Tag Archives: Serious Case Review

Great Ormond Street kept report into Baby Peter secret?

Posted on by

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!

Update on publication of Baby Peter Serious Case Review

Posted on by

I received an update from the Information Commissioner on progress (or not) on my request for the Serious Case Review (the document compiled immediately after Baby Peter’s death) to be published.

Subject: Information Commissioner’s Office[Ref. FS50234513]

Dear Ms Featherstone,

 Re: Freedom of Information Act 2000

Complaint about the London Borough of Haringey – FS50234513

As you know, we have been considering whether we are in a position to make a final decision. In December, we decided that it would be necessary to arrange a meeting to discuss some of the issues raised by this case involving some senior staff members. Unfortunately, due to work commitments just before and after the Christmas break, it has not been possible to arrange this meeting until now. We expect the meeting to take place next week and before the end of January. I hope you will accept our apologies for this delay. I will update you again as soon as possible.

 At least I feel they are looking properly at my request – as Ed Balls disagrees with me vehemently. I think if your read the following original post – tell me if you think I am right – or whether Ed Balls is right to want to keep this under wraps. His chief argument is that staff will not speak if they know the Serious Case Review will be published. My view is that it is a duty to speak out and that if there were a public inquiry or tribunal – they would have to under oath.

This was my original post on the issue – in full as link didn’t seem to be working.

Serious Case Review – Baby Peter and Beyond

I have been trying, ever since Baby Peter’s tragic case, to get the Serious Case Review published. A Serious Case Review (SCR) is produced after any such case by the agencies involved in that child’s care. It tells the chronological story of who did what and when. It is an invaluable document – but it is kept secret. An Executive Summary is published – but that really doesn’t tell anything like the whole story.

I have been battling to change this – so that SCR’s can be published. In Baby Peter’s case I have asked the Information Commissioner to publish the SCR for Baby Peter. I don’t believe that the ambition of that over-used phrase ‘lessons must be learned’ can ever be fully realised if the causes and actions are hidden.

The Information Commissioner came back to me to ask for more information as to why I thought it would be in the public interest for the SCR to be published. I sent him my reasons – which I paste below – and now the Information Commissioner is going back to Haringey Council for further information. This was my email to the Commissioner:

Having been Leader of the Opposition on Haringey Council when Victoria Climbie died and now MP in half of Haringey during the Baby P tragedy – I have come to the conclusion that a contributing factor to cases like these (and others) is the secrecy, the closing ranks culture and the lack of transparency.

The Serious Case Review (version 1) which I was allowed to read virtually under lock and key in the Department of Education (where I could not make notes or record any part of the document) was an eye opener to me. The executive summary of the same document which is published did not reflect the key problems, in my view, that were at least part-causal in the eventual tragedy.

The thing that struck me most was the litany of casualness with which people did their jobs (appointments missed, not followed up; files lost, handovers not done, meetings not attended). There was a litany of failures like these at every level, virtually by every person and every agency. I think that most people would expect that once a child is on the protection register and their case being brought to the Safeguarding Board – that there would be a rigour about all aspects connected with them.

This casualness and lack of care is only really demonstrated if you get to read the whole document. It does not come through in the summary and itself is cumulatively causal in my view.

Literally hundreds of professionals across the country emailed me about their knowledge and experience – as did the general public. I believe that the phrase which is dragged out ‘lessons will be learned’ won’t be fully possible if the facts of the case and the failures in the case are kept hidden. As I say, the Executive Summary, does not reveal the extent of the small, but cumulative failures – which I believe many professionals would recognise in their own fields and therefore be able to do something about. Therefore it must be in the public interest to be able to see the whole document.

Simply issuing another 150 Laming-like recommendations every time a tragedy happens simply adds procedures that take professionals away from their work without ever being able to see the why and wherefore of such recommendations – nor to judge or be able to critique the new ways from an informed position. The issues are kept between local authority, the other agencies and the Government – so keeping out those who would, could and should benefit from reading the whole story.

I am not an expert nor a professional – but unless and until we really open out all the issues around cases such as these – there will continue to be an air of defensiveness and self-protection which work against the safety and well-being of children at risk.

Social workers need to work in an atmosphere of support and good management – which can only come from opening up the real events, letting them stand there for all to see – and those in the professions taking those lessons away.

The argument Ed Balls makes to me against publishing the Serious Case Review (s) is that staff would not speak freely if they knew that what they said might be published. My view is that anyone working in any field where there is such an event has a duty to speak and say what happened. They would have to if the case goes to public inquiry or hearing. Names and personal information should be anonymized. It was anyway in the SCR I read and social workers were referred to as social worker 1 or social worker 2. It is also the case that quite a lot of time elapses between the event and the publication as the SCR is written immediately (usually) and the case and the trial and exposure comes much later.

