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!

Great Ormond Street Hospital – did they hear what I was saying?

I finally got to meet the Chair (Baroness Blackstone), the CEO (Jane Collins) and several non-executive members of the Board of Great Ormond Street yesterday.

I was there on two counts. The first was to ask why Kim Holt, the whistle-blowing, senior paediatrician who raised concerns over child protection in Haringey and was not listened to, had not begun to be re-instated having been on ‘special leave’ for two years despite agreement to so do. The second thrust of my meeting was about issues around bullying and unhappiness amongst medical staff and what had been done to address those issues.

I am not going to blog the detail today – but I did take notes. Suffice to say I tried to warn them but when I walked out – I really wondered whether they were able to hear what I told them.

Kim Holt's character and professional witnesses intimidated?

Since the publication of the report last week  into Kim Holt’s (one of the Senior Consultant Paediatricians in the Haringey Child Protection team) allegations of bullying by management – which have seen her on ‘special leave’ for two years – I hear tell of what appears to be intimidation, or at very least, harassment.

Many professionals who work in the various departments associated with child protection – health, children’s services, etc. – gave witness statements to the report’s authors supporting Kim – stating how valuable her work was, what an excellent professional she was and what an advocate of good practise in child health care etc etc etc. In fact, the report itself praises her and states there is no criticism of her professionalism whatsoever. What the report doesn’t do however is investigate the bullying or the management’s ignoring of warnings about danger to the children it is meant to be protecting.

These witnesses were (and still are) pretty scared of speaking up and coming forward. I know – I spoke to several during the course of Kim’s case and they all spoke to me on the basis that I would not name them. I think this speaks volumes for the case that Kim makes of management bullying and the very serious outcomes that a bullying and silencing management begets – in that warnings are ignored and people are too scared to go public.

Kim was one of the four consultants who signed a letter to the management of Great Ormond Street Child Protection team saying that children were in danger because of a variety of things not being done properly. The letter also stated that the consultants were concerned because management was ignoring their warnings.

Now – post publication of the report – it would seem that those witnesses who were promised anonymity may find themselves being approached by their management and asked if they have given evidence on Kim’s behalf. News has reached me – as they say.

I would say this is a classic example of bullying. Now who is it who could possibly want to know who may have supported Kim against the establishment?

Great Ormond Street and Kim Holt

A report, published today by NHS London, investigating the allegations of Kim Holt is the result of the investigation that I got for Kim to try and get justice for her (see previous post). But it wasn’t only justice for Kim – it was also about trying to make sure that the management of the child protection health team came under the same spotlight that the sacked managers in Haringey Children’s Service had come under for their part in the Baby Peter tragedy.

The failings that Kim (with three other senior consultant paediatricians) had alerted Great Ormond Street Hospital (GOSH) management to were so serious, that when they were ignored by management, they had to resort to signing a letter jointly to Dr David Elliman and Jane Elias – the management team at GOSH. The letter was quite explicit and expressed the doctors’ concerns and also expressed their anger that those concerns were being ignored and their view that this put vulnerable children at risk.

The report is very critical of Great Ormond Street (GOSH) and the senior managers – but where is the resultant action? As I said in my last post – if there is no consequence to poor management, if no jobs are lost – then what is going to make senior managers take notice next doctors tell them children are in danger. Nothing!