PACA believe that Dr Sabah Al Zayyat has been appallingly treated. It has taken a long time to get something in print, but at last one of our members has managed it, albeit on a personal basis.

PACA wonders about the nature of scapegoating, and whether it is normally done deliberately, or associated with wilful blindness.

For the article you may follow the link below, or just click on the title above to read it here:
http://www.bmj.com/content/343/bmj.d4691.extract/reply#bmj_el_269426

Accountability for the failure to protect Baby P.

Ivor T Rowlands, Retired engineer

The article is concerned as to whether there has been a cover up with regard to the Sibert and Hodes report and the implication of dishonesty and bad faith by Great Ormond Street Hospital [GOSH]. As reported similar concerns have been voiced by Lynne Featherstone and the GOSH response has been principally concerned with the defence of the managements actions and integrity. I am happy to accept their good faith but totally reject that the numerous repeated apologies for the catalogue of management errors made constitutes an adequate response if faith in the management of GOSH in particular and child protection in general is to be restored.

The concern is with GOSH management’s accountability for a whole series of actions with regard to the death of Peter Connelly. I include Baroness Blackstone in the management command of GOSH because she has become involved in this issue from the earlier stages and has aligned herself with the management to the degree that I think she is now equally accountable for their conduct.

At present the general public’s understanding of the failure to protect Peter is that it lies with Dr. Al-Zayyat, “the doctor who failed to notice Peter’s broken back”; few, if any appreciate the many failures of GOSH that played the major part. This is a gross injustice that needs to be righted so far as that is now possible.

The issue for GOSH is one of management competence and accountability throughout a whole series of bad decisions and judgments. That managements be held accountable for their performance is a necessary requirement for the good governance of all organisations and, in this case, for responsibility to be justly ascribed and future child protection improved The relevant decisions are described in the order they occurred.

1. Establishment of the Child Development Centre [CDC] at St. Ann’s in 2003.

Clare Dyer reports that two senior GOSH staff members have stated that the decision to operate a partnership in such a clinic was a mistake and naive. In my opinion an institution such as GOSH, with all the expertise available to it both from staff members with relevant past experience and external advice, has no business being naive; it is management incompetence. The eventual abandonment of the arrangement to my mind demonstrates that this is now recognised.

2. The deterioration of the service and the consultants letter in 2006.

The article also reports that the situation within the CDC deteriorated resulting in a letter by the then four consultants which, inter alia, classified child protection as high risk. In my opinion this letter described a safety critical situation and deserved appropriate response. The Children Act states that the welfare of children is paramount, a status accorded nowhere else in law. Again in my opinion, the only options available to GOSH in that situation were to immediately ensure the resources were adequate [for example by secondments from GOSH] or to close it, with temporary arrangements to cover existing commitments. GOSH did neither, merely exhorting staff to do their best. Budgetary constraints have been reported as a reason for this but, bearing the clear declaration of the Children Act in mind and also the declared reasons for starting the CDC, it is simply not credible that GOSH resources could not meet the need in either financial or resource terms.

I believe the management failure at this point led directly to the failure to protect Peter and is its prime cause.

3. The treatment of Dr. Kim Holt.

This issue has been well ventilated and at least to some degree resolved by the Bevan Brittan investigation. The resolution is due to the persistence and steadfastness of Dr. Holt and in no part due to GOSH seeing the error of their ways so far as the evidence I have seen suggests. It is yet another in the catalogue of errors by GOSH and failures to comply with NHS requirements, importantly an instinct to suppress issues and a total failure to acknowledge and accept the good faith actions of a whistleblower.

GOSH has apologised [again] but if I have read the full text of the apology it reads more like an expression of sympathy for distress resulting from an act of God than an acknowledgement of specific GOSH failings.

4. The appointment of Dr. Al-Zayyat. and her consultation with Peter.

The article describes the circumstances of Dr. Al-Zayyat’s appointment as a locum consultant in 2007 when there were only two consultants in post and her experience and training did not meet the requirements for the position in critical areas. In my opinion this was an act of desperation to staff the CDC and was consequent to the failure described in 2. above.