OFSTED did an audit of Serious Case Reviews and found that nearly two thirds, I believe, were inadequate. So – additionally – this would not have come to light without OFSTED’s exposure. If they were published – these inadequate SCRs would have been exposed much earlier. So – whilst the Serious Case Review I am most concerned about is obviously the Haringey one – it is clear there is a wider issue too.

So – I believe it is totally in the public interest for the Serious Case Review to be published. Secrecy, lack of transparency and openess and closing ranks are at the heart of the problem in Haringey.

I hope you find in favour of publication.

Kind regards
Lynne Feathestone

Serious Case Reviews – Baby Peter and beyond

Posted on by

I have been trying, ever since Baby Peter’s tragic case, to get the Serious Case Review published. A Serious Case Review (SCR) is produced after any such case by the agencies involved in that child’s care. It tells the chronological story of who did what and when. It is an invaluable document – but it is kept secret. An Executive Summary is published – but that really doesn’t tell anything like the whole story.

I have been battling to change this – so that SCR’s can be published. In Baby Peter’s case I have asked the Information Commissioner to publish the SCR for Baby Peter. I don’t believe that the ambition of that over-used phrase ‘lessons must be learned’ can ever be fully realised if the causes and actions are hidden.

The Information Commissioner came back to me to ask for more information as to why I thought it would be in the public interest for the SCR to be published. I sent him my reasons – which I paste below – and now the Information Commissioner is going back to Haringey Council for further information. This was my email to the Commissioner:

Having been Leader of the Opposition on Haringey Council when Victoria Climbie died and now MP in half of Haringey during the Baby P tragedy – I have come to the conclusion that a contributing factor to cases like these (and others) is the secrecy, the closing ranks culture and the lack of transparency.

The Serious Case Review (version 1) which I was allowed to read virtually under lock and key in the Department of Education (where I could not make notes or record any part of the document) was an eye opener to me. The executive summary of the same document which is published did not reflect the key problems, in my view, that were at least part-causal in the eventual tragedy.

The thing that struck me most was the litany of casualness with which people did their jobs (appointments missed, not followed up; files lost, handovers not done, meetings not attended). There was a litany of failures like these at every level, virtually by every person and every agency. I think that most people would expect that once a child is on the protection register and their case being brought to the Safeguarding Board – that there would be a rigour about all aspects connected with them.

This casualness and lack of care is only really demonstrated if you get to read the whole document. It does not come through in the summary and itself is cumulatively causal in my view.

Literally hundreds of professionals across the country emailed me about their knowledge and experience – as did the general public. I believe that the phrase which is dragged out ‘lessons will be learned’ won’t be fully possible if the facts of the case and the failures in the case are kept hidden. As I say, the Executive Summary, does not reveal the extent of the small, but cumulative failures – which I believe many professionals would recognise in their own fields and therefore be able to do something about. Therefore it must be in the public interest to be able to see the whole document.

Simply issuing another 150 Laming-like recommendations every time a tragedy happens simply adds procedures that take professionals away from their work without ever being able to see the why and wherefore of such recommendations – nor to judge or be able to critique the new ways from an informed position. The issues are kept between local authority, the other agencies and the Government – so keeping out those who would, could and should benefit from reading the whole story.

I am not an expert nor a professional – but unless and until we really open out all the issues around cases such as these – there will continue to be an air of defensiveness and self-protection which work against the safety and well-being of children at risk.

Social workers need to work in an atmosphere of support and good management – which can only come from opening up the real events, letting them stand there for all to see – and those in the professions taking those lessons away.

The argument Ed Balls makes to me against publishing the Serious Case Review (s) is that staff would not speak freely if they knew that what they said might be published. My view is that anyone working in any field where there is such an event has a duty to speak and say what happened. They would have to if the case goes to public inquiry or hearing. Names and personal information should be anonymized. It was anyway in the SCR I read and social workers were referred to as social worker 1 or social worker 2. It is also the case that quite a lot of time elapses between the event and the publication as the SCR is written immediately (usually) and the case and the trial and exposure comes much later.

OFSTED did an audit of Serious Case Reviews and found that nearly two thirds, I believe, were inadequate. So – additionally – this would not have come to light without OFSTED’s exposure. If they were published – these inadequate SCRs would have been exposed much earlier. So – whilst the Serious Case Review I am most concerned about is obviously the Haringey one – it is clear there is a wider issue too.

So – I believe it is totally in the public interest for the Serious Case Review to be published. Secrecy, lack of transparency and openess and closing ranks are at the heart of the problem in Haringey.

I hope you find in favour of publication.

Kind regards
Lynne Feathestone