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!

Reaction to Ofsted report into Haringey's Children's Services

Commenting on the Ofsted update report on safeguarding in Haringey Council’s Children’s Service,  Lynne Featherstone, Liberal Democrat MP for Hornsey & Wood Green, says:

“Clearly, a lot of people have been working hard, so that Haringey can achieve the basic service of protecting children.

“I tentatively welcome progress, but stuck in my mind is the fact that Ofsted gave this Children’s Service three stars weeks after Baby Peter died.

“There are clearly, still, significant shortcomings in key front-line services and I will continue to press for more openness and transparency, so we can have lasting confidence that they are getting it right.”

Councillor Robert Gorrie, Leader of Haringey Liberal Democrats, adds:

“I can only thank the committed efforts of the staff who are desperately trying to get this service up to scratch.

“However, I remain deeply concerned that only one in three vital checks of children at risk are happening on time.  To me, this is deeply unsatisfactory and not of a high enough standard to prevent another child falling through the safety net.”

Haringey – New Ofsted report

The second inspection of Haringey’s Children’s Service has now reported. Last time they found that Haringey was not improving fast enough. This time – the report finds that they have done better. Given the staff are working very hard to improve things and there is a new Director – I would hope that this is the case.

The only question mark is really over how much confidence we can have in Ofsted. This is the inspectorate that gave Haringey 3 stars during the period that Baby Peter was falling through the Haringey net – and when it went public – gave them 1 star.

Hopefully – Ofsted too have improved their inspections and would not be fooled again by doing a desk inspection where Haringey provide (as they say happened last time) false information.

But I am very glad if, at last, things are getting better – both for any children at risk in Haringey – but also for those staff who have had to come through one of the most demoralising and difficult work situations that can be faced.

A debate on who inspects the inspectors

Following on from my recent post on who inspects the inspectors, I raised the issue in Business Questions in the Commons.

The point I made was that with OFSTED giving 3 stars to Haringey just before the Baby Peter tragic story broke – and giving them 1 star soon after – we needed a debate on how to inspect the inspectors.

Harriet Harman – actually said she thought this was an issue for consideration. There was a lot of support in House for my request for a debate – so fingers crossed.

Of course, it’s even worse than I had time to state in the Commons (you only get a few words before Mr Speaker has a go at you for verbosity). Recently the judge in the Sharon Shoesmith appeal is having to investigate whether a hand written note which apparently instructs everyone at OFSTED who has emails re the Baby P case to delete them is genuine and whether its instruction was followed.

If it was – and emails turn out to have been deleted – this is just outrageous. We wait to hear the outcome of the judge’s investigations.

Who inspects the inspectors?

Our health care appears to be in chaos with reports of failing health trusts, hospitals that have disastrously high levels of deaths and medicines sold abroad as poor old Britain can’t afford them.

The hideous tales from Basildon University Hospital last week epitomize how bad things are. An unannounced visit by the Care Quality Commission (CQC) found “Third World” conditions. The death rate at the hospital was one third higher than it should have been.

However, it wasn’t that long before that Basildon got a very good rating from its CQC inspection. Moreover, it is a Foundation Trust hospital – which status you are only meant to gain on being excellent.

We need to really look at inspections!

The same syndrome was seen in the Baby Peter tragedy in Haringey where OFSTED inspected Haringey’s Children’s Services and gave them a three star rating just before the Baby Peter case broke – and then immediately after in the urgent investigation for Ed Balls, Secretary of State for Children and Families gave them a one star rating. As with Basildon, it is only after tragedy has struck and a new inspection carried out that the truth has come out over the real state of affairs.

OFSTED said of their earlier inspection that Haringey Council had misled them by giving them false information. That first inspection was what is called a ‘desk inspection’ I believe – where conclusions are drawn from paperwork and data records and not actual physical inspections or interviews.

I think this symptomatic of three things really.

Firstly, I don’t have real confidence that inspections and evaluations are properly impartial. The regime imposed by the Labour government is one of hoops that have to be jumped through (in many spheres of operation) in order to get gold stars which then lead to autonomy and / or extra funding. There is a huge incentive for all concerned to produce and find results which result in these desirable outcomes.

The second problem seems to be the quality of inspections themselves. For OFSTED to say that Haringey mislead them by not providing accurate information damns OFSTED for not seeing through such a scam just as much as it damns Haringey for trying to get high marks in an inspection through falsifying or not providing proper information.

Interestingly, during the urgent investigation that followed the Baby Peter case, I had information from people working in the departments that people who wanted to speak out were not allowed to talk to the inspectors. Only those chosen by management were allowed to give evidence. Talking to the people the managers don’t want you to meet should be a basic part of any inspection that is meaningful.

Thirdly, there is far too little comeback on the inspectors when they get it wrong. All manner of public services have had searching inquiries and overhauls as a result of tragedies in the last few years. But the inspection bodies have been largely untouched.

It’s a common sign to see a senior service manager in the media under pressure to resign (often rightly so). But you don’t see those responsible for inspections that missed the real story under similar pressure.

The sign of real lessons being learnt from the Basildon tragedy should be seen not just in our hospitals – it should also be seen in our inspections bureaucracies.

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.