I am privileged to have access to an expert analysis of the available information on the conduct of Dr. Al-Zayyat’s consultation with Peter. Some of the main features are as follows it was a long standing clinical appointment with no child protection connotations; Dr. Al-Zayyat took on the consultation from a sick colleague; no social services were in attendance; Dr. Al-Zayyat had no nursing assistance; she was about to be confronted with an accomplished con merchant, Tracy Connelly [as demonstrated by the video clip]; a person she believed to be the foster mother was present and supported Tracy; Peter was fractious with a history of head banging.

Dr. Al-Zayyat was not negligent, the consultation took an hour and she sought advice but no designated doctor for child protection was in post. Dr. Al-Zayyat referred the child on for consultation at GOSH and had Peter not been killed the consultation would probably have not attracted further attention.

It is argued that while a better performance from Dr. Al-Zayyat may be wished in identifying abuse despite the circumstances of the consultation, several important factors in that consultation were the direct responsibility of GOSH for which no one has been held to account.

5. Information to the Serious Case Review.

Clare Dyer covers this issue comprehensively but there is still no explanation of how on earth GOSH came to such a view. Again the Children Act is relevant: the priority clearly lies with supporting the SCR to prevent future failures as far as possible. Peter is dead and nothing further can be done to benefit him so to that extent the trial is secondary. As regards legal advice which seems contrary to this, further advice should have been obtained – there are as many opinions as there are lawyers. As for the police, contact them again to inform them that you are passing the full report to the SRC together with a request that is kept secure.

If it is accepted that GOSH acted in good faith, then GOSH must equally accept that their judgment on this issue was appalling, contrary to the public interest and, in my view, incompetent.

6. The subsequent experience and treatment of Dr. Al-Zayyat.

The article does not discuss the consequences of the saga for Dr Al- Zayyat in detail. Following Peter’s death and the consequent public furore, particularly when the prosecutor in the trial of Tracy Connelly et al stated unwisely and unnecessarily that Dr. Al-Zayyat had probably missed Peter’s broken back, Dr. Al-Zayyat became a public hate figure. She was hounded by the press and the subject of a 1.5 million signature petition to Downing Street that she be struck off.

Shortly after the prosecutor’s statement, it must have been apparent to GOSH, as it was to many other doctors, that the probability of Peter’s back being broken at the time of the CDC consultation was small but I am not aware of any public statement by GOSH to that effect. Equally GOSH made no public statement regarding its own failure to resource the CDC adequately and its potential contribution to the failure to protect Peter. Such statements would have relieved the pressure on Dr. Al-Zayyat, their employee to whom they owed a duty of care, not to mention the moral imperatives and common humanity that the situation demanded. Later, when more details of the back injury were known, medical opinion was clear that the injury would have caused death within hours and therefore could not have been present at the CDC consultation; Peter would have been incapable of sitting up and being weighed on scales during the consultation.

GOSH continued to employ Dr. Al-Zayyat for nine months after the consultation and was considering her for a permanent position. When the public furore blew up, GOSH’s attitude seemed to change and gave the perception of wishing to use Dr. Al-Zayyat as a scapegoat for their own failings. Whatever the truth of the matter, GOSH terminated her employment and referred her, as complainant, to the GMC. It is not at all clear as to why this was necessary and why the matter could not have been dealt with by an NHS inquiry.

Those close to Dr. Al-Zayyat at the time relate that she was petrified at the prospect of a public hearing, fearing that the press harassment would begin over again. Psychiatrists stated she was suicidal and she returned home to Saudi Arabia where she remains in poor health.

Later the GMC held a second hearing in Dr. Al-Zayyat’s absence at which her counsel requested voluntary removal from the register which was refused by the GMC and her counsel stated that they would apply for Judicial Review. The hearing nonetheless proceeded to a telephone interview with an obviously sick and distraught Dr. Al-Zayyat which lasted about three quarters an hour. As complainant, GOSH could have halted this inhumane process at any stage by withdrawing the complaint; GOSH did nothing. This interview must rank as one of the most disgraceful occurrences by a body with “Medical” in its title and GOSH was party to it. The GMC have not published the transcripts of this hearing – I wonder why that could be? Perhaps GOSH could publish them to make the public aware of the degrading, humiliating treatment to which Dr. Al-Zayyat was subject. Mr Justice Mitting eventually overruled the GMC and strongly criticised them for their perverse conduct.

