Published in Hospital Doctor, November 1, 2007
Child protection: Unfair dismissal
The GMC were utterly wrong to have punished paediatrician Dr David Southall over the Sally Clark case, new research suggests. Is the council now redeeming itself? Jonathan Gornall reports
HAS the GMC finally woken up to the various realities and imperatives of the Laming report,1 Safeguarding Children2 and the 2004 Children Act?3 Judging by the statement accompanying the launch of its new guidance for the treatment of children and young people,4 a document that came into effect on 15 October, it would seem so.
"All doctors have a duty to safeguard and protect the health and well-being of children and young people," it announces, as though it were the first organisation to reach that conclusion.
Never mind, better late than never.
However, bearing in mind the crisis caused by the GMC's determined ongoing pursuit of Dr David Southall, the organisation's fresh observations on child protection will be of particular interest - not least to the 53 paediatricians who in April signed a paper in the US journal Pediatrics claiming that the GMC's actions were deterring doctors from raising concerns about child abuse.
In 2004, a GMC Professional Conduct Committee found Dr Southall guilty of serious professional misconduct for having raised concerns about the safety of Sally
Clark's surviving child.
At the time, 1999, Clark was in prison, having been found guilty of the murder of her first two children.
The new GMC guidance has this warning for doctors who hesitate to raise such concerns: "Your first concern must be the safety of children and young people. You must inform an appropriate person or authority promptly of any reasonable concern that children or young people are at risk of abuse or neglect, when that is in a child's best interests or necessary to protect other children or young people. You must be able to justify a decision not to share such a concern ..."
In GMC-guidance-speak, the word "must" has a precise meaning, conveying "an overriding duty or principle". What's more, "serious or persistent failure to follow this guidance will put your registration at risk".
In other words, if a doctor in Southall's position failed to notify others of his concerns, he could expect to be hauled up on a charge of serious professional misconduct. Southall and his lawyers might be forgiven for finding this a little confusing.
The guidance continues with reassurance for any doctors who might share that confusion: "You will be able to justify raising a concern, even if it turns out
to be groundless, if you have done so honestly, promptly, on the basis of reasonable belief, and through the appropriate channels."
Actions, of course, speak louder than guidance, and it is interesting to set this new template against the GMC's actions in 2004 in the Southall-Clark case.
There was no question, not even at his GMC hearing, that Dr Southall had raised his concerns "honestly" and "promptly" and "through the appropriate channels". On 27 April 2000, he had watched a TV documentary in which Steven Clark described how, in 1996, he had been alone with his 68-day-old son, Christopher, in a hotel room when the child had suffered a nosebleed, just ten days before his death.
From his own work with covert video surveillance of parents suspected of abuse, Dr Southall believed that spontaneous nosebleeds in such a young child were extremely rare and, unless there was an underlying medical cause, that frequently they were associated with trauma, such as that caused by attempted suffocation.
Fearing for the safety of the Clark's surviving child, the very next day he
contacted the child protection unit of Staffordshire police.
Which leaves just one question: did Dr Southall act "on the basis of reasonable belief"? Fresh evidence has just emerged, in a paper published on 24 September in Pediatrics,5 that suggests that he did.
In 2004, the GMC panel - without a child-protection expert among them, despite GMC guidance that "where possible the defendant doctor's expertise or field of work is mirrored by a panel member" - dismissed Dr Southall's concerns as "a theory about the case that you presented as fact as underpinned by your own research".
In other words, in the inexpert panel's view, the expert doctor's concerns had not been based on a reasonable belief. As a result, they concluded that his actions had been "precipitate and irresponsible".
Dr Southall was suspended from child protection work for three years, a sentence extended in July for a further 12 months.
Shortly after the shockwave of the GMC's Southall judgment ran through the child-protection community, the Royal College of Paediatrics and Child Health decided to investigate the issue of nosebleeds in very young children.
The published result is Epidemiology of Oronasal Hemorrhage in the First 2 Years of Life: Implications for Child Protection,5 coauthored by Neil McIntosh, the college's vice president for science, research and clinical effectiveness. It appears to show that the GMC was utterly wrong to have treated Dr Southall's concerns so dismissively.
The study looked at 77,000 A&E attendances by children under two years old in Lothian over a ten-year period, and found just 16 cases of nosebleeds, all of which were admitted for observation.
Of these, eight cases were associated with visible trauma, four with low platelet counts, two with apparent life-threatening events and two with upper respiratory tract infection. Review of histories suggested that seven of the 16 cases might have been caused by abuse.
Only eight of the nosebleeds had occurred in children under a year old and only one in a child younger (at 58 days old) than Christopher Clark had been (68 days) when he suffered his reported nosebleed. This was one of the cases associated with possible abuse.
"Epistaxis is rare in the accident and emergency department and hospital in the first two years of life, and is often associated with injury or serious illness," McIntosh et al conclude.
They add: "The investigation of all cases should involve a paediatrician with expertise in child protection."
The paper's numbers are impressive and its conclusions startling.
This is not, it should be said, about whether Dr Southall's concerns in the Clark case were groundless or otherwise - that point has never been tested and, according to the GMC's new guidance, would be beside the point in coming to a decision about whether a doctor had acted appropriately - but about whether he was justified in raising them.
This study suggests that he was entirely right to have done so, and that the GMC was wrong to have punished him for so doing, in the process discouraging other doctors from becoming involved with child protection.
At the conclusion of its 2004 case against Dr Southall, the GMC panel noted that "at no time during these proceedings have you seen fit to withdraw these allegations or to offer any apology".
That, of course, was because he continued to stand by them, as was noted
by GMC lawyer Richard Tyson at the GMC hearing in July that extended his suspension from child-protection duties.
"There's been no substantial change in Dr Southall's position," said Tyson. "He still thinks he was right to do what he did and this, we submit, shows a continuing lack of the necessary insight."
Now, it seems, there are very good reasons for the GMC to consider offering an apology and making an admission of its own lack of insight - not only to Dr Southall himself but to the unknown number of children placed in grave danger by its misunderstanding of child protection issues.
References 1. HMSO 2003. The Victoria Climbie Inquiry: report of an inquiry by Lord Laming. (www.tinyurl.com/ 2m9682) 2. Commission for Social Care Inspection 2005. Safeguarding Children. (www.tinyurl.com/ 2umcjs) 3. The Children Act 2004. (www.tinyurl.com/r3ds9) 4. General Medical Council 2007. Children and Young People. (www.tinyurl.com/2suxrq) 5. McIntosh N, Mok JYQ et al. Paediatrics 2007. (www.tinyurl.com/2nellw)