GENERAL MEDICAL COUNCIL
FITNESS TO PRACTISE PANEL (PROFESSIONAL CONDUCT)
Wednesday 29 November 2006
44 Hallam Street, London, W1W 6JJ
Chairman: Dr Jacqueline Mitton
Panel Members:
Mrs Leora Lloyd
Mr Alexander McFarlane
Dr Sameer Sarkar
Mr Arnold Simanowitz
Legal Assessor: Mr Robin Hay
CASE OF:
SOUTHALL, David Patrick
(DAY THIRTEEN)
MR RICHARD TYSON of counsel, instructed by Messrs Field Fisher Waterhouse, solicitors, appeared on behalf of the Complainants.
MR KIERAN COONAN QC and MR JOHN JOLLIFE of counsel, instructed by Messrs Hempsons, solicitors, appeared on behalf of Dr Southall, who was present.
(Transcript of the shorthand notes of T. A. Reed & Co.
Tel No: 01992 465900)
I N D E X
Page No
DAVID PATRICK SOUTHALL
Cross-examined by MR TYSON (Continued) 1
THE CHAIRMAN: Can I just shout, it appears the microphones are not working, but while that is sorted out can I just say good morning, and we apologise for the delayed start, which was again unfortunately down to transport problems affecting a member of the Panel. Hopefully this matter can easily be resolved.
MR TYSON: Madam, again whilst we are in a semi-formal situation, can I explain that the gentleman at the back is a member of my chambers, who is here to see how GMC Panel hearings are conducted as part of a learning curve, and I would be grateful if he could remain where he is. I have asked my learned friend and he has no objection.
THE CHAIRMAN: Yes, I do not see any objection from the Panel either.
MR TYSON: I am obliged. (After a pause) Madam, do you want us to rise whilst this matter is sorted out?
THE CHAIRMAN: I am just about to seek advice.
MR COONAN: It might just be a simple electrical problem because our lights yesterday in our rooms all tripped and it took a little time to come back on, so it could be a trip switch, simple as that, somewhere in the building.
THE CHAIRMAN: I take it that perhaps it is not practical to try and proceed without the microphones. This is very regretful, but the Panel Secretary says that the staff do not know what the solution is, so I think perhaps it would make sense for us to rise until we are told that the problem has been solved. Sorry about that.
(The Panel adjourned for a short time)
THE CHAIRMAN: The problem appears to be fixed, I am delighted to say.
DAVID PATRICK SOUTHALL
Cross-examined by MR TYSON, Continued
MR TYSON: Dr Southall, we were dealing with the SC files and I was going to take you to various other aspects of policy relating to them before one gets down to the actual ones we are dealing with in this case. Can I ask you, please, to look at Professor David’s observation, which forms the basis of Appendix One, by looking at C3 at 7(a). You see he sets himself the question, question 10, as it were:
“Is it appropriate for a paediatrician to remove (or cause to be removed) an original document from a child’s medical records and place it (or cause it to be placed) instead in an alternative file that is kept and stored separately from the child’s medical records? Further, is it appropriate to place (or cause to be placed) in such alternative file an original document that should be in the child’s medical records?”
Just as a matter of generality, can I just take you through these to see what we agree and what we disagree on.
A Yes.
Q If we go through 415 together:
“It is hard to see how one could justify removing an original item from a child’s medical records unless that item had been placed there incorrectly, for example a laboratory report that had been misfiled and related to another patient. Removal of original items from a child’s medical records would be [regarded] as a form of tampering with the medical records, and would be quite unacceptable. Once an item had been removed, it would cease to be accessible to others involved in the care of the child.”
What observations do you have on that, Dr Southall?
A I agree with it, and we did not remove items from the main hospital medical file. We had additional items which we put in our own files.
Q Then this perhaps covers 416:
“Failing to place (or causing such a failure) an original item in the medical records would be no different in its inappropriateness, its seriousness and its effects from removing (or causing the removal of) an original item from the medical records.”
What I have to suggest to you is that is in effect what you were doing with these SC files, that you were placing original medical records which should have been in the hospital records in the SC file, thus making the originals unavailable to anybody else.
A Okay. I do not agree that 416 is the same as 415. This is additional data collected by a tertiary hospital department, 4,500 files here (you mentioned yesterday), of which 99 per cent are fairly simple, they are copies of the recording result, the patient data form, and possibly a special data collection form. Almost all of these are tiny files, very thin. The ones that are big are the child protection files, like the ones we have been dealing with. Now, again, answering 416, I think that it was our policy to have these original medical records
(I accept the word “original”) in parallel with the main hospital medical file, and that this was not just our practice, but the practice of most tertiary centres in the country at the time.
Q Well, there is a difference, is there not? There is a difference between having, as it were, the day to day stuff like the printouts, and things like that, which we have discussed.
A Yes, exactly.
Q You have accepted that there are matters in there, such as in the SC files, that should also be in the hospital medical records, such as the reports.
A We have been through this.
Q We have been through that before. Where we are apart is where there are other original documents that are in the SC files that should be in the hospital medical records.
A What I am trying to say, I suppose not very clearly, is that in 4,500, 99 per cent of them there will be copies in the main medical records. They were there for other reasons. In the child protection group, which is the group where there have been complaints – and
I hesitate to say that there has, as far as I can recall, no complaints about the other 4,300 and whatever it is records, no complaints, it is only the child protection cases that there is a complaint.
Q The issue of principle, you would say, is that all child protection matters should automatically not be in the main hospital records?
A This is the policy that we had at the time. I accept that policies have moved on, many of them for the better, I accept that completely, but at the time we were evolving policy and our situation, and of course you took us to the 1997 and then there is a later one, 2006, North Staffs protocol policy which are different.
Q Just so that I understand it, Dr Southall, you are saying as soon as there is, as it were, a whiff of child protection, you are then putting things out of the main hospital records into the SC file, is that your case?
A Not putting them out of; instead of putting them into the main medical record, we put them into the special case file. It is not just a whiff. These are serious cases. I mean, they are not minor issues – not “minor issues”, that is the wrong word; if you look at child protection general in a hospital admission situation, many of the query child protection issues turn into being natural medical problems. With our tertiary hospital work, these were difficult patients to start with, with problems defying local paediatricians. If there was a question mark over child protection, it would then be a reasonably serious question, not a whiff. That is the only word I did not like.
Q Well, I will happily rephrase it. As soon as there are child protection concerns, it is your policy to make sure that none of this appeared in the hospital records, but was maintained solely in the SC files.
A That was the policy, yes.
Q I understand what you are saying. Do you see the problems that if you have a parallel system of files and there is an original document in one file that should be in the main file, there is a risk that on people wanting to see various documents, that that, if it is in the wrong file or in a different file, could get missed?
A I agree.
Q The risk perhaps is at its most graphic when if you have a report, or an important bit of clinical correspondence, and if that is missed the consequences can be serious, can they not?
A They can be serious.
Q I do not need to have to remind you of what happened in the Sally Clark case, do I, in relation to documentation?
A I think that is not at all similar in its parallel to what is going on here.
Q Let me just help, for the benefit of the Panel, it is right, is it not, that there was a bacteriological report in relation to one of the two children in that case, where the mother was accused of murder, that did not emerge for some time?
A That is correct.
Q That bacteriological report was not in the main or the disclosed hospital records?
A I think, if I remember correctly, it was in the pathology department. The baby had died. It was not an ongoing clinical issue.
Q It was only much later, and after the criminal trial, where that report, which was not in the hospital records, emerged?
A Yes.
Q When that document emerged it indicated that there was a possibility that the particular child had, I think, what is known in the trade as staph a, or staphylococcus aureus, and that was one of the grounds on Mrs Clark’s second appeal that enabled that second appeal to be successful?
A This is still different. This was the disclosure of a bacteriology report which was kept in the pathology laboratory. A lot of pathology reports remain in the laboratory. It is up to the clinicians involved to disclose them if they feel they are appropriate to disclose.
Q You see, I suggest to you there is absolutely no difference in principle here, that if medical records are asked to be disclosed and you do not disclose the existence of the SC file, and if in the SC file there is an original document that is nowhere else, you run into precisely the same risk as was faced in the Clark case.
A Well, it depends on how well organised the link between the hospital main record and the special case file record was as far as each child was concerned, and we did our best,
I cannot say it was perfect, but we did our best to make that link. We had the nursing staff, the administrative staff, they all knew about it.
Q We have been through this before, Dr Southall. You have accepted that there was nothing in the hospital notes, either at the Brompton or at North Staffs, that indicated in the hospital notes that there was another file.
A There was no tracer card but there were links available and everybody knew, but
I accept that if I did it again, if we went back again, I think we would have a tracer card. The only danger in a tracer card though is a real danger, which is that if, as you saw, Mrs H got access to her medical records, which she did (the main one I am talking about, she told us about it), and she saw a tracer card saying there is a special case file on this child because there are child protection concerns, because that is what it is about, there could have been some consequences at the time. We were dealing with the most dangerous group, which is the suffocation group, most of the time. I do accept that ideally we would have had a tracer card, and it could have been designed in a way that made it safer.
Q Just for the record, you are not saying that any of the cases here, certainly Mrs H’s case, was a suffocation case, are you?
A Oh no, no, I did not want to make that point at all; I was just making the point that our work at the time was quite considerably involved with covert video surveillance. I think you know---
Q Are you not running ahead of yourself here, Dr Southall, with respect, that the issue is not whether the person seeking disclosure is going to get ultimate disclosure, because under various access matters you as the consultant in charge have got various rights to disclose, it is a question whether in the first place the person seeking disclosure knows of the existence of the file?
A Well, in the cases here there was clearly some problems with that, and I do accept that there were some problems with that. They were seeking the disclosure for reasons of complaint. It is clear though that there were not issues relating to the safety or the well-being of the child. I do not think there is anywhere in any evidence – maybe I am wrong, but
I cannot see any evidence – that any child has suffered as a result of the system you are criticising.
Q The issue is accessibility generally to these files and the integrity of those files. Can
I move on.
A Can I just answer that?
Q Yes, certainly.
A Accessibility and integrity relate to the clinical care of the child, and that is what really matters, that is what we are all here for, the clinical care of the child, and I do not think there is any evidence, looking at it, that there was any harm. However, I do accept that things evolved and could have been better with time, and were better.
Q We are all of course concerned with the welfare of children, both as human beings and as lawyers and clinicians, but that is not the point. What this case is partly about is accessibility and integrity of medical records. That is why you are here. Can I, having made that point, move on to another point.
A Sorry to be difficult, Mr Tyson, but there has been press coverage of this to say that
I created harm to children as a result of keeping these files, has there not? There has. I think I just wanted to clear up that point that I cannot see any harm to any child as a result of what our policy and our practice was. I accept though that your other point is clear. That is what this discussion is now about.
Q You have made your point and I will move on to make other points. As far as matters of procedure are concerned, concerning the files, I think you have agreed – and can I just clear it up – that as far as the SC files, it was, as it were, your idea in the first place to have SC files?
A Yes, it was my idea.
Q You were responsible for their creation?
A I was.
Q You were responsible for the integrity of those files, if I can put it that way?
A Yes, I am.
Q And that you were responsible for informing others of their existence?
A I was.
Q You heard the evidence of Mr Chapman that he indicated that you, as the lead clinician, were responsible for telling, as it were, medical records of the existence of these files?
A I did. I did tell them.
Q I suggest to you that you did not.
A Ah, well the trouble is, you see, I cannot prove by producing letters and discussions that we had when I left the Brompton Hospital, but there were discussions and the medical records did know. You can see from letters there were links to the medical records department. The trouble is this is, what, 14 years ago, this is not just yesterday, and so it is difficult for me to prove, is it not, a negative, which is what you are talking about.
Q In the two files that relate to the Brompton, you went in 1992, did you not?
A Yes.
Q The file relating to Child A was created in 1987?
A Yes.
Q The file creating in relation to Child H was created in about 1989, September 1989?
A 1989, yes.
Q By 1992, in relation to both of those cases, your clinical involvement was over?
A Yes.
Q Child protection matters were over?
A With regard to Child A they were over fairly quickly. Child H, there was continuing involvement after I had gone to the North Staffordshire. I am pretty sure I went to meetings in Wales about the case.
Q I need not take you to it, but you submitted a bill in relation to your work in that case, which we can see in the SC file if we have to, December 1991?
A I accept that, yes.
Q I suggest that by December 1991, when you submitted your bill, as it were, that your involvement was essentially over?
A I still think that there were occasions where I might need to refer back.
Q So the rationale for taking these files over from Brompton to North Staffs could not be either child protection or clinical. We are only left with clinical audit, essentially?
A No, not quite. If we accept – and I made a mistake when I gave my evidence-in-chief about the numbers – and if we say there are, say, 2,500 files going to the North Staffs from the Brompton, 1 per cent are going to be child protection files perhaps and 99 per cent are clinical still, and of those a proportion would require ongoing clinical care when we had moved. They were still having the home monitoring, they were still having their non-invasive ventilatory support, so there was a proportion of the special cases files ---
Q In the two that I am putting to you, the Child A and the Child H files ---
A The A and the H.