Conclusion

Of the medical staff involved only two have faced public sanction, Dr. Al-Zayyat and the GP, Dr Ikwueke. Dr Ikwueke’s case is not discussed here only because GOSH was not involved. Dr. Al-Zayyat is a Saudi national, an immigrant to this country welcomed because of her skills and was working in one of the most deprived areas of the country. She is recognised as a good person dedicated to doing her best for her patients. She did Peter no harm and committed no crime. If the description naive is to be applied to anyone in this saga it is perhaps Dr. Al-Zayyat But she is still seen by the public as the doctor who missed Peter’s broken back, a belief now known to be wholly untrue. She was caught up in a situation she could not possibly have foreseen in a non viable clinic to which she had been recruited despite not having the required experience or training. The price she has paid is to be a public hate figure, her health and career destroyed and her family life damaged, including that of her two daughters who have seen their mother destroyed. Where was the child protection for them?

Like GOSH, both doctors apologised for any part they played in failing to protect Peter but to no avail. By contrast, I believe that much the greater part of the responsibility for the failure to protect Peter lies with GOSH and for which no-one has been held to account or accepted accountability. Despite the fact that all formal proceedings against Dr. Al-Zayyat are now finished I am not aware of any public statement by GOSH in her support or stating that Peter’s back was not broken when she examined him. The perception persists that Gosh is content to let matters lie and all the public anger for the failure to protect Peter be carried by the two doctors, principally Dr. Al-Zayyat.

This situation is a national disgrace and needs to be acknowledged. It is past time that management at GOSH faced their responsibilities and followed the recent impressive displays of public accountability by the Metropolitan Police Commissioner and his assistant.

If I have misunderstood matters I stand to be corrected and it is important that I should be because I know that many share similar views.

Ivor Rowlands. [Mr.] Cheshire

Competing interests: I have supported paediatricians engaged in child protection for many years. I am a non-medical member of Professionals Against Child Abuse [PACA]

Currently the topic of Shaken Baby Syndrome is being aired. The following links lead to relevant information. The first document (starting “Yes”) is not in our opinion mainstream; the second comment (starting “No”) mirrors PACA’s stance and reflects mainstream opinion.

Reference: “The triad of retinal haemorrhage, subdural haemorrhage and encephalopathy in an infant unassociated with evidence of physical injury is not the result of shaking, but is most likely to have been caused by a natural disease.”

Link to Article: No – RORKEvSQUIER-No.pdf
by Rorke-Adams LB J Prim Health Care 2011, 3:161-3

Link to Article: Yes – RORKEvSQUIER-Yes.pdf
by Squier W J Prim Health Care 2011, 3:159-161

The following post gives a few examples of GMC behaviour which we feel could be seen as inconsistent.

GMC double standards:

Number 1:

GMC insisting that Dr Al-Zayyat attends a FtP Hearing over the allegation that she missed Baby Peter’s broken back (even though it might have been broken after she saw him) because: “there was a public interest in having the complaints against Dr Al-Zayyat scrutinised in public and in having the panel reach a formal decision and announce its findings of fact in public”. This is to satisfy “the maintenance and promotion of public confidence in the medical profession and the maintenance and promotion of public confidence in the GMC’s performance of its statutory functions”. Even though this doctor is back in the Middle East and suicidal and wants voluntary erasure.

versus:

GMC accepting breast surgeon, Mr Gilmore’s application for “voluntary erasure” from its medical register just before a FtP Hearing, stating “Our primary role is to ensure that those doctors on the medical register are fit to practise: however, in dealing with concerns our process must be fair to the doctor concerned”. See: http://www.telegraph.co.uk/health/8105203/GMC-has-let-down-public-over-breast-surgeon.html

Number 2:

