wrong, turn out to have failed to spot a myriad of problems. We need whistleblowers to be listened to and followed up on.

And, above all, we need to ensure that all those running similar services in future know the full lessons of what went wrong and why and how – so that they can do their level best to ensure such mistakes do not happen again.

But there are still too many unanswered questions.

Why did all four senior consultant paediatricians in the children’s health team resign, go off sick or go on special leave? That’s why there was a locum –the locum who unbelievably didn’t recognise Baby Peter’s broken back and broken ribs. Has whatever caused that health team to descend into such chaos really been sorted?

And what about the inspection regime that gave three stars when only weeks later Haringey Children’s Services was damned to hell by that same inspection authority – Ofsted? What value in the next inspection – whichever council it may be – saying all is good?

What about, what about, what about?

Too many questions to fit into this one speech are still unanswered – and that is why we still need a public inquiry and we need to publish the Serious Case Review.

We cannot stop innocent children being born into families where – instead of love and comfort – they get cruelty and misery – but we can and must do better than we have.

That must be our commitment. That must be our mission.

Support the motion.

Two years since the Baby Peter tragedy

A spate of phone calls and texts from the media remind me that it is two years since Baby Peter was ‘allowed to die’. The anniversaries will come and go. The investigations, inspections and reports come and go. But what will really change?

The fear that haunts me is that the words are easy – ‘lessons must be learnt’ – but we heard that beating of the chest and wringing of hands post Victoria Climbie – but nothing much actually changed at Haringey Council. New processes were brought in post Lord Laming’s inquiry – but the culture of Haringey didn’t change one iota. It remained arrogant, unwilling to let in the light scrutiny – or even to be questioned. That defensiveness, secrecy and closing of ranks allowed a second tragedy of immense proportion to take place despite the promises that lessons would be learned.

What I think is that unless and until processes take place in a culture that is open, welcoming of questioning and where people do their own job to the highest standard possible (not relying on tick boxes but on conscience, good training and supervision) it could all happen again. I fear that some of the investigations and recommendations, followed by numerous action plans and inspections feel like lots is being done – but real change can only come from leadership at every level.

Sadly, secrecy prevails. The Government refuses to hold a public inquiry. The Government refuses to publish the (now two) Serious Case Reviews.

We still need that inquiry. Whilst Haringey, quite rightly, was held firmly in the spotlight of blame as the lead agency, the other agencies have had relatively scant focus. They have contributed their reports to the investigations – but the pressure is not so focused.

In terms of health – the managers at Great Ormond Street who refused to take the concerns of four paediatric consultants seriously (the four who signed a letter to the management flagging up the dangers for children because management were not listening) are still in place.

Ofsted, who inspected Haringey at the time of Baby Peter and gave them a three star rating which plummeted to one star post Baby Peter scandal, have got away virtually scot free.

The police, whose poor handovers and missing files led to the Crown Prosecution Service saying that had this been done properly they might have been able to bring an early conviction, are out of the limelight. And so on and so on.

Ed Balls says he doesn’t want to publish the Serious Case Review – even though this would allow professionals right across the country in all the agencies to witness the litany of failures, both personal and systemic – and so learn for their own services and their own work.

The shock of that document (which I am still forbidden to speak about – and I only saw the first one not the second one re-commissioned by Balls) is the casualness with which people did their jobs. To most people, if a child is on an at risk register – we would expect more rigour and absolute professionalism around such care. What we see is lots small failures: files lost, people not attending important meetings, missed appointments unchecked and unquestioned, inadequate or no handovers, etc etc etc.

How can lessons be learned when the details of what went wrong and how and why are kept secret?

So – I plough on trying to get things out in the open and done publicly. That is the first step only in my view. In Haringey, at least, the people have changed. The accountable people have actually lost their jobs – which at least sends the message that there is a point to the position – that there is responsibility and consequences. But as I say – in the end the two things I believe would offer better protection are a change in culture and the reinstatement of personal responsibility within any function – above and beyond putting a tick in a box.

Who should be Labour's Chancellor?

How on earth can Gordon Brown think that Ed Balls is the answer? Do not Ed and Yvette have equally damaging question marks over their housing arrangements? And does he really think that re-ordering the deckchairs on the Titanic would have helped?