Q -- the only rationale left for taking them would be clinical audit?
A And/or the possibility that in the future there would be a need to revisit the child protection question marks. But, remember this was a policy for the whole batch. We did not say, “Well, we can go to 2,500 and divide them up into lots of categories. Some can stay at the Brompton, some can come.” We did not do that; I accept we could have looked at it that way, but we did not. We took the whole lot with us.
Q It is a criticism of you and I suggest that what you should have done is actually left, in the Brompton Hospital, clinical records relating to these children that belonged to the Brompton Hospital?
A I accept the point, but remember there was nobody left at the Brompton who was doing anything like the work we had been doing.
Q So, for the two reasons which we have gone over and over again, (1) for the following clinician, if a child happened to arrive at the Brompton so the following clinician would know, and (2) for the purposes of any request, whether by lawyers or others, for the case records?
A Okay. Now, for following clinicians, if the child returned to the Brompton was the first point that you made. The child would not return to the Brompton because, supposing that the paediatrician in Barnsley wanted that child seen again by us, he would know that we had moved to Stoke on Trent. It was widely known by everybody.
Q But if the child was referred by his GP to the Brompton for any particular purpose – and it need not be, as it were, anything to do with respiratory matters – it would be important, would it not, that that clinician at the Brompton would know that there had been child protection concerns involving this child because that would inform that clinician’s judgement of the case?
A I am just thinking it through. The child would have to go back to the Brompton because of a complex respiratory or cardiac problem; that is all the Brompton dealt with. So supposing that happened and the child went back and out comes the hospital medical record and they will see “Dr Southall, consultant” involved, and they will see the monitoring stuff, the admission for overnight monitoring. They would not see, as you rightly say, necessarily any child protection issues, although in fact there were some still remaining in the notes from the hospital social worker, if I remember, in, say, Child A. But regardless, okay. They would almost certainly contact me because they would want to know a bit more about what we had found.
Q Why would they have to do that, Dr Southall? Why cannot they just look at it in the notes, in the hospital notes where it should be, that there were child protection concerns, and if and insofar as they wanted to contact you they could contact you subsequently, rather than, when they are dealing with the matter, to call for the notes and deal with it then and there?
A Because that assumes that the notes are just the only thing that drive communication between doctors. It is not like that. I mean, doctors talk to each other. The GP has all the records. The GP would have raised the question with the referring consultant. It is part of a system.
Q But the importance of clinical notes, as we have gone through over and over again, set out in the Department of Health Guidance, is that they should be complete and accessible. All I am suggesting to you is that by you taking the original SC files and everything connected with child protection that you could away from the Brompton you were making the Brompton notes lacking in integrity and not of assistance to following clinicians?
A I think that is one way of looking at it and I accept your opinion, and it is largely the opinion of Professor David I know, but there is another approach, which is to say that we were the people continuing to look after these patients and it was important we had the data with us. The response to that would be, well, we could have photocopied all 2,500 and put them into the medical records. I accept that. There are things we could have done differently, but … Okay.
Q We are apart on that.
A We are.
Q I will move on.
A We are apart, but I accept the opinion. It is just different opinions, and remember this opinion you have got is with hindsight. We were the ones doing it there and then at that time, in the absence of protocols and guidelines from the government. They did not come in till, what? 1999? We are talking 1986.
Q You accepted the principles. I went through the Department of Health principles and you said that those principles applied whatever the time, so despite the date of the Department of Health ---
A Hang on. I said they represent gold standard practice in 1999.
Q We need not go through it again, but with respect, you did. When I went through those Department of Health guidelines on the medical records you did not say they represented the 1999 gold standard. You said and agreed with me that they were matters of universal application which had been in existence for ever, really, because they were appropriate guidelines and timeless guidelines. I will move on; if anybody wants to ask questions arising out of that they can, but that is my distinct recollection. Can I now deal with the particular item relating to clinical correspondence between paediatricians?
A Sure, yes.
Q Can I take you to the two paragraphs of Professor David’s report to set the tone for this, and could you go, please, to his second report at 7(b) in C3 at page 31? Can we first look at paragraph 75? (After a pause) Professor David says:
“Indeed it seems to me particularly important that correspondence between clinicians that voices child protection concerns should most assiduously have been placed in the patient’s medical records. It is an important general principle that this kind of information should be shared between professionals, and one would want any clinician who looked at the hospital records of a child to be fully informed about child protection concerns.”
I ask you please, Dr Southall, what, in that paragraph, do you find objectionable?
A I do not, but I include the special case files as part of the patient’s medical records; so I do not find it objectionable at all.
Q But the problem is, and it is a recurring problem, that you kept out of the hospital medical records the child protection concerns?
A I have already said that the special case files were part of the hospital medical records, therefore by keeping them there I kept them in the hospital medical records.
Q But they were not disclosed or disclosable?
A They were disclosable if people, the right people, need to know for the right reasons.
Q You made a deliberate policy to keep them away. What I am failing to understand is this issue: If you keep them in a separate place under lock and key, how is it that other following clinicians can be aware and be fully informed about child protection concerns?
A We are going back over it all again, because basically the children we are talking about, the child protection issues, comprising 1 per cent of these special case files, say, are tertiary referrals. They are coming to our hospital from another hospital and from a GP and a community, sometimes long distances. The real aim behind keeping child protection records separately is to protect confidentiality issues and safety issues. We have been through all this already.
Q Can I just look and see how consistent you have been in your policy in relation to this matter, which you say is so important that you should keep these matters out of the main hospital records. Can I ask you, please, to look at a bundle of documents which is going to be in a file which is going to be given to you and to the Panel members now? I will explain, when you have it, what it is. (Same handed)
THE CHAIRMAN: Is this going to be given to the Panel?
MR TYSON: Yes, it is.
THE CHAIRMAN: C16.
MR TYSON: (To the witness) Can we open up this file and look at the index please, doctor? This is from the hospital medical records. All of the clinical correspondence contained in the hospital medical records has been reproduced in relation to the children there placed.
A Yes, fine.
Q Culled from the original medical records.
A The Brompton ones? Either Brompton or Stoke, is it?
Q Brompton or Stoke.
A Yes, fine.
Q The section in the original hospital medical records relating to those children has been extracted and put into these sections.
A Yes, fine.
MR COONAN: I just wonder whether you could indicate in the index which medical records they emanate from since this is new material.
MR TYSON: Yes. I thought it was self-evident, but if my learned friend needs it for the record I will quite happily put it on the record.
MR COONAN: Speaking entirely for my part it was not self-evident to me and I would just like the clarification.
MR TYSON: In relation to Child A this is the clinical correspondence from the child’s medical records at the Royal Brompton.
THE WITNESS: Can I write on mine, or should I not?
MR TYSON: You should not.
THE WITNESS: Should not, right.
MR TYSON: In relation to Child B it is the clinical correspondence from the hospital medical records relating to Child B at North Staffs, the North Staffordshire. In relation to Child D it is the clinical correspondence from the medical records held on this child at the North Staffordshire Hospital. In relation to Child H it is the clinical correspondence from the medical records relating to this child at the Royal Brompton Hospital. Item 5, which we will come to in another context, is the clinical correspondence from the medical records held in relation to that child at the Great Ormond Street Hospital.
(To the witness) Look, please, first, in relation to Child B under tab 2. You will recall in relation to this child that you had made a diagnosis of Munchausen when the child was at your hospital in September 1993?
A Child A we are looking at? Sorry.
Q No, Child B under tab 2.
A I am sorry, Child B. Yes, that is right. Yes, that is correct.
Q You made your diagnosis at the hospital in relation to that child?
A Yes.
Q In September 1993?
A Yes.
Q You told Mr Coonan yesterday that thereafter, of course, everything connected with this child relating to child protection concerns should be in the SC file?
A Yes.
Q Could you look, please, at page 10? The photocopying seems not to have been perfect, but it is the second document in.
A I have it.
Q This is a letter, is it not, from you to Dr Lewis, one of the paediatricians involved in this case, relating to child protection concerns because he was unhappy that he had not been invited by you to the strategy meeting that you had held?
A Yes, there was a mistake there.
Q It deals with aspects of child protection in that he was putting to you that in certain circumstances doctors could be agents provocateur in relation to this matter.
A Yes, he was.
Q This, according to your test that you gave to the Panel yesterday, this letter should be in the SC file and not in the medical records.
A Yes.
Q But it is in the medical records.
A It is in both, I think. Is it in both?
Q I cannot assist you with that, but you said that you had a policy of dividing the two up.
A Yes.
Q I am just looking at the consistency of your policy.
A I understand what you are doing. I do understand.
Q My overall submission to you is that there is no overall policy. It is entirely random where anything ends up.
A That is not correct. There is a policy but I accept that this obviously was in the medical records.
Q And according to your test, should not have been.
A No. There is a slight issue over this. I am not defending it but I am just saying it depends where the letter comes from and is going to. But this was a letter from me and there was a policy for it to go in the special case file, especially when it contains these issues.
I agree with you. So if it is in the hospital records, I do not know how it got there.
Q It should not have been there, should it?
A No.
Q Then if we go over to page 12, this is a letter from you to Dr Issler.
A Yes.
Q It encloses a medical report on this patient, which you are doubtless familiar with, but it actually mentions on the second page in – page 14 in fact –
“I have little doubt that Child B’s case is one of Munchausen’s syndrome by proxy”.
A Yes.
Q Again, according to your policy, this should not have been in the main hospital records should it?
A It should have been in the special case file.
Q And not in the main hospital records.
A Not according to my policy, no.
Q Then the last one in here is a document we will come to in another context later. But here we have from the original hospital records what your clinical impression of this child is.
A This is the discharge recording result, which we agree--
MRS LLOYD: I am sorry, I did not hear the last question.
THE CHAIRMAN: We have difficulty with external noise, which unfortunately we do not have much control over. Perhaps the answers could be given when the noise is not going on.
MR TYSON: Dealing with the last item under Tab 2 in this bundle, we see there what your clinical impression is of the diagnosis.
A Yes.
Q Is that not one of the problems that you have in your allegedly rigid criteria where child protection goes into one file and anything that is non-child protection goes into another file? Is not the basic problem that you have that in a significant amount of cases you have been referred precisely because there are child protection concerns?
A That is true. In this case there were child protection concerns.
Q And you were referred because there were child protection concerns in this case.
A A combination of child protection concerns and apnoea, because the apnoea was the main concern, yes.
Q If you are referred with child protection concerns, according to your policy as
I understand it, then everything, even the original arrival of this child, should be in a separate file.
A It cannot work like that.
Q Exactly.
A It is a grey area. What has happened here is that at the time of discharge, or around then, it was agreed, as you know, that the recording result goes in to the hospital main file, which was done. On that is written the diagnosis, which is the child protection diagnosis. The summary which is also around the same time – it is three days later but it is a discharge summary effectively – which is the preceding letter and report has also gone into the medical record. It is at the point of discharge, I think I was trying to point out yesterday, that the policy was that thereafter, after the diagnosis had been made and the discharge of the child from our unit, all ongoing continuing correspondence could go into the special case file and not the hospital file. So the one thing that does not fit with that is the first letter to Dr Lewis. The other two would fit because it is at the time of discharge and thereafter, as Professor David put it, there would not be any danger of the mother finding this in the medical records, would there, because the child had just been discharged? Whereas if you were earlier in the process, there is some problem.
Q I do not see the point you are trying to make – it may well be me – because you are saying that as soon as there are child protection concerns, the matter goes into the SC file.
A I think I said that as soon as the child has had a diagnosis made of child protection, then the child leaves our unit because we had the child in our unit for clinical purposes, to find out what the diagnosis was. We are not a child protection management system. We are a physiological clinical, physiological monitoring and recording system. We made the decision. The child is discharged. Thereafter any communication the policy was to put it in the special case file, such as case conference records, etc.
Q And clinical correspondence between paediatricians.
A Yes.
Q You see here is clinical correspondence between paediatricians. Here you are saying to the paediatrician that you have little doubt that this child’s case is one of Munchausen’s syndrome by proxy. You go on to say,
“I have been asked by Dr Issler to give advice on how best his condition can be managed. I feel the next and most important step is to arrange for the child’s separation from the mother”.
A That is the discharge summary, yes, the discharge summary. I accept that the letter to Dr Lewis was taken a month later and that should have been in the special case file. I do not know how it got into the hospital file. I think it is in both, but anyway. This one, the discharge letter and the discharge hospital recording form are both in the hospital records. It is a closure of the event. It is a closure of the admission.
Q What I am failing to understand is why, if you have got this policy that as soon as you mention child protection problems they should go into another file, these are not. These are kept on the hospital medical records of the child. But we will move on to another child. Can we go, please, to Child A? This is Tab 1 and this is all the clinical correspondence relating to this file in this tab. Can I take you, please, to page 39? Actually I will not take you to that because it appears that the second page of that report is missing.
A There are quite a few missing, actually. It is a report. It is a summary.
Q Then at page 40 we have reference to decisions made at a case conference.
A Yes.
Q Why is that in the main clinical records relating to this child?
A I would not have put that there. That is probably put there by the hospital social worker.