GMC erase names from medical register of Professor Sir Roy Meadow (Founding President of RCPCH) and Professor David Southall OBE for giving honestly and reasonably held opinions in child death cases – both now overturned in High/Appeal Courts, with GMC actions said to be irrational, inappropriate. Both were experts in child protection esp relating to infant deaths.

versus:

GMC actions, eg short term suspensions, in cases of doctors dealing in child pornography (ie child abuse media). For example, Hereford Times Jan 2010: “GMC have suspended a family doctor who downloaded an “abhorrent” collection of child sex stories. Dr XX was described as a “sexual deviant with an interest in children” at the General Medical Council hearing. The GP, who practised at XX Surgery, admitted to using his home computer to download written pornographic material. But the GMC cleared Dr X of misconduct, as it believed his fitness to practise was not impaired by the fetish. The Manchester panel heard that Dr X, a GP of 25 years, downloaded the material between 2003 and 2007″.
…
In 2008: “Out of five doctors convicted for possessing child pornographic material, four were allowed to continue in practice and one case is still to be considered”.

If those of you who follow the link to Andrew Gilligan’s blog want to know more, perhaps you could read the NHSL (National Health Service for London) report on this matter at this link:

National Health Service for London report

Andrew Gilligan’s blog

PACA is delighted that justice has been achieved in the case of David Southall, with the Court of Appeal today overturning the decision of the GMC’s Fitness to Practise (FtP) Panel in December 2007 to erase his name from the medical register.

The Appeal Court determined that the GMC Panel had been prejudiced by an inappropriate view that David Southall should not have undertaken an interview of a mother to investigate the death of her child. The three judges considered the Panel’s approach “was not one based on evidence”. PACA always considered the finding of the FtP Panel perverse and another example of the GMC’s harassment of leading child protection doctors. [...]

Download the full press release as PDF: Failure of Medical Regulation – time for an inquiry into the integrity of the GMC after David Southall’s appeal win

Soon after the broadcast a complaint about the programme was made to Ofcom.

Ofcom’s response is published in the Ofcom broadcast bulletin issue 148 on page 138 and on. (see link below).

Needless to say the complaint was not upheld.

Ofcom is The Office of Communications, a government body.

Link:
http://www.ofcom.org.uk/tv/obb/prog_cb/obb148/Issue148.pdf

This is a link to an article on the Sunday Telegraph website:
http://www.telegraph.co.uk/news/uknews/baby-p/6739202/If-Great-Ormond-Street-had-listened-to-me-Baby-Peter-would-still-be-alive-says-consultant.html

On reading this article PACA has released the following press statement:

6/12/2009

STATEMENT BY PACA: DR KIM HOLT SHOULD BE THANKED AND REINSTATED

[Download PDF version]

For immediate release:

PACA (Professionals Against Child Abuse) wishes to express its support for Dr Kim Holt, Consultant Paediatrician, following the publication of information about concerns she and others raised in 2006 about the management of children’s health services in Haringey.[1]

Dr. Holt was one of four Consultant Paediatricians who wrote to their managers listing numerous concerns which they had raised for at least two years at that stage.[2] Many of these were the same as factors identified by the Care Quality Commission when it reviewed the death of Baby P.[3] Only one of the four Consultants is currently in post.

PACA notes with concern the fact that Dr Holt has been excluded from her job for over two years, is currently on a temporary secondment, with no long term job security and that she has always been clear that she wanted to return to her original post. PACA notes that Dr. Holt stated that considerable efforts were made to have her removed.

It appears that Dr. Holt is yet another NHS whistleblower who has been badly treated by the NHS after raising legitimate concerns. This is unacceptable. Following the Stafford scandal, health ministers repeatedly stated that whistleblowers enjoy full legal protection from the Public Interest Disclosure Act 1998.4 If this were truly the case, Dr. Holt would not have suffered these detriments. We would welcome a statement from a minister on this matter now.

PACA suggests that Dr. Holt should be thanked by her employer, Great Ormond Street Hospital for Children NHS Trust, which should also offer her a public apology. It should reinstate her and supply the necessary resources to allow her to do her job. It should also compensate her for the unnecessary costs she has incurred, including those relating to unnecessary legal costs and maintaining her skills whilst excluded from the workplace. We do not see that any other course of action is in the interests of vulnerable children, the wider community, and the NHS.