I suppose reading The Observer’s praise for the Liberal Democrats as “consistent and principled” and it being time to give us our due together with Polly Toynbee’s suggestion that people should vote Lib Dem in the Euro elections on Thursday may feed his mania. The pressure to come up with an answer is unbearable – but there are no answers from Labour that can appease the unhappiness and disgust stalking our land.

And I notice the sudden desire of Labour apparatchiks to make friends of the Liberal Democrats and try desperately to breathe life into the dead dodo of some sort of arrangement has been peppering the pages of the papers. They wished! The Tories too flirt with and praise us. A plague on both their houses is my own sentiment!

Great Ormond Street failed Baby P too!

When I found out that the last doctor to see Baby Peter failed to recognise a broken back and ribs – like the rest of the nation I thought she must be a terrible doctor. And she clearly was. However, I also read that she was a locum – and ever since then I have been digging and digging to find out why there was a locum and what lay beneath.

I found out. And whilst I have no doubt that Haringey Labour Council and Sharon Shoesmith were first in line for retribution being the lead agency and lead individual – I have also had no doubt that there were other agencies who were just as bad.

There was a locum because the consultant pediatricians, four of them, in the children’s health department in Haringey (commissioned by Haringey PCT and run by Great Ormond Street – GOSH) had either left, been off permanently sick or on special leave! On digging I found that these doctors had raised their concerns with GOSH and been ignored. Yet again – management taking no notice of dangers being flagged up by professionals – just as the police and a senior social worker at Haringey raised concerns that Baby P should be taken away from the family.

I raised it on my blog. I got Norman Lamb (Lib Dem Health Spokesperson) to raise it in a health debate. I raised it myself in a speech in the chamber. But it is only now that investigative journalist for the Evening Standard, Andrew Gilligan, has found out the real detail of the story and broken it in the paper that the part that GOSH and Haringey PCT played in Baby P’s death is coming to light. He actually has a copy of the letter to the management at GOSH saying that they don’t believe the management has taken their concerns seriously and listing the reasons that children’s lives were at risk.

And yesterday – the Health Care Commission report into Baby P’s death also came out with findings that make it clear that there were systemic and individual failings in GOSH and the Health Trusts – all scandalous stuff.

What has been going on in children’s health in Haringey is practically a mirror image of what was going on in Haringey Council, Children’s Services and the Safeguarding Board.

I hope that this now all comes to light and that equally drastic and appropriate action is taken.

Needless to say – I will be writing to Ed Balls in this regard.

How the police failed over Baby P

Good Friday – and BBC Radio 4’s Today programme booked me early bird time – 6.45 am – to talk about the leaked information showing police failings in the Baby P case (click here to hear the piece).

What the leak – to Tim Donovan of BBC London – basically revealed was things like notes not being taken, a case report languishing in a drawer when the case wasn’t handed over and so on. Each of these ‘failures’ being small in themselves – except that this was a child known to be at risk and therefore we, the public, would expect absolute rigour in all procedures – not the sort of casualness exemplified.

Because the spotlight was so firmly on Sharon Shoesmith and Labour Haringey – rightly so, as they are the lead agency and she had the lead position and was accountable under the Children’s Act of 2004 – the other agencies (health, lawyers and police) have not come under the same scrutiny. That’s one reason why I’ve consistently pushed for a full public inquiry.

And furthermore – I want Ed Balls to admit that he was wrong in refusing to publish the full serious case review. The part each agency played in the ultimate tragedy of Baby P is important if he really means that ‘lessons must be learnt’ and ‘this must never happen again’. Unless everyone involved in protecting children can know what went wrong and why – they can’t learn the lessons that need to be learned.

Although I was looking forward to mostly having the day off – I agreed to do the Today interview because the issue is incredibly important – and my concern has always been that with the passing on of the media tsunami the underlying issues would simply not be addressed. Anyway – my sense of duty was rewarded ‘cos in the green room was Clark Peters (of The Wire and new film in which he plays Mandela). So that was interesting – but then a small woman walked in and sat next to me.

She turned, extended her hand and said “Carole King”. “Carole King the singer?” I stuttered stupidly. “Yes” she said. You have to understand that this woman’s songs were the backdrop to my life and love life in the 70s and then again when I sang all the songs from Tapestry to my girls to sing them to sleep. What a treat. And she said she would perhaps come back next year to do a tour. What a morning!