Q It should not have been, should it, in the main clinical records, according to your rules, in the hospital file?
A My rules applied only to my team, not to the hospital social work department. So
I cannot govern that.
Q This is not taken from the social work file. This is taken from the clinical correspondence file in the Royal Brompton records.
A I know, but if you look at it, it says,
“Confidential. Not to be photocopied”,
at the top, and then it says, “Principal Officer”, Kensington and Chelsea. I suspect, because
I have seen others like this, that the social worker at the Royal Brompton Hospital put this into the main medical file, but I did not. It is not something that I filed.
Q And it should not be there.
A I cannot decide what other people put in the main hospital medical file. I can only decide what we put in. Sometimes it is a grey area. We could have a policy but mistakes – not mistakes. These are not errors. It is a grey area. It is not an absolute black and white policy. I would not want you to think that. But this I did not put in the notes.
Q You say it is a grey area and not a black and white policy. It is a matter for the Panel of course, but that is not how it came over to me yesterday. Can we go over to the next page, page 41? This is a letter from one consultant paediatrician in Cornwall to a consultant in child psychiatry again in Cornwall, to which you have been copied.
A Yes.
Q It acutely concerns child protection matters, does it not?
A Yes.
Q The handwriting on the top right hand of page 41 is in your handwriting.
A That is my handwriting.
Q So you have not followed your own policy, have you, by saying that this should go into the main hospital records?
A I agree. I have not.
Q That shows lack of consistency with the policy.
A Yes.
Q By your own hand.
A This is by my own hand, yes.
THE CHAIRMAN: Can I inquire whether the external noise is causing a distraction so great that we should adjourn temporarily?
MR COONAN: I was about to rise, Madam. It is really a matter for the Panel and also for Dr Southall, because I am very concerned about the external noise and obviously the Panel have to absorb what Dr Southall is saying. If there are distractions, being human, it would be unfortunate. So I am really concerned about the quality of the receipt of his evidence.
MR TYSON: I share my learned friend’s concerns and I wonder whether we could rise for a short time to see if we can get an indication from the workers as to how long they anticipate working, and whether we can make arrangements when we have found out the basic facts.
THE CHAIRMAN: That is a good suggestion. We will rise for a short time and see if we can get any useful information that would help us make a decision on this matter.
(The Panel adjourned for a short time)
THE CHAIRMAN: Mr Tyson, it seems events have been conspiring to prevent you continuing your cross-examination. I trust this will be the last.
MR TYSON: We have had three glitches so far.
THE CHAIRMAN: We are told that the workmen have now disappeared.
MR TYSON: Thank you. Dr Southall, we were looking at the Brompton medical records relating to Child A and I had taken you to a number of documents in there. Can I take you to the last document I need to refer you to, at page 53? Just so we are clear what 53 is, we can see at the top of page 53 it gives Child A’s address and says,
“Information obtained from parents and Team Leader of [district hospital there mentioned] and Great Ormond Street”.
A Yes. If you go to page 52 that might be the cover for it. “VM” is the social worker. Again, just to explain this, I think that some of these documents were put in there by other people. I have no control over that. This one, which you drew attention to just before the break, in my handwriting, it is my decision. So it is incorrect and it is inconsistent. But if you look at the size of that file compared with the size of the special case file on Child A, you will see that although it is inconsistent, it is not grossly inconsistent. The number of pages in the special case file are enormous compared with this, but I accept it is inconsistent.
Q This is an extremely sensitive document, is it not, giving background of Child A’s parents in not wholly flattering terms?
A You are talking now about the last document?
Q I am talking about document 53 to the end.
A That is a social services document that was not put in there by me. I think it was put in there by social services. It is something that is very confidential, as you say, with not at all ideal material in it. It is there. I think we have to distinguish between this time, which must have been after discharge, and issues during the admission. I think – I do not know if I can get this across – during admission there are issues of danger in disclosure of confidential material, during admission. After admission, if the child is not going to come back, as was the case, then it is not quite so important, but it is still a confidential issue. So I cannot be black and white about this policy. I know you want me to be, but I cannot be. It is grey.
Q It is grey, and my central point that I keep putting to you is that there was not really a policy. It was purely random as to whether documents ended up in the medical file or not.
A That is not so. I have already said that this letter with my name on it, inappropriately put into the hospital files, comprises a minute proportion of what was in the special cases file about child protection. It is not random.
Q The problem is if, in the medical file to your knowledge, social service material appears in there, then the cat is out of the bag, is it not, and why are not all the other documents in the hospital main records if social service type records are appearing in there? It makes no sense, does it?
A I am just going to try to explain. This cat out of the bag issue raised by
Professor David and now by you has some merit to it in the sense that the danger during admission is if the parents see something. The parents could see something that would alert them to the fact that child protection issues are under scrutiny and it could be harmful to the child. After discharge from the hospital it is not a danger issue any more, so it is not a big issue whether they are in the hospital notes or the special cases file notes, from my point of view, from a danger point of view.
Q I hope the Panel noted that answer, that it is not a big issue which file they are in, because you made it clear yesterday that there was a firm policy that there should be separation even after discharge.
A Not a firm policy, a policy. I accept the policy.
Q We will move on to another child, Child H. You will see the notes relating to Child H at Tab 4. You will recall that Child H first came to you pursuant to a referral letter in March 1989.
A Yes.
Q Can we look at page 17 for a moment? That of itself raises child protection issues, does it not, in view of the manuscript wording?
A It does and of course you heard from Mrs H that she saw it and raised it with
Dr Samuels, that is why it is a bit worrying that it was there, but it was there.
Q At page 23 we see a letter with which the Panel is familiar.
A Yes.
Q This again is a letter in the main hospital notes which reflects child protection issues, amongst others.
A Yes, after discharge though, which is an important point.
Q Again, you were making the point yesterday when you were turned to all the clinical correspondence in the Child D case by my learned friend, Mr Coonan, that one of the reasons why all that correspondence was not in the main hospital notes was that it was post discharge. You cannot use it for both. You cannot use it as an excuse for both, can you?
A You are right, but that is not how I am using it. This was a closure document. This was the end of this child’s admission. I had to write something down. It was written. It closed the case. The child had left the hospital. Thereafter you have seen the size of the special case file, there is a pile of material coming in on child protection issues. It is massive this H file. What could have happened is, if my policy had not been there, all this stuff would have had to go into the hospital file and any time a document like this crosses the hospital system into the filing system, all manner of things can happen to it. It can be in this file, it can get lost, it can be seen by inappropriate people. I accept that it is not a perfect system we have, but it is what we were trying to do the best we could with. It is not perfect.
Q I will not make the point again. I say there is no system. Can we look at page 25, please?
A Yes.
Q This is a letter from the social worker to H’s family solicitors giving information, child protection information, talking about a multi-disciplinary information and sharing meeting called in view of your concerns because it was your view that the child’s parents were pursuing a rare and life-threatening illness on the child’s behalf that does not exist. That is pure child protection, is it not?
A Yes.
Q This is your handwriting, is it not?
A Yes.
Q You have said that it has to go into the hospital records.
A Yes.
Q So you have no excuse for that decision, have you, according to your policy?
A No excuse, no. I am not trying to excuse it. I am saying it was not black and white.
I am not trying to excuse it. You are right and you are picking up on it, and that is fair enough.
Q Then if we turn to page 27 through to page 31, this is a report by you relating to child protection matters some 14 months after the discharge of this child.
A Yes.
Q It should not be in, according to your version of the policy, the main hospital notes, should it?
A No.
Q If we turn to page 32, we see a letter from you to the local authority again relating to child protection matters and the case conference minutes.
A Yes.
Q Again, that should not have been in the main hospital records, should it?
A No, it should have been in the special cases file.
Q That is another inconsistency, is it not?
A Yes, it is.
Q If we turn to page 33, similarly a letter in September 1991, again from you to the local authority, again relating to child protection matters, again another inconsistency, would you accept?
A Page 33, yes.
Q It should not be in the main hospital file.
A No. According to the policy it should be in the special cases file.
Q Pages 34 and 35, one only has to read the heading,
“Recommendations following the conference held on the H family”,
to see that this is a record of the decisions of a case conference.
A Yes.
Q It should not be in there.
A No.
Q An inconsistency.
A The inconsistency, we have got to be careful; there are some that are definitely mine, there is no question about it, I have got my name on it, I have put “Hospital and SC File” or whatever. I do not know who filed these in the hospital notes. It is possible that these case conference minutes did not come via my office. They could have come straight into the notes from social services. So whilst I accept that there are inconsistencies here in the policy,
I completely accept those which have got my handwriting on, I do not know who put the others in there, if you see what I mean. With Child A there were two consultants, there was Dr Warner and myself, and it is possible that some of them were him.
Q Again, you were the consultant involved in this hospital with this child.
A With H?
Q Yes.
A Yes, definitely.
Q If you are saying that the hospital records, the clinical records, are wide enough, because this all comes from the clinical correspondence section---
A Oh, I know that.
Q ---and this is in the clinical correspondence section of these notes, you must have been aware that this kind of material was coming into the clinical correspondence.
A Ah, was I though? How could I be aware? Why would I look again at the hospital medical records after they had been discharged? I do not know that I was aware. I would look again at the special cases file notes of course whenever I needed to look something up, but I would not go back and dig out the hospital medical records, and I think there was some evidence that they disappeared for a while as well---
Q Not evidence that we have heard. Here are matters with which you were involved, because you were an attendee at the case conference in question.
A On absolutely, I am not denying that. What I am saying is that I am responsible for putting into the hospital medical file those which have got my handwriting on, personally
I cannot get away from that at all, but I do not know who filed these. For all we know, the hospital social worker filed them in the medical records, or gave them to the medical records department to file. I cannot say whether I did it or not.
Q The fact remains that these hospital medical records contain a large number of confidential documents which, according to your policy, should not be there?
A I am not saying they should not be there - hang on. After discharge, my policy was that anything that came through me should go into the special case file, anything that came through my department should go. The fact that there are items in here which should not be here according to that policy does not mean that everybody followed that policy. Our department would hopefully follow it. I cannot be sure either that they always did.
Q If your policy was, as the lead clinician, that sensitive case conference child protection matters should be put in a separate file, why did you not issue any directive, which could be found on the main hospital records, to that effect? You see, I have to suggest to you that in fact again there was no such policy, and, secondly, even if there was, it was an entirely ineffective policy, because the danger which you were seeking to avoid was to have sensitive child protection matters appearing in the hospital records.
A This is complicated. The danger is whilst the child is in the hospital. That is the danger period. Afterwards it is not so much danger as a matter of patient confidentiality.
I mean, the size of Child H’s special case file, you have seen it, it is huge. Most stuff obviously did go in. Now, sometimes I allowed material, wrongly in my view, looking at this, with my name on to go into both; it does not fit the policy, but some of this material was put in the hospital medical records not by me, and I would not even necessarily know they had gone in the medical records. I do not go checking the medical records on somebody being discharged on a regular basis.
Q What I am saying to you is that you should have ensured, if this policy was a policy as you assert, you should have ensured that everyone knew what the policy was, so that the danger which you are saying, that confidential child protection matters should not be, as you put it, widely available.
A I believe there was a policy – well, I am sure there was a policy, it was my policy. How rigidly it was enforced, I accept I did not rigidly enforce it and I did not rigidly enforce it even on myself at times, I accept that, but there was an intention of trying to keep the child protection material in the special case file after discharge particularly.
Q You can see where I am coming from, can you not, is that I positively assert through Professor David that child protection matters should be in the main hospital records?
A Yes. I respect his/your opinion, but I think there is room for opinions here, because there was no strong guidance coming from government in 1986 or 1992 about this. We all did our best. I accept that it is not perfect, and it is grey, it is not black and white.
Q Can we just move on through this file just so I can identify the documents. We have been looking at documents 34 to 35, and you accepted from me that that should not be, according to your policy, in the main hospital records.
A Yes.
Q Can we go now to page 36 and 37, which are some more cases conference minutes, and again, according to your policy, these should not be in the main hospital records, is that right?
A Yes, same principle.
Q Again, a further lot of case conference minutes starting at page 38 and going through to page 47, again should not, according to your policy, be in the main hospital records?
A Correct.
Q Then turning to page 48, again some considerable time after discharge, over a year after discharge, we have a fax sent to you personally, saying “Press report as requested”, and if we turn over we see the press report relating to Mrs H and her difficulties as she saw them, if I can put it that way.
A Yes.
Q Again, this should not, according to your policy, be in the main hospital records, should it?
A It should not and I did not put it there.
Q It was addressed to you.
A Yes, but that does not mean I put it there.
Q Well, what other explanation is there?
A Well, somebody else put it there. I mean, it was not me personally. That does not mean that I am not responsible for this, and I accept what I have just told you, that the policy was not adhered to in a hundred per cent way.
Q You cannot use, as it were, the social services excuse, that they must have put it in here.
A No, no, of course not.