We note that Great Ormond Street’s spokesperson finds it “difficult to comment until an independent investigation is completed.” We understand that the report from the investigation was supposed to have been published in September 2009. Ongoing delay appears to prevent Great Ormond Street from addressing important issues. We believe that it is in the public interest for that report to be published. When it is, PACA members will study the report to see what implications it may have for other individuals involved.

John Bridson Chair PACA

—

Notes

1 BMA News Review, front page headline, 21 November 2009; Sunday Telegraph, 6 December 2009.

2 A. Gilligan, Doctors raised alarm over ‘high risk’ at Baby P clinic, Evening Standard 12th May 2009

http://www.thisislondon.co.uk/standard/article-23689559-doctors-raised-alarm-over-high-risk-at-baby-p-clinic.do

3 CQC, Review of the involvement and action taken by health bodies in relation to the case of Baby P, 2009 [Draws on previous independent investigation] http://www.cqc.org.uk/_db/_documents/Baby_P.pdf

4 See, for example, Ben Bradshaw MP, Minister of State for Health, House of Commons Hansard 18 May 2009.col 1227W.

Information about PACA: Children are the most vulnerable members of society. Sometimes the very people who are expected to protect them place them at risk. It is then that professionals who work with children have a duty to protect them. PACA believes that vulnerable children need dedicated paediatricians, nurses, social workers, teachers and the law to protect them. PACA was formed in response to high profile cases against paediatricians at the General Medical Council at which it became clear that the present regulatory systems did not protect children and were open to abuse by those who sought to discredit professionals who stood up publicly for children’s rights. PACA advocates for children’s rights by campaigning for regulatory organisations to be trained in child protection, for the interests of the child to be paramount, and for professionals who stand up for children to receive fair treatment.

Introduction

Dr Southall was struck off the medical register by the GMC pending an Appeal.The Appeal was heard and a judgment published in May 2009.

This confirmed the GMC decision to strike him off, there was just one more chance, a short two hour verbal appeal to be held in October 2009.

STATEMENT From Dr Southall following the Appeal conclusion 22/5/09

“Although very disappointed with this judgment, I intend to seek leave for a further Appeal.

“I wish to make it clear that I completely deny the accusation made by Mrs M who has been supported in pursuing her false allegations by Mrs Penny Mellor, the leader of a long-standing campaign against my child protection work.

“The version of what happened in that interview with Mrs M as part of a section 47 child protection inquiry requested of me by the Family Court was exactly as described by the Team Leader in Social Work for the case who was present throughout.

“This Social Worker had been qualified for 10 years, possessed a number of higher professional qualifications in child protection and had met me along with her supervisor on only one occasion prior to and not at all after the interview.

“In her report prepared for the GMC hearing, she stated “I am certain that Professor Southall did not make such an allegation during that interview.”

“I find it difficult now to understand how any doctor in the UK can undertake a sensitive discussion or perform an intimate examination in the presence of an appropriate chaperone and be safe from false allegations.”

We have learnt over the last few years that no one and no profession is infallible. Some people can see the myths, but others are blind to them and are led by their prejudices.

Link to the Law Commission Consultation Paper on Expert Witnesses (PDF)

Text of the response by David Murray:

“You invite comments on the Consultation Paper.

PACA, is a group of Consultant Paediatricians and doctors together with lawyers, social workers and psychologists involved directly in Child Protection, or indirectly in the defence of doctors maligned in the media and punished by the General Medical Council for acting for the abused child against the abusers. May we ask you to consider the points made in the attached letter? We would be delighted to offer advice on the medical and forensic implications of working in this difficult field where our duty to children now requires us to defend ourselves against unfounded and often malicious commentary.