Q That is the only point I wish to raise in relation to consistency or lack of consistency. Can we move on, please, to another area, and this is a related area, because I just ask you to accept, and I can show you the documents, if necessary, but I was wondering if we can just deal with this shortly, that in terms of the correspondence that we are dealing with - for instance, in relation to Child D, can we just look, just to remind you what I am talking about, if you look at the heads of charge and at Appendix One, and you will see that a considerable amount of the items in relation to Child D relate to clinical correspondence.
A Child D, yes, definitely.
Q You see, the point I have just been putting to you is that the policy was not followed by you within the hospital consistently. The second, and different, aspect which I am going to put to you is that you are aware, as both your solicitors and my solicitors have accumulated in the course of preparation of this case a huge amount of medical records from a number of hospitals.
A Yes.
Q In relation to items, we have been able to follow correspondence through, so if a letter was written by you to, say, Professor Warner at Southampton, then one may also see how Southampton dealt with it and whether it is in his file or not.
A Yes.
Q By way of a cross-check, can I just see if you will accept from me, and if necessary
I will have to go to the original material, but, say, 1(a), the letter from Professor Warner, which you filed in a separate file, he in fact filed it in his own clinical notes.
A Fine, yes.
Q (b), which is a letter from Professor Strobel at Great Ormond Street, that is filed by him at Great Ormond Street in the Great Ormond Street hospital records.
A I accept this. You do not need to check.
Q For instance, ©, the letter from the GP, that is filed within the GP’s notes.
A Yes, fine, I accept that.
Q Basically, there is a virtually complete (I am not saying it is entirely complete) cross-check that in the clinical correspondence section of Child D it is invariably that the sender or the recipient would have filed the document in the main hospital records.
MR COONAN: Well, before the witness answers that, my learned friend says “invariably”. If there are cases that my learned friend is aware of in Appendix One where that practice is not demonstrated on the records, then I would invite my learned friend to identify that, because the word “invariably” may mean many things.
MR TYSON: Sorry. In the interests of speed I was trying to deal with the matter carefully, but I will particularise, because my learned friend has made a legitimate request, and I will particularise. The letter at 1(i) from Professor Warner was filed by Professor Warner.
A It was.
Q At 1(j) the letter from Professor Strobel was filed by Professor Strobel. Turning to 2, the letter from Professor Strobel to Dr Rodgers, of which you were copied in, that was filed both by Strobel and by the GP in their main records. Looking at 2(b) the letter from Strobel to Rodgers was filed both by Professor Strobel at Great Ormond Street and by the GP. The letter at 2© from Whiting to Professor Strobel was filed by Professor Strobel and by the GP. The letter (d) from Strobel to Dr Whiting was filed by Professor Strobel at Great Ormond Street. The letter from Whiting to Warner at (e), with a number of recipients of which you were one, also Great Ormond Street was one, it was filed by Great Ormond Street.
A Professor Warner was not.
Q Sorry?
A What about Professor Warner?
Q It is not filed by Professor Warner.
A Well, do you know why? Sorry, I should not ask you questions.
Q Exactly, you should not ask me questions. I am putting to you all this correspondence at my learned friend’s request, and saying where it was filed. The letter at (f) from Professor Warner to Dr Smart was filed by Dr Smart and filed by Great Ormond Street. The letter at (g) from Professor Warner to the local authority was filed by Professor Warner and by the local authority and by Great Ormond Street. The letter at (h) from Professor Warner to
Dr Smart was filed by Professor Warner and filed by the GP and filed by Dr Whiting, as was (g). The letter at (i) from Professor Warner to Dr Smart was filed by Professor Warner and filed by the GP and filed by Great Ormond Street. The letter from Professor Warner to
Dr Smart at (j) was filed by Professor Warner, filed by the GP and filed by Great Ormond Street. The letter at (k), from Professor Warner to Dr Smart, that was filed by Professor Warner, filed by the GP and filed by Great Ormond Street. The outgoing letter to Professor Warner was filed by the GP. Similarly (b) your letter to Professor Warner was filed by the GP. Your letter to the local authority was filed by the GP, and (d) your letter to the local authority was filed by the local authority. Your letter (f) to Mr Haverson was filed by
Great Ormond Street. Your letter to Mr Evans at (g) was filed by the local authority, filed by Great Ormond Street and filed by the hospital where, amongst other hospitals, Dr Whiting was based. The letter at (h) was filed by Great Ormond Street and filed by the hospital where, amongst others, Dr Whiting was based. So in each case Great Ormond Street would file these matters in the main clinical records, and, apart from about two occasions, I think, that Professor Warner at Southampton would file these in his main clinical notes.
A So just on that, I mean, it is clear that all this material is available in the clinically relevant caring doctor’s records. So I just come back to the claim that this was doing harm to children by us having them. It is not. It is there available.
Q I am not saying it is doing harm to children as a main thrust of this case. My thrust of this case is that you were keeping records which were not in the main hospital records which I positively assert should have been in the main hospital records, and you deliberately kept them out of the main hospital records. That is the accusation.
A Okay. Then I accept that opinion, your opinion and Professor David’s, is completely reasonable, but we had a different one which I do not think is harmful, and that is my concern, that any child was harmed by this approach.
Q I follow that up with a supplementary, just so you are clear, that if and insofar as you did have a policy, it was not followed, in that there are a number of records, as we have just been through, within your own department which, on your own evidence, should not have been there.
A I accept that – not consistent.
Q Can we move on, please, to some individual items within Appendix One, and can we go to Child A at Appendix One, and this relates to the MRI report.
A Yes.
Q Let us see if we can just agree some basics about this. Do you accept that the MRI report in the SC file is the original?
A I do.
Q Do you accept that it is a medical record?
A Yes.
Q Do you accept that that document should have been in the main hospital medical records?
A I do accept that.
Q Do you accept that the report was not in the medical records in that form until a photocopy was sent by you, in the way that we have seen, in about August 1995?
A I do not completely accept all that, because there was copy available in the hospital records at the Brompton. We do not know whether there was an original inside the X-ray folder, because I think that went, did it not – it was destroyed or something happened to it?
Q There is no evidence, and on this I rely on Mr Chapman amongst others, there is no evidence that the report, in the form that we have it in the SC file, was at the Brompton from the moment it was taken until the moment you gave a photocopy of it back to the Brompton in August 1995?
A There is no evidence, no, but it is possible it was there. We just do not know, that is the trouble.
Q You have seen the letter written by Mr Chapman to indicate that he did a numerous amount of searches and that appears to be the case.
A I accept this. This MRI report should not have been in the special case file. I have said that all along. It should have been in the main hospital medical record. What I am saying is I did not put it there, nor did I direct that it should be put there, and I do not know how it got there. What I do know though is that these medical records, both the special case and the hospital medical records, have been the subject of inquiries, and we have already seen that material has been put into the special case file that has nothing to do with either the medical records or the special case files. I do not know, it is possible, I am not saying it happened because I do not know, but it is possible that this mix up in where it should be was something to do with that. It is certainly wrong and I accept that it should not be there, it should be in the medical records. There is no difference between us on this.
Q I need you to accept this final point, that there came a time – and perhaps we ought to just look at the letter so that you can see the point I am making. Can you look, please, at file C2, section 3(b) at page 22. Are you there?
A I am sorry, lost now. I have got section (b) for Bertie.
Q Yes, (b) for Bravo, page 22.
A 23?
Q Page 22.
THE CHAIRMAN: I appreciate your difficulties, Mr Tyson, but I think we do have difficulties hearing you with your microphone there and facing the other way. (After a pause) Thank you for trying.
MR TYSON: (To the witness) You see this is a letter from you to Mr Chapman?
A Yes.
Q Dated 15 August 1995, where you indicate to him:
“We always kept our own medical records for all the special cases that we dealt with at the Brompton Hospital. I have arranged for these to be photocopied and enclosed with this letter.”
A Yes.
Q We heard from Mr Chapman that he made a list of all the matters that you did enclose with that letter and we have seen that under item 8 is the MRI report?
A Yes.
Q Thus it was that I put to you that until August 1995 the records at Brompton did not hold either an original or a copy, but in August 1995 they got a copy?
A Yes, indeed, from me.
Q From you. Is there any particular reason why you did not feel able to return the original at that time?
A No, no reason.
Q Is there any particular reason why there was no record of the report in the Brompton until August 1995?
A There should have been. It should have been there, yes.
Q Do you accept that this was a report that was particularly requested by Mrs A for a number of years?
A Yes.
Q Could you look at tab 3(a)? You see at page 1 of that a particular request for that MRI report made as long ago as August 1987?
A Yes, I do see that.
Q And that there was a further request made in 1991 which I will give you the reference for from the SC file, and I can take you to it if necessary, but perhaps you can accept it from me. For the sake of the record I am looking at C5, page 32. There was a request for all the medical records form a firm of solicitors called Donne Mileham & Haddock in March 1991?
A Yes, I accept that.
Q Actually, in order to be fair to you, I need to take you to C5 because I do not want to be accused of making any bad points. C5 at page 32. (After a pause) You see the request at page 32, the general request?
A Yes, I do.
Q Can I take you please to page 25. Do you see that is an internal memo to, amongst others, you, relating to this letter from the solicitors, and the memo asked you to preserve all the notes in their entirety? It is an internal memo seeking for a preservation of these notes as a result of the letter?
A Yes, is that sent to me?
Q It has got your ticking and this is your handwriting?
A That is different. That means I received a copy.
Q Yes, I said you were a recipient of the memo.
A Okay, fine. It was not sent to me.
Q No.
A No, fine. Sure.
Q We can all see who it was sent to, but you were clearly a recipient of it?
A Yes.
Q Because this is your manuscript at the bottom, is it not?
A It is mine, yes.
Q You have ticked that you have received it?
A Yes.
Q You have indicated that this request should include the hospital and the SC notes?
A It should go to it, it should go to both, yes.
Q It is right, is it not, that the SC notes were not disclosed, only the hospital records were disclosed?
A To who? Sorry.
Q To the family solicitors?
A That is a different issue. Later you mean, by Mr Chapman?
Q Are you authorising here – and this is the question – disclosure of the SC file to the parents?
A Where is that? Sorry. Where?
Q At page 25. Are you authorising disclosure of the SC file?
A No, I do not think I am. I think that just means this piece of paper should go in the hospital and SC files. I cannot be sure of that, but ---
Q I do not want to make a bad point.
A No, no, I know what you are trying to say, but I do not think I can use this to say that
I was trying to disclose both, because I do not think that is the case. It is not the truth. I just do not know what it means, but it looks like it should be filed in both – that piece of paper.
Q It is clear that the MRI scan was not in fact disclosed at that time, is it, because we have a further letter from a further set of solicitors, going back to C2, at 3(a). At the top right-hand corner, certainly in mine, a (d) on the top. Do you have it, Dr Southall?
A I have got it, yes.
THE CHAIRMAN: I am sorry, we are in 3(a)?
MR TYSON: 3(a) at (d), and there is a (d) in the top right-hand corner. It is about six pages in. (After a pause)
A Could I just say something about this MRI?
Q We need to see that we have all got it. That is the pause.
A Yes, sorry. That is fine.
Q We can see that this is a request from solicitors, Thomson Snell & Passmore, to the Brompton solicitors, in particular requesting for the MRI report at item 2?
A Yes, and can I just say that is what I was going to come back to. I earlier made the point that there had been a lot of inquiries which could have mixed up hospital and medical record files. That does not apply to this because these inquiries were later and I would not want to mislead you. These inquiries did not start until really 1999, so therefore that is not an excuse that can apply to this mis-file. I just want to make that clear.
Q You are being very fair. You cannot use, as it were, inquires into the files in relation to either Child A or Child H, can you, because they were both Brompton children and the inquiries which were dealt with in North Staffordshire did not involve Brompton children?
A They might have done because there were complaints being made to the North Staffs Hospital by the parents. It is not for that reason. The reason that this “earlier excuse” that
I raised does not apply is because it was in 1995 that I found, if you like, that it was in the wrong place and sent it to Mr Chapman, and that was before the inquiries. So this cannot be explained on that mechanism. It is not just because they were at the Brompton, if you see what I mean.
Q We have got a renewed request, which I say is the third request. There was one in 1987, there was one in 1991 and this is the third request for the MRI coming in 1994. So far it has taken, as it were, seven years of requests and still the MRI scan has not appeared?
A I did not have access to the hospital medical records in 1994 or 1995 after I had moved, so I would not have known, if you like, until I got Mr Chapman’s letter, that it was missing.
Q But you would have been aware of the 1987 request and the 1991 request? We have just been through those?
A Yes, I think we have been through those. Yes.
Q You were written to, I would say, on three occasions following this request by
Mr Chapman asking you for your, as it were, missing records, the records you had taken from the Brompton to North Staffs. Perhaps we can pick this up in the next section, which is section (b). You see this is a letter of 22 March?
A Page 6?
Q Page 6, indicating, over the page:
“The medical records contain only reports of the recordings and I enclose copies.
I have been informed that you may have some records in your possession at the University of Keele relating to the treatment and care of certain children in Royal Brompton Hospitall”,
and asking for, in that case, copies of the recordings arising out of that?
A Yes. Is that not ---? Sorry.
Q There was a further request.
A Before we leave that one, is not that a request for the recordings?