The Paper itself uses inaccurate evidence to illustrate poor medical and scientific expertise. It would make more sense to have used as an example of misleading expert evidence, not the Clark case, but a case in which such evidence had been shown conclusively to be in error, and for that error to have lead directly and materially to an unjust conviction, rather than to pick a case where the finding of murder was based on convincing medical and forensic argument remote from the supposed failings of expert witnesses, and then use that imagined failing to claim that such events are a problem. There is no “dogma that holds that two or more unexplained infant deaths should lead inexorably to the conclusion that a murder has been committed”, nor do Meadow or any other paediatricians cleave to it as the commissioners hold. There is no evidence that, “multiple cot deaths in a family could have underlying genetic causes”, nor can it be reliably stated that the occurrence of a second cot death is “usually from natural causes” when all, some, or none of such cases might be murder. How are we to reach sound conclusions as to the merits of procedures designed to protect against misleading opinion when the examples used to adduce such a necessity are so flawed that they discredit the real experts and take their lessons from the opportunist incompetent?

Meadow is not an example of flawed expertise but an expert traduced for being too astute and prescient. It was he who first realised that his ally in the comforting and treating of the sick child, its mother, may be the agent of its distress. Is it not odd that the country’s most distinguished expert in the misfortunes and murder of children should be the focus of an inquiry into flawed medical expertise? Is it not ironic that the wrong target has been selected with the expert of great value to the Court confused with the inexpert ‘expert’ who makes clinically implausible suggestions of a cause of death that are just sufficient to persuade the Court that there is a real dilemma and that justice is best served by prevarication?

Those who deserve scrutiny are not the leading figures in paediatric and forensic medicine but those whose imaginative diagnoses serve their purpose in Court but would be lethally dangerous if made at the bedside of a critically ill child: the retired haematologist who thinks Victoria Climbié died of a rare disease that inflicted marks on her body that seemed, to all but him, the indentation of the bicycle chain used to beat her, the retired biochemist with the first ever case of a novel syndrome to explain a child dying full of salt, the microbiologist who added to a dead baby’s list of injuries, typical of violent suffocating assault, the clinically unsound diagnosis of an infection of such ferocity that it overwhelmed the child in its bouncy chair in no more than ten minutes, the doctor flown in to say that dreadful injuries could have been caused by epilepsy rather than brutal contact with a banister rail. Constructive advocacy acts in the interest of clients but seldom for truth or the protection of vulnerable children. A great injustice has been done to Sir Roy Meadow and to the murdered children and should not be added to.”

PACA is saddened to learn that David Southall’s appeal in the High Court
today was unsuccessful in overturning the decision of the GMC’s Fitness to
Practise Committee to erase him from the medical register in December 2007.

The GMC have held three Fitness to Practise Hearings against David Southall:
in 2004, 2006-7 and in 2008. Only in the 2007 Hearing did the outcome lead
to a permanent restriction on David Southall’s ability to practise medicine.
PACA believes the GMC have acted inappropriately and have been improperly
influenced by a skilful and hostile media campaign by parents involved in
alleged child protection cases and their advocates. PACA is now concerned
that today’s result will have further serious and negative effects on the
willingness with which doctors will engage in child protection.

Internationally acclaimed and eminent paediatricians involved in child
protection have sustained repeated harassment in recent years, including
from the GMC. PACA considers that the GMC preliminary assessment procedures
have been ignorant of the nature of child protection procedures in the
Family Courts and that this case should never have been brought against
David Southall; that he has always given honestly held opinions, based on
extensive experience in complex child protection cases and solely with the
purpose of protecting children has never been questioned.

The disciplinary actions of the GMC, today supported by the High Court, will
be a further deterrent to paediatricians and other health professionals from
engagement in child protection work. Last year, the Royal College of
Paediatrics and Child Health voted overwhelmingly to express their grave
concerns about the GMC’s actions in the cases of both Professor Meadow and
David Southall. PACA considers today’s action will be a disservice to
children. The GMC should act only to encourage doctors to report child
protection concerns and engage in child protection work, by making them feel
safe from disciplinary actions, unless the doctor has been shown to have
acted incompetently or with malice.

We will provide full comment when we have read the full judgement.

[Update - the full judgement can be read here: Final_Southall_22_05_09.pdf (236 kb)]