Q Yes, it is a request for the recordings.
A Not for the file, it is for the recordings, that is the tape recordings, is it not?
Q Yes.
A That is not a request for the ---
Q It would not be a request for the file because that is precisely my point, that
Mr Chapman was not aware that you had a file.
A Right, okay.
Q He was not aware of the existence of something called an SC file for another five years.
A But he was not asking for disclosure of the MRI or anything like that.
Q He would not know that you had had it, but he was giving you general requests for materials that you had, because we can go, for instance, to page 18. In July he was requesting, as put by your counsel to Mr Chapman, for all other documents, at the bottom of number one?
A Yes. Fine, yes.
Q Then he repeated that request for the third time in August, where again you just have to take it from me rather than refer to it. It is in the SC file, C5 at page 6.
A I am sorry, I rushed through page 18. I want to just be clear what you are saying on page 18. What was missing was, he thought, some notes, was there not, in the main medical records between the 16 and 29 January, and no other records between the two dates exist. He wants confirmation of that, does he not? Any records written between those dates. I thought he was referring probably to the medical records between those dates, because that is what was missing. He encloses a copy, does he not? “I enclose a copy of the medical case notes …” showing those missing ones. Then I wrote back in August.
Q Then you had another reminder about notes generally in the SC file at page 6 and 7 on 7 August. That is at C5, page 5, if you want to be taken to it.
A I will just have a look. Page 5, is it?
MR SIMANOWITZ: Can I have the reference?
MR TYSON: Yes, C5 at page 6, the letter of 7 August.
A He is saying, “I write therefore to ask if you have any separate notes in relation to …”.
Q Yes. The solicitors have asked if any notes were missing, and he is asking if you have any separate notes in relation to the treatment of this child at the Royal Brompton Hospital in your possession.
A Then I write back, do I not?
Q Yes, you have made an internal note to, doubtless your secretary, or words to that effect, “Can I have S/C file?”
A Then I write back.
Q Then we come back to the letter of August that I have taken you to.
A 15 August, yes. So I was not holding them back. It just takes time.
Q You were not volunteering them, were you?
A Sorry?
Q You were not volunteering the existence of the SC file to Mr Chapman, despite these three letters to him?
A On 15 August I am being completely open and saying, “There are the special case files.”
Q Can we move on to Child B? You see in Appendix One you are dealing with the referral letter from the hospital.
A Yes.
Q Can we just remind ourselves of your admission in relation to this document, which is at D9? It says,
“It is admitted that,
1. The Special cases file for Child B contains original hospital medical records as follows…Fax copy of a letter from Dr Khine to Dr Milner dated 2 September 1993”.
That is what we can refer to in shorthand as the Crawley referral letter.
A That is right.
Q You have also admitted, in paragraph 2,
“These documents are not contained elsewhere in the hospital medical records at North Staffordshire Hospital”.
You have also admitted,
“There is no original hard copy of the letter from Dr Khine to Dr Milner dated 2 September 1993 in the North Staffordshire hospital medical records”.
A Yes.
Q Could I ask you, please, to look at the original SC file in relation to this child? You produced, when you were giving evidence in chief, or showed us that there was a fax clip, if
I may put it that way, in the original file.
A Yes.
MR TYSON: Could I ask you, please, to look at a copy of these documents which are similar to, but not identical with, D14? (Document handed)
THE CHAIRMAN: This will be C17.
MR TYSON: Before we come to the actual content, can I ask you to confirm, because you have the original in front of you, that this is a photocopy of the original clip?
A Yes, it is.
Q So C17 is an accurate photocopy of everything in that fax clip in the original SC file relating to this child.
A Yes.
Q You can put away the original now and we can concentrate on C17. It appears, and
I would be grateful for your confirmation, that this fax clip in the original consists of three separate faxes. Can we pick it up, please, at the Crawley referral letter, which is three in? Are you there?
A I am there, yes.
Q If we look at the fax header at the top, we can see this is a fax of 2 September sent at about 4.29.
A Yes.
Q The second page – this is page two of whatever that fax was. Then page three of that fax is the next page.
A Yes.
Q If we see, looking at the typing on that page, he says,
“I have enclosed a copy of my letter on her last admission, Dr Lewis’s last Out-Patient Clinic letter and Dr Issler’s letter from Greenwich for your interest”.
A Yes.
Q We can pick up those letters if we look – I am afraid it is in the wrong order – in the clip. We can pick up the letter from Crawley to the GP at the last two documents in this clip. If you look at the top you will see pages 4 and 5.
A Yes, I have it.
Q That is pages 4 and 5 and that is the letter from the Crawley Hospital to the GP referred to there.
A Yes.
Q We can pick up the Dr Issler letter at pages 6 and 7. Look at the document entitled, “Paediatric Department, Greenwich Healthcare”. Do you see that?
A Yes.
Q The letter to the GP was numbers 4 and 5, and we can see looking in the top right hand corner that this letter is pages 6 and 7.
A Yes, it is.
Q We can pick up the earlier letter from Crawley to the GP, which is pages 8 and 9, and they are directly behind the original Crawley letter in the first place.
A Yes, they are.
Q Do you see in the top right hand corner, that letter, which has something on it which prevents us seeing the date because there is a “No” stuck on there, but it is numbered 8 and 9.
A Yes.
Q On 2 September 2003, between 4.29 and 4.34 there was this nine-page fax sent.
A Yes.
Q Which included the Crawley referral letter.
A Yes.
Q There was a second fax, was there not, which is the first two pages of this bundle C17, which was on the next day, 3 September?
A Yes.
Q That was a two-page fax from Crawley to your registrar.
A Yes.
Q Which merely enclosed the radiology report which we see on the next page.
A Yes.
Q It is in relation to the radiology report, and not in relation to the Crawley referral letter, that you have put that note that we have seen on the first page of C17.
A Yes, it is.
Q That instruction that it should go to the hospital was only an instruction in relation to the radiology report.
A Yes.
Q That instruction did not include an instructing relating to the Crawley referral letter because that had been received the day before.
A Yes.
Q I just want to clear up any misunderstanding, if misunderstanding there was, because
I think it was asserted when you gave evidence about this that this instruction on the top of C17 related to the Crawley referral letter.
A It was indicative of my view that these letters coming from Crawley Hospital should go to the ward, and that means the hospital file. It shows my thinking that this material should be in the hospital file. Clearly the bigger one, if you like, is the original referral letter and this is a follow-on and they had obviously forgotten to put it in the original fax. But it is indicative of my view that they should go in the hospital file.
Q Look at the third fax, please, which is on the third page. Again, you see that this is on 3 September at a time shortly after the receipt of the radiology report, the Atkinson Morley’s radiology report.
A Yes, it is two minutes, is it not?
Q Yes. Can I just put a proposition to you to see whether you accept it? Could this be a sending, or the resending of the radiology report from your Academic Department to the ward, which you faxed to the ward? Is that destination station the ward?
A You are right. That destination fax, 713946 is my Academic Department. The 718001, I do not know where that is. That is not --
Q So just for the benefit of the Panel, the first page of C17, that is a fax number with which you are not familiar, and are you saying that the third page, that number is your department?
A I am familiar with the third page fax. That was the Academic Department and still is. No change in that. But the first one, I am not sure where that is. It is not the Academic Department fax number.
Q A simple point I need to put to you in relation to this for the sake of fairness is: were you responsible for the fact that – sorry. You were ultimately responsible for the SC file, were you not?
A Yes.
Q The Crawley referral letter remained in the SC file and never made it into the hospital records.
A Am I responsible for that?
Q You are ultimately responsible for that error, are you not?
A Ultimately I am, of course. In this case there are some issues. I think we have an issue about the investigation by the hospital management of the inquiries and so on. This special cases file does contain material which should not be in it at all. You know what I am talking about.
Q I have seen the first few pages.
A Yes, you have seen it. But it is also clear from this that I wanted this in the hospital notes, the second thing.
Q You wanted the second one in, I accept that. It says so.
A All I can say is that it should have been in the hospital notes, the referral letter and all of this. I accept that and it is my responsibility if it was not.
Q Can we move on to Child D? This, the Panel and others may think, is a matter of more serious weight than the other two because there were other explanations in relation to Child A and Child B. In relation to Child D, we are looking here at the particular ones in the particulars set out in Appendix One. I need not trouble you with the matter of principle because we discussed the matter of principle earlier in relation to those. I just want to draw your attention to a number of documents within that, so could you take out the SC file relating to this child, which is at C6?
THE CHAIRMAN: Mr Tyson, before you begin on this, can I just check, are you happy to continue or do you think it would be a good idea to take a break?
MR TYSON: I am very happy to make up as much time as we possibly can, so I will continue for as long as possible because we have had a number of interruptions.
THE CHAIRMAN: Yes. I just wanted to be sure that Dr Southall---
MR TYSON: I am happy. We are witness dependent here. I am in Dr Southall’s hands.
A I am fine, madam, thank you. I am happy to carry on.
THE CHAIRMAN: For a little while.
A Yes, indeed.
THE CHAIRMAN: I mean, if we can go for another fifteen or twenty minutes, if you feel able to do that.
MR TYSON: You were taken through these by your counsel and I am not going to go through each and every one, and we have dealt with the principle. There are one or two
I would like to take you to, and the first in time is at 305. When you gave evidence about this the other day, this is classic paediatric correspondence, is it not, between two paediatricians who are involved in this child? It contains clinical information.
A I would not call it a classic letter because it is a very complicated situation.
Q Yes, but it is a letter that contains clinical information about this child.
A Yes.
Q Between two consultants.
A Yes.
Q When you were giving evidence about this, you said that the reason why this letter was not in the main clinical file was because one of the recipients was Mr Martin Banks, who was from the local authority.
A Also because it has got, you know, child protection concerns in it.
Q Yes.
A According to the policy, which we have been through, and after discharge from hospital three months earlier, that is why it is in this patient’s case file.
Q I will not deal with the issue of principle because I have already dealt with it. Can
I take you to another letter within that. Can you look, please, at 275, and can you keep a finger in 275 and, with your finger in that, go to 264, and, keeping your finger in that also, go to 229. Can you confirm that on 229 the words “To S/C file” is in your manuscript?
Q Can you confirm that the word “File” on 264 is in your manuscript?
A The word “File” is, yes.
Q That is all I ask.
A Yes.
Q Can you confirm that the word “File” at 275 is in your manuscript?
A Yes, it is.
Q There is a distinction between the two, is there not, that you are specific here in which matters are to go into the file and which matters are to go into the SC file?
A There is a difference between the two orders, if you like, in what is written, yes.
Q You knew the difference between an SC file and a file; you were very specific about it.
A Well, no, I am not. It could be that just on that particular day I did not feel like, or did not write “S/C”, but I meant it. That is all it can mean. It is not specific.
Q Because the ward clerk, or the clerk, following your instructions, has actually put in under “File” at page 275, and “File” at page 264, what the hospital file number of this child is.
A Oh yes. It is my secretary. It will not be the hospital ward clerk, it will be my secretary.
Q In your department.
A Yes.
Q So she, who is very used to your ways and your instructions – is that fair?
A Yes.
Q ---has interpreted when you put something called “File” as an indication that this is to go into the main hospital file as opposed to the SC file?
A No, I do not think that you can automatically assume that. Especially if we go to 275, where “S/C” is on the top right hand corner as well in manuscript. I cannot be sure what this means without talking to her, but I suspect what she did was she went straight on the hospital HISS system and picked up the hospital number. She may then have gone and looked in the special case file register, which is in the secure room – no, it was not actually; the register,
I do not think, was in the secure room – and then found it and put it in the SC file. I do not know, I mean, I am just speculating, but I do not think it means she put it in the hospital file. That is what I am saying.
Q Why, whenever the word “File” appears, and I can take you through a lot more of the correspondence if you want, there is an automatic reference to the hospital number?
A I do not know, but what we do know is these letters are not in the hospital file, are they?
Q No, but that is one of the mysteries about this, because you are instructing, I suggest, that they should go into the hospital file, and that is your instruction, your manuscript instruction is saying “Hospital file”.
A No, it is not. If it was saying “Hospital file” it would say “Hos” or something like that, because we have seen that elsewhere.
Q When you want it to go into the SC file you make it specific such as at 229?
A That is definitely specific.
Q Yes.
A I mean, there is all manner of possible explanations for this, which I cannot give you.
Q Just to follow it through, just very quickly, if you look at 226, for instance, you are specific.
A I am specific, yes.
Q Looking at 214, you are equally specific, I suggest---
A Non-specific I would say.
Q Yes, you are saying “File”, you are not saying “S/C File”.
A Correct.
Q I suggest to you that the reason why there is a difference is because there was in fact a difference, and that you are accepting broadly, when you say “File”, that this is important clinical correspondence that ought to be in the main hospital records?
A No, that is not correct. I suspect, thinking about it more, because this is important, the point you have brought it up, I had not noticed it before, it is something like I have put “File”, my secretary would get the hospital number and come and show it to me and I would say “S/C file”. That is probably what happened, but I cannot be sure.
Q Well, I suspect there is a more fundamental distinction, but I understand what you are saying, because you know when you want it in the SC file. We see in 214, do you see, there is a reference to the hospital number there, after the word “File”?
A Yes.
Q Then if we go, say, to 212, you said “S/C”.
A Yes.
Q Going back to 210 you said “S/C”.
A Yes.
Q Then we go to an important letter, clinical letter, at 208, we are back to “File” again.
A Yes, but no hospital number this time.
Q Again, not “S/C”, which you have managed to put when you think you want to put it in the SC. I mean, there is a clear system here. When you want something to be in the SC file you actually say so.
A I mean, I do not know how many thousands of pieces of paper I have through my desk every single day, so sometimes I might write “S/C file”, sometimes I might write “File”, if
I really wanted it to go to both it would be “Hospital and S/C”, if I wanted it in hospital it would be “Hospital”. I mean, I cannot explain it.
Q Well, I just suggest to you and put it to you formally that when you say “File” you mean hospital file and when you say “S/C file” you mean SC file.
A I do not think so. That is not what I interpret.
Q Because you are an intelligent man, Dr Southall, and when you want to put something in the SC file you actually say so and give instructions accordingly.
A I have already said I cannot accept your assertions because I do not know, but it is more likely, I think, that some days I would write “S/C file”, some days I would write “File”, if I wanted it to go in both I would write “S/C + Hospital”, if I wanted it to go in hospital
I would write “Hospital”. When I write “File”, I do not know, I cannot be sure.
Q Can we just go towards the beginning of this file, just to pick it up again at page 30, and we see your manuscript there is a request, “Can I have [the child’s] hospital [and] S/C file”.
A It is, yes.
Q Why would you be wanting both if, according to your system, since 1993 you had been putting all child protection matters in the SC file?
A Maybe it is something to do with the adrenalin, I do not know. I just cannot remember.
Q Is that not a further bolster to what I am saying to you, that you were intending to run two files at the same time here, putting important clinical correspondence in the hospital main file as well?
A No, I think that was the reason because I do not recall ever having that view.
Q Can I ask about page 25. This is a letter that contains important clinical information,
I think you would accept, setting out the views of Professor Warner about this child, and dealing entirely with clinical information concerning this child?
A Yes, it is. I agree with you it is a most important clinical letter that is being sent to the most important clinical person, that is the GP, plus Professor Strobel is also involved in the clinical care, and copied to me because of my previous involvement three years earlier.
Q Yes, and you have written “File”.
A Yes.
Q Again, the hospital file number is there put, and I put it to you that that was your intention, that this important clinical letter should go in the file.
A No. I still come back to the argument we had earlier – discussion, sorry.
Q There is nothing confidential, especially confidential, about this letter that it needed to be put under lock and key in your Portakabin in North Staffs as a---
THE CHAIRMAN: Excuse me, Mr Tyson, again we cannot hear the question; I think the combination of the outside noise and the fact that you are not speaking into the microphone. Could you repeat the question, and perhaps we could look for a time to have a break fairly shortly.
MR TYSON: I will just finish this letter. You have accepted this letter at page 25 contains important clinical information.
A I do.
Q Sent to the most important clinical person in relation to the child, i.e. the GP.
A I do.
Q I think you have also accepted that it does not contain any child protection matters.
A Yes, and I think I said in-chief that this could have been appropriately filed in the medical record as well.
Q I would suggest to you that you intended it to be filed in the child’s clinical records because you have written the word “file”?
A No, I have already been through all this. I do not think that is true.
Q Hence your loyal secretary has written what the file number is underneath?
A We have been through this.
Q Yes.
A There are several possible explanations.
Q There is one last point about that. There is nothing in particular confidential about this letter, is there?
A No.
Q Sorry?
A There is not, no.
Q That is shown by the fact that one of the recipients is in fact the mother herself?
A Actually now I have turned over the page there is an element of confidentiality in the sense that the child protection coordinator is listed, so perhaps I missed that, and I think I did in-chief did mention that that was on there. So, there is a confidential element to this, yes.
Q But surely not, because whose confidentiality are you seeking to protect when you sent this to the person with parental care of the child? The mother?
A Her confidentiality, because if this got into the wrong hands and people saw it, it would not be in her interests – the mother’s, I mean, not the child’s.
Q It is an important clinical letter and what you just said could happen in virtually every medical record concerning virtually any child. It contains confidential matters, the confidentiality of which has to be respected?
A Yes, I agree, and I have already indicated yesterday I think that I had some concerns about the hospital medical record system at that time not being adequately confidential. Anyway, we have been through that.
MR TYSON: I have reached my time, and your lunch.
THE CHAIRMAN: We will break now until five past two. I need to give you the normal warning, Dr Southall. I have not given it to you today, so I do need to remind you.
(Luncheon Adjournment)
MR TYSON: (To the witness) We are still on Appendix One, but we have reached Child H. Just to remind you, if you would like to look at Appendix One relating to this child, do you see we deal with it in three separate sections. There is one that is a collection of clinical data, then there is the manuscript entry and then there is various correspondence?
A Yes.
Q Dealing with the collection of clinical data, could you look, please, at C7 and go to page 25-31? This is a document which we can see on its face is one with your name at the top and it says it is:
“FORM TO BE USED FOR COLLECTION OF CLINICAL DATA ON ALL CASES (WITH OR WITHOUT DOWN’S SYNDROME) WHO ARE REFERRED FOR ASSESSMENT AND MANAGEMENT OF POSSIBLE AIRWAY OBSTRUCTION PROBLEMS
TO BE USED IN ADDITION TO (NOT A REPLACEMENT FOR) THE FORM WHICH IS USED FOR BASIC DATA COLLECTION ON ALL CLINICAL CASES.”
A Yes.
Q We can see that in relation to this particular child – and just for the benefit of the Panel we can just flick over to see what it is – it is essentially a questionnaire to be asked, presumably by one of your workers, of a mother, of various aspects of the child’s history and care?
A That is right, yes.
Q Is that a fair way of putting it?
A Yes, it is.
Q We can see that it is an extensive form which asks a lot of detailed questions about a child?
A Yes.
Q Let us see what we can agree. Do you agree that this is a medical record?
A I agree.
Q Do you agree that it is an original medical record not to be found in the hospital medical records?
A I agree.
Q Do you agree that it contains information on or about this child not available in the hospital clinical records?
A Yes.
Q Does it follow that as it contains important clinical information about a child not available elsewhere, it should in fact be in the main hospital records?
A That is where we part, because what had happened was we got a number of children who were presenting with airway obstruction-type problems, coming to us from all over the place, and we were realising that we could help identify these children, not only with recordings but also with the information that we were getting – the snoring and caving in of the chest during sleep, these kind of things. It was not widely known about in the medical community at the time so we thought the best way forward was to collect the data in more detail than would normally be collected by the junior doctor clerking the child in. That is why we prepared this form, so that we would have … Supposing we had 30 cases. We would be able to have some consistency about the history, because if you do not have this and you have 30 different doctors, or maybe 10 different doctors taking the same history in the ordinary way, you might miss out things that could be relevant to the publication of the data later that will help other doctors. That is the rationale.
Q It still related to the clinical care of this particular child at this particular admission, did it not?
A Well, that is where it is slightly debatable really. This is where we get into the distinction between research and clinical audit.
Q I am not going to go down that path with you.
A No, but you do not need this data to treat that child, but if you collect this data on 30 children and you had a consistent pattern, that might be helpful with future children. That is what it is about. It is that kind of formula.
Q But it is also helpful, surely, in this particular child if this particular child comes in with possible airway obstruction problems. You are focusing your questions to a child who has entered your clinic with possible airway obstruction problems and thus surely it is relevant to that child, just as it is relevant, you say, to your clinical audit later?
A It is relevant to both, but the reason it is collected is related to the clinical audit issue.
Q As it is relevant to both, surely, as there is a clinical element, its place is in the hospital records of this child?
A When I said we parted, what I am saying here now is that my opinion is it is most important that it is in the special case file, but there is no problem with it being copied and put in the medical file as well. There is no problem with it. But it is most important for the special case file. So I accept ---
Q You know what Professor David says about it. He said it should, because it has important clinical information, be in the patient’s notes.
A I understand his opinion.
Q Can we move to the next item please, which is at page 20, if we go back a few pages in this document. To look at this in perspective can I ask you please also to take out file C2 and can we look at C2 at 3(d)? (After a pause) I am sorry, the (d) section relating to this child is in C1, and I apologise for that, but you ought to keep C2 as well because we go straight into C2 as well on this bit. Just to look at section (d), this is the clerking admission when this child came for the second time to the hospital?
A Yes, it is.
Q Just by way of reference point, we can see that on the last day of the admission (page 10) the houseman or registrar who signed that note discussed the matter with Martin Samuels?
DR SARKAR: Madam Chairman, I do not think we have got the right reference.
MR TYSON: C1, tab 2(d).
MR MCFARLANE: The last page in the bundle.
MR TYSON: C1, tab 2(d). I will start again. You see that these are the clerking notes on admission on the 15th and on the last page, page 10, there is a discussion about the case by the house officer with your colleague, Dr Samuels?
A Yes.
Q That is all we need to look at in C1 because we then go on in the continuation in C2 at (e), which is the first document in C2. This is the nursing Cardex relating to this admission and we see that the child and parents were seen by Dr Samuels, p.m., on whatever day that is. I cannot read it.
A The 16th, I think.
Q The 16th, yes. Turning back to the SC file note, but perhaps for convenience it is at (h) within this C2. We have the same document again. When you responded through your solicitors formally about this matter you indicated that it would appear from the nursing Cardex and the like that this is a note of that meeting by the parents with Dr Samuels?
A I am not sure I did agree that. I accept it is a note by Dr Samuels. I accept that it is a summary of his views. Whether or not it occurred during the discussion with the parents is not something I know. Looking at it, it looks like a summary; in other words, he has gone and looked through everything and produced a summary, so I do not think I agreed that it was a contemporaneous of his meeting with the parents, otherwise it would have been in the hospital records, that is the bottom line, in the notes, following on from the SHO registrar. This is a different document.
Q Can we just look at the second to last page in C2 that you are looking at? Can you just go to the penultimate page of the whole bundle, page 19.
A Yes.
Q It has got 19 at the top? Do you see that?
A Yes, I have it.
Q It is the last page, page 19. The last page in the whole bundle.
A I have got it yes.
Q What you say is:
“This document looks like an original. It is a note made by Dr Samuels. I think it is the note made by Dr Samuels on 16 March when he reviewed [the child] prior to discharge …”.
A Yes. That is still not incompatible with what I have just said a few minutes ago, when he reviewed the case of the child. What you are suggesting is that he made this note when he saw the child there on the ward and I would argue that, having now looked at this in more detail, in particular the paper on which it was written, this was not what he looked at, he wrote when he saw the child actually in the ward with the parents, it was something he did afterwards when he put everything together for me to write my letter.
Q We are not talking to Dr Samuels here.
A That is the thing. I cannot be sure.
Q I cannot put precise matters in relating to that because only he can help us as to that?
A I accept that.
Q But it is quite clear that he is taking into account matters that he has learnt from the parents when he saw them at that time?
A Agreed, that is why ---
Q That is why he has the parental view?
A Yes, exactly. I think it is after he has seen them myself.
Q So it derives from, amongst other things, his meeting with the parents. Could we perhaps agree on that?
A I can accept that completely, yes. Absolutely.
Q It is thus a clinical note, is it not, because it is recording that which he learnt when he saw the parents on 16 March?
MR COONAN: This is hypothetical. I am sorry to interfere, but as my learned friend has said, we need Dr Samuels to explain the status of this document and I think with that caveat the person to be asking is Dr Samuels, with respect.
MR TYSON: I do not accept that, in view of the particular question that I asked this witness. The witness accepted that it derived, at least in part, from a clinical meeting with the parents and I went on to ask him if, because of that reason, if for no other, it should be in the clinical notes, and in my submission it is a fair and logical question to ask. I do not understand my learned friend’s objection, but I will be guided by the Legal Assessor because I do not want to take any bad point.
MR COONAN: The witness said it “appears” to be, in part, derived from a meeting with the parents. That is as far as he has gone.
MR TYSON: I think he went further than that, because he accepted that it was. Why cannot I ask him that question?
THE LEGAL ASSESSOR: The question appears to be based on what the doctor in his answer said the document appears to be. That is my understanding of the evidence. If that is the case, Mr Tyson, this would be a question based on a hypothesis. If I have misunderstood the witness’s evidence then it might be allowable. Perhaps you could elucidate with the witness by asking him again what his view is of the document itself as to its origin.
MR TYSON: I thought I had elicited that, but obviously I had not elicited it to the satisfaction of you, so I will carry on. (To the witness) We see in this note it says, “parental view”.
A Yes.
Q That parental view would have been obtained by Dr Samuels talking to the parents.
A Yes.
Q And the overwhelming likelihood is that he obtained that information when he talked to the parents on 16 March.
A Yes.
Q If that be right, which it appears to be, as you say, then it is, at least in part, this document, a note of that interview with the parents.
A “In part” is the important point.
Q The “parental view” part.
A That bit there appears to be a note about the parents’ views obtained by Dr Samuels, yes.
Q It is. Not “appears” to be.
A I accept that, yes. It is.
Q Thus that should be in the child’s clinical notes, should it not?
A Again, I am not the person to answer that point, to be honest, to be fair. If it was to be, he would have written it in the notes next to the registrar’s, as a handwritten note. For some reason he has decided he is not going to write it in the notes. He is going to go through the history, go through the notes, add it all together on this sheet, put it all down and
I presume he gave it to me to write my letter. That is what I think happened.
MR TYSON: Do not answer this question until your barrister has had an opportunity of intervening. Are we going to hear from Dr Samuels?
MR COONAN: I do object to that. It is a matter for consideration at the appropriate time. It is always open to the other side to call him.
MR TYSON: You need not answer the question. But you can understand the Panel’s difficulties if we do not hear from him.
A Yes.
Q It is recording clinical information about this child, is it not?
A Yes, it is.
Q It is directly related to the child that has been referred to you in relation to the problems of that child.
A Yes.
Q There is nothing about this document, is there, that indicates it is anything other than a clinical medical note?
A There is in the sense that we saw yesterday, or whenever, that it is on a scrap piece of paper. It is not inside the hospital medical record. So it is on a scrap piece of paper and my own view is that it was given to me to use to write the letter. I could have thrown it away but I did not. I never throw things away – that is just me – and I put it in the special cases file, which is part of the hospital records as far as I am concerned.
Q This document, there is nothing on its face, is there, to say it is a memo to you to write a letter? There is nothing to indicate that a letter would necessarily be written as a result of this note?
A No, you are right. Looking at it as it is, but when you look at it compared with the letter I did write, you can see how much it forms the basis of the letter.
Q There is no dispute about that. One can do a simple comparison.
A Yes.
Q But there is an important difference, is there not? If one looks at the bottom section, when it says, “needs”, and lists a number of things that the child needs --
A Yes, four.
Q It does not record any discussion with the parents about those listed needs. Nor does it record, does it, the parents’ agreement to those listed needs?
A No, it does not.
Q I have further questions arising out of that note and the letter later, but we are still in Appendix One territory now rather than dealing with the concept of the letter that followed.
I have made my points about that and I formally have to put it to you, with the backing of Professor David, that this was an important clinical note, not in the child’s hospital records and it should have been in the child’s hospital records.
A My response is that it was in the records. It was in the hospital records, the special cases file. However, I am not at all sure and again you would have to talk to Dr Samuels, that it should have been in the main medical file. I am not at all sure about that. He may have had good reason not to put it in there. There are all kinds of possibility.
Q There is a balance of correspondence in the SC file that I need to put to you. Perhaps the easiest way I can deal with it is to refer you and the Panel back to C9. If one works from the back of C9, working your way forward, you will come to the manuscript note about which I have just been asking you. Are you there?
A Yes.
Q I just remind both you and the Panel that C9 is each and every document that appears in Appendix One, all in one place. So moving on from that manuscript note I am going to ask you globally about all the letters that follow thereafter because they are all, as it were, Appendix One matters. Dealing with the first letter, you wrote to Dr Dinwiddie, as we know, with the letter that was copied to the paediatrician at the Royal Gwent.
A Yes. That was the sort of discharge letter.
Q Making various recommendations. This is the letter in response to your letter.
A Yes, it is.
Q Surely it is normal clinical correspondence between two paediatricians relating to and immediately following the child’s admission.
A It is.
Q Surely as an original letter, it should be, in its original form, in the child’s hospital medical records?
A Going along with what we discussed yesterday, the cut-off being the discharge of the child from the hospital, this goes into the special cases file according to the policy that we have been discussing.
Q Dealing with the next letter, again this contains important clinical information about this child and in particular it is in response to your letter. It contains important clinical information that this paediatrician had been unable to see the child. That was important information, was it not?
A It is important with regard to the child protection management and I cannot remember now whether the letter I sent to Dr Weaver -- is this in response to my discharge letter? I am trying to remember.
Q No, this was in response to your Woman’s Own letter.
A Which was only in the special cases file. So it is consistent there, then, that it is staying within the special cases file now.
Q What I am not understanding is that this case arrived with child protection concerns, and that is emblazoned all over the child’s medical hospital records.
A It is not emblazoned. It is in a small handwritten sentence.
Q It is there.
A It there though, I agree, and it was important that it was there because it was helping us to feel that maybe we needed to look at that important issue.
Q And any following clinician knows there are child protection concerns because it sees it written on a letter from Great Ormond Street, and is being prevented by you from seeing, in effect, how it went.
A There was no follow-on clinician in the Brompton Hospital.
Q But there could be.
A How? That is where I find a problem.
Q As I say – we have been through this before – a child could have come with cardiac problems and the hospital records would have been called for in relation to that child. They would have seen that the child was admitted to you with a suspicion of Munchausen from Great Ormond Street and there is no way, from the child’s hospital medical records, that that clinician could have followed the story through about that important information.
A We have been through this because I think the chances of that happening are remote. The chances of a child with a complex cardiac or respiratory problem coming in again under a different consultant at the Brompton when there was actually only, when I left, three paediatric cardiologists, no other consultants.
Q The point is that the integrity of the medical records does not depend on the view of any one clinician as to whether or not that child may ever come back. It does not fit the principle, does it?
A It fitted with the approach we took. But I accept the opinion. I am not making a huge issue of it. It is our opinion that this was an appropriate way of doing it – my opinion perhaps.
Q Dealing with the next letter at pages 55 and 56, the letter of 12 June again from
Dr Weaver to you. Again, this contains important clinical information, first of all, about the difficulty she was having seeing the child and what she heard about the child through other sources, that he was dyspraxic and that he was not quite 100 per cent neurologically. This is important clinical information, is it not?
A It is important clinical information, and it pertains predominantly to the issue of child protection. As you know, it was us, our department, that pursued this vital child protection issue. I mean, I just feel that this is the central issue that matters to the child, that we adequately followed up the child protection questions and we dealt with them. We did not put them to one side and leave them. We actively pursued them to help this child. As you know, this child’s tracheostomy was closed and his whole life changed, and I think that is the message.
Q That is your view. It is not for the purlieu of this Panel as to what happened thereafter. There are numerous views as to what happened thereafter. The issue surely is this: you are saying it is in the interests of the child to keep parallel files, to put it neutrally. Professor David says completely the opposite, that it is in the interests of the child that all readers of the hospital notes should be aware that there is a child protection problem and how it panned out. That is just an issue of principle.
A I understand his opinion. Now let us come back to that if I may. The way that this case moved forward was for me to have in front of me easily available, in chronology, all the correspondence and issues coming in. So at a glance I could look at this file and proceed to act, which I did. If it had been that every time something came in I had to get the hospital notes from the hospital, which can take as you saw from Dr Branthwaite’s notes up to two weeks to find, this is not going to be in the interests of sorting this problem out. We had had so many problems with hospital records, as had most doctors at that time – losing them, they are misfiled, the notes are not in them. We at least had a system of reliable follow-up. That is part of the issue.
Q There is no problem in principle of you having a copy of originals in your SC file.
A Okay.
Q The issue and principle, and the whole thing upon which Appendix One is based, is that medical records are in your SC file and nowhere else. If you had a convenient expert witness file, fine. If you want to keep copies of those documents to help you with your child protection concerns, fine. But you should not be taking originals or ensuring that original hospital records are in the SC file and nowhere else. That is the gravamen of the charge against you. You understand that?
A That is a very fair point and I have no problem with that point. At the time though, such guidance as there was, or was not, to help in that way was not available and we did what we thought was best at the time. Looking back 20 years from now, as Professor David is and saying it is much better to do it that way with photocopies, I cannot disagree. I think it would have been okay, except for the issue then of patient confidentiality, which is a different issue, which I have tried to put across earlier.
Q As we have seen, Dr Southall, in relation to this patient, there are numerous child protection letters in the main file anyway, including case conference minutes.
A Yes. But every time my secretary says – if I say to my secretary you are going to file this case conference in the hospital records, she sends it to the hospital records clerk to file. There are problems, or there could be – I mean it is fine most of the time, but it could be that that vital piece of paper ends up somewhere where it should not. At least with my system it stayed in the department and went into the secure room.
Q Known about, I suggest, by nobody else except your department, but we have been through that. Can I move to page 114, please, the penultimate letter in C9? This again contains important clinical information about monitoring of the child.
A This is the one that I agreed already should have been in the hospital file as well because this does contain clinically relevant information relating to the whole issue of monitoring and recording. I accept completely that that is my fault because it has “SC”, and that is me, so that should have been filed in SC and hospital notes. I have accepted that already.
Q Again, in relation to the last letter, this contained important clinical information about the child, including that at that time it would appear that the tracheostomy repair had yet to take place.
A Which one is that?
Q This is the last letter, 332.
A No.
Q Important clinical information about the tracheostomy.
A Yes. Basically the tracheostomy had been successfully closed by this stage. There was a leakage from the site where the tracheostomy had been. That is quite common.
Q That is important clinical information, is it not?
A It is important for the hospital caring for him clinically, for the GP – I presume that is Dr Stubbins now. I note it is not copied to Great Ormond Street, so they are missing out on it.
Q I am talking about this being a letter to you, from a consultant paediatrician to a consultant paediatrician -- indeed by now you had gone up to North Staffordshire --containing important clinical information about this child.
A Well, as I said, I am not clinically involved with the child at this stage. It was important for us to hear about to sort of close the child protection issue. It is important to note of course that she, that is Dr Weaver, the district paediatrician, knew where to write to me. That is an important issue, is it not? It is not as if I have disappeared, or that people could not communicate.
Q We will move on from Appendix One to the further heads of charge relating to computers and computer information, and would you like to remind yourself of the allegations in head of charge 15, head of charge 15(a), which says:
“On the computer system held at the Academic Department of Paediatrics, North Staffordshire Hospital you maintained, or caused to be maintained, the medical records set out in Appendix 2.”
You have admitted that.
A I have, yes.
Q Then subparagraph (b):
“These computer medical records are not contained in children’s hospital medical records at either the Royal Brompton Hospital (for Child A and Child H) or the North Staffordshire Hospital (for Child D and Child B).”
That you have not admitted.
A No.
Q So I will have to ask you questions about that.
“© Neither Child A nor Child H were treated at the North Staffordshire Hospital, but only at the Royal Brompton Hospital.”
Which you have admitted.
A Yes.
Q The consequences of paragraph 15, we would say, are those set out in paragraph 16.
A Which I have not admitted.
Q Which you have not admitted.
A No.
Q You see, just to help you, if we look at Appendix Two of the heads of charge, there are essentially four patients’ data, Child D, H, A and B, and three discharge letters, as it were, set out in the Appendix.
A Well, there are three patient data forms and then there are two discharge---
Q Three discharge, but I will come to that in more detail.
A Oh yes, sorry – no, two discharges.
Q Three discharges – two for H and one for B.
A Okay, right, sorry.
Q Can we look, please, at C10.
A I am sorry, did you say Child B on Appendix Two? My Appendix Two does not contain B, does it?
MR TYSON: It should. There is an allegation relating to Child B in Appendix Two and
I am sorry if it is not in front of you.
MR COONAN: I had rather assumed it was because I took Dr Southall through C9 in relation to Child B, and I had been assuming that Appendix Two does contain that.
MR TYSON: Yes, it does.
MR COONAN: Well, not according to the Panel apparently.
THE CHAIRMAN: Has Dr Southall got the amended one?
A I have got two, that is the problem. I have got a yellow one and a white one. It is on the white one, and I have just found it. Is it the white one that is right? Sorry, my fault. Now, I understand.
MR TYSON: You see it is in relation to four children.
A Yes, it is.
Q The additions in relation to Child B are late additions for reasons which will be familiar in view of your little exercise with both sets of solicitors on 31 October, where documents were produced then and there by you.
A I remember it now, yes. Fine.
Q Can you look, please, at C10.
A I have got it.
Q There are fourteen pages in it. Can you just flick through those pages, so that you are familiar with the material in there, before I ask you some global questions about C10 generally.
A Yes. Okay.
Q Do you accept that all the printouts in C10 are medical records?
A Yes.
Q Do you accept that those printouts are not in the hospital medical records?
A Yes.
Q Do you accept, subdividing that for a moment, that the printouts relating to Child A and H are not in the Royal Brompton Hospital medical records?
A Are not in this form, exactly, yes.
Q The printouts for D and C are not in the North Staffordshire Hospital---
MR COONAN: You said “C”, Mr Tyson.
MR TYSON: Yes, when I should have said “B”, not in the North Staffordshire medical records.
MR COONAN: Could you ask the witness to look at the documents, rather than dealing with it like this, to be fair. I hope I am not intervening unnecessarily, but I think it is important that he actually focuses on each of the records in respect of each child before he is asked a question.
MR TYSON: Page 1: that printout, I suggest to you, is not in Child D’s North Staffordshire Hospital medical records.
A Yes, it is not.
Q 2, I need not trouble you with because it is another version of 1. At page 3, that printout is not in Child H’s Brompton medical records.
A In that form?
Q In that form, that printout.
A The exact printout, no, it is not.
Q Page 4, that printout is not in the Brompton medical records of that child.
A In that form.
Q That is right, is it not?
A Yes, you are right.
Q Page 5, that printout is not in Child H’s Brompton Hospital medical records.
A No, it is not.
Q Page 6 I need not trouble you with, nor page 7, nor page 8, because they are each copies.
A Yes.
Q Page 10, that printout is not in that child’s hospital medical records at the Brompton.
A No.
Q That is correct, is it not?
A That is correct.
Q It is also correct, is it not, that the printout at page 11 in relation to Child A was not in Child A’s hospital medical records at the Brompton?
A It is the same as 10.
Q So if I was right for 10, I am right for 11?
A Yes.
Q Going to the next child at 12, that printout is not in the child’s hospital medical records at North Staffordshire.
A No.
Q You are agreeing with me?
A I am agreeing with you.
Q At page 13, that printout is – I am pausing because I see a little manuscript scribbled note which says, so that everyone can see what my manuscript scribbled note says, it says “C2 section 5©(iii)” - and the document at page 13 is in the child’s hospital medical records, I suggest to you.
A Yes, so the Appendix Two is not right then, is that right?
Q No. It is perfectly right. When I made a global point your barrister was right to remind me that the global point is not global, it is wrong on page 13. There is a slight difference, as you yourself pointed out in-chief, that the one at page 13 does not include reference to Dr Issler.
A That is right. There is something wrong with this computer because it should have both Dr Issler and Dr Hyatt on, as does the original in the medical records.
Q The broad concern, and just taking from your mind page 13 of C10 for the moment, is that these computer printouts were not produced by either hospital when the patients sought documents from either hospital.
A Okay. I think we went through yesterday that you can divide these into two groups---
Q I am going to do the dividing.
A Okay, fine. Sorry.
Q I am just putting the global matters to you. The broad concern, save for page 13 at C10, is that these computer printouts were not produced by either hospital when patients or their lawyers sought them.
A Okay.
Q Equally, save for page 13 at page 10, were not produced by the respective hospitals when Field Fisher Waterhouse, acting in this matter, sought them either.
A Okay.
Q The concern is that they were only produced this year in 2006 when specific questions were asked by Field Fisher Waterhouse, “Are there computer records on these children as well as paper records?”
A Okay.
Q Hence the description, so you know, that these are described in the heads of charge as secret medical records, because whether parents had asked for them, lawyers had asked for them, or Field Fisher Waterhouse had asked for medical records relating to these children, under none of those three trawls had these computer printouts been produced, and there was no knowledge therefore that there was in fact a parallel computer system as well as a paper system. That is the seriousness of this charge, if I just explain that to you.
A I think that is helpful, because that makes it clear that the secrecy is not secrecy from the point of view of doctors knowing about it, because doctors did, because they were sent, these discharge letters, to doctors, copied to doctors. They were not secret in that sense.
Q I am just putting it globally, but I will come specifically in relation to one part of it. The history of this matter is that you stored computer records on your own computer at the Royal Brompton.
A It is a hospital computer in my department. That is the difference, I think. It is not my own computer.
Q Yes, but not connected to the hospital network.
A Not on the network, no.
Q It is a stand alone computer.
A That is definitely true, yes.
Q That stand alone computer went with you up to North Staffordshire.
A Yes, with agreement of the hospital management.
Q I understand that is asserted by you, but you accepted that we have seen no documentation relating to that.
A That is because I cannot find any. It is a long time ago, it is fourteen years ago.
Q Later, the information on the, can I say, Brompton stand alone computer that was taken to North Staffs was transferred to a North Staffs computer when the other one became time expired.
A Yes, fine.
Q Equally, just as the Brompton computer was stand alone, so was the one that you used at North Staffs.
A Not connected to the network.
Q Not connected to the network.
A No.
Q It had a limited amount of people who had access to it, namely yourself, Dr Samuels and one or two others within your department. That is right, is it not?
A One nurse that was going between the wards and the department, so there was a link, because the Clinical Nurse Specialist worked both on the wards and in our department.
Q Yes. That access was not only to those few people, but also it was a passworded access, was it not?
A Yes, it was, for security reasons.
Q There were two kinds of documents that you retained on your computer. There is one that globally we can call recordings.
A Yes.
Q The second one globally that we can call patients’ data.
A Yes.
Q If we can just concentrate on recordings for the moment, the recordings were effectively the equivalent to a report of your monitoring.
A Yes. They formed a sort of discharge summary. 99 per cent of these records, these special case files and computer records, that is all you will have in the file. They are a discharge equivalent, if you like.
Q According to the Jawad memo that we looked at earlier - and I give for the benefit of the transcript a reference to that, it is C3 7(d)(i) - according to the Jawad memo, a printout in that form should have been on the hospital records, should it not?
A From the date of the Jawad letter, in that form, phrase is important because there was a proforma before that period, so the computer itself may have produced a proforma but it did not produce the data inside the boxes.
Q Just to help the Panel, it appears there are three examples of recordings equivalent to a discharge letter in C10. Perhaps you can help me, if I am right, and look at page 3in C10.
A That is one, but this one is not right. We went through this yesterday. This is on the wrong header, et cetera.
Q Yes, I am not taking any point on that.
A Fine.
Q Just an example of records, and you can see that of this kind of document there were 1856, if we look at the left-hand corner?
A Yes.
Q A similar matter under recordings is page 4.
A Yes.
Q And a similar matter under recordings is page 13?
A Yes, that is the one we were looking at, yes.
Q Those should, and one of them was indeed, in that form in the hospital medical records?
A One was; that is number 13. The H cases, I think we went through this yesterday, because a different way of presenting the same data was in the hospital medical records
Q Can I say straight away that I accept that similar information is available on a similar form, manually.
A Fine, that is all I want to make.
Q In the medical records.
A Yes, thanks. That is all I was saying.
Q That is why I have been particular about the printouts.
A Right.
Q I do not make the same concession where I come on to the next matter, which is patients’ data.
A Okay.
Q Just globally, would you accept from me that in relation to patients’ data, that is derived from the SC file and not from the patients’ main hospital records?
A These are all SC files?
Q Yes.
A Yes, they are.
Q These kind of patients’ data forms are only drawn up if the patient is on the SC file?
A Yes.
Q There are three examples of that in C10 and perhaps you can confirm whether I am right. At page 1, in relation to Child D?
A Yes.
Q At page 5 in relation to Child H?
A Yes.
Q And at page 12 in relation to Child B?
A Yes.
Q Just as we have got three examples of recordings, we have also got three examples in C10 of patient’s data?
A Yes. Four, because Child A as well.
Q They have in common, do they not – and you can check if this is true – that they all give the SC number, but despite there being a space for the hospital number, in none of the ones to which I have referred you does the hospital number appear?
A I am just checking but I am sure you are right.
Q Yes.
A Sure, okay. I am sure you are right. That does not mean it should not be there; it should. It should be there.
Q 1, 5, 10 and 12?
A Yes.
Q I suggest to you that one of the reasons it is not there is your desire to keep this kind of information not cross-referenced?
A That is absolutely wrong. The reason it is not there is because of human nature. People do not fill in forms properly. I have had this throughout the whole of my career. You can designate a form to be filled in so that everything is filled in, but when it actually happens it does not happen, and it is not because we were trying to hide anything, which is what you are trying to suggest. We were not trying to hide a link, that is absolutely incorrect.
Q So it is coincidence, is it, that from 1990 to 1994 each of these printouts of a patient’s data does not contain the hospital number?
A I think we need to look at them because, first of all, the one on Child A, which is on page 10, this is really almost meaningless piece of paper because hardly any of this is filled in and I suspect this is purely a computer database evolution issue.
Q But it still relates to that child?
A Yes.
Q The SC number in relation to that child, and records the fact of admission at the bottom line?
A I do not think any of that is actually filled in computer-wise.
Q It has:
“Hospital: N Staffs … Duration.”
A It was not North Staffs, it was the Brompton, that is the point.
Q It has the waiting time, which I do not understand what that means.
A Well, exactly.
Q Minus 72 … Whatever.
A It does not mean anything and I think this is what this is about. This is almost irrelevant data. It is out of date, it is an attempt, I suppose to build the database with using retrospective input of data, which has not worked very well.
Q But it is still there and it still relates to that patient?
A Yes, sure.
Q Without that hospital number filled in, it would appear, some time in October 1990?
A I do not know because at that time I do not think the computer data was properly set up even. I cannot even remember how this data entered into the database.
Q Let us examine, please, three patients where there is material. Can we look, please, at page 1?
A Yes.
Q Broadly, I suggest to you that matters there are not in the main hospital notes. If we look at the diagnosis on page 1, the diagnosis was in fact Munchausen’s in that case, was it not?
A Actually when the patient’s data is entered into the computer it is at the beginning of the admission, at the referral point. This is not a discharge letter. This is, if you like, equivalent to what the hospital record takes as the admission clerk’s entries. So the multiple allergies and low body temperature would be the presenting medical problem at the beginning and this then forms the substrate for the next database, which is the recording database, so that the information, like the address, moves across to the recording report bit.
Q The diagnosis is not a diagnosis, is it? It is just the presenting complaint?
A You are right, it would be better to put that as the presenting complaint. That is a better description of it.
Q Can you help me as to “B/weight”? Is that birth weight?
A That will be birth weight.
Q And “GA”, what is that?
A Gestational age at birth, so if the baby is premature, as this one appears to be at 34 weeks, it means they are six weeks before their due date.
Q That is important clinical information, is it not?
A Yes.
Q I have to suggest to you – and I will be corrected if I am wrong, but I have been fairly careful about that – I have seen neither the birth weight nor the gestational age in the child’s hospital medical records at North Staffs?
A Could I have a look? Would you mind? Could we look at it, because I would like to check that? I cannot remember without looking. I would like to check it because the admitting doctor should complete those two points. All children being clerked in our hospital unit should have their birth weight and gestational age documented in the medical record.
Q By the admitting doctor?
A Yes.
Q In relation to this child, which is Child D, we find the relevant record at C2. The admission record relating to this child is at 4(g).
A Right, I have got it, yes.
Q If it assists I could not find it in the Cardex at all, which is the second page which immediately follows.
A Right, okay. The first part of this, 29 November, is the out-patient department clerking.
Q That is on page 601?
A 601, 602 and then it comes to ---
Q He is admitted at page 606.
A Yes. You have got here a history of immunisations and so on. Somewhere here should be the birth weight and gestational age of the baby, of the child as a baby. That is standard in our records so I do not understand where it is, but it is not here.
Q It is not there, is it?
A No, you are right, it is not there, and it is very important. I think any doctor, any paediatrician in my position or a junior doctor, should complete birth weight and gestational age as part of the clerking, either in the clinic or on the ward. You are absolutely right,
I cannot see it, which is wrong. It is not good practice.
MR COONAN: Can you look at page 606, five lines down?
THE WITNESS: Yes, I had missed that. It is there, the 34 weeks – 34/40.
MR TYSON: And the weight?
A It is not there, but it should be.
MR COONAN: There is a box for the weight on page 601.
MR TYSON: On admission?
MR COONAN: The birth weight, unrecorded.
MR TYSON: Yes, that is not recorded.
MR COONAN: But it is a proforma.
THE WITNESS: There it is, yes.
MR TYSON: It is not there.
A No, this is what I say about if you go through any medical records in any hospital you will find that although doctors are supposed to fill in every single box, they do not. In a way having the back up of our special case files helps – I mean you could argue – to deal with this.
Q But we have a situation here where important clinical information relating to this child is not only not available in the hospital medical records, it is not only not available in the paper SC file, and the only place we can find it is in a pass-worded computer system with three people who can have access to it?
A I agree; there is no argument with you about it, except to say these are all part of the medical record. That is you have got the SC, the main file, the computer; they are all part, so there is a sort of back-up system if you like. Somewhere you can find the information.
Q But information like that should be in the main hospital records, should it not?
A It should, yes. It is here in the proforma. It should have been filled in but it was not filled in, but you have still got it on the computer.
Q Can we go, please, to document number 5, unless there is anything else. I do not want to be accused of cutting you off in your prime.
MR COONAN: Could I ask Mr Tyson just to look at tab (h) at page 616. I am sorry, I do not want to give evidence, but it seems to me an efficient way of dealing with it. The top right-hand corner.
MR TYSON: (After a pause) It is in the Cardex.
A Interesting. That has got the SC number on as well, that document.
Q It is interesting, too, that someone has managed to work out the difference between pounds and ounces and kilograms.
A Yes.
Q Can we look, please, at page 5, again looking at the diagnosis. This diagnosis does not relate to any of the discharge matters given by Dr Bush when he did either of the two discharge certificates in this case?
A I think just like we have just been through with the other one, this should not be diagnosis, it should be presenting problem, because the “?? Muchausen” is of course relating to the letter from Dr Dinwiddie. I think what has happened is whoever filled this in on the computer by the look of it was looking at the referral letter to fill it in, and I think therefore “diagnosis” is not right, and that is a good point. It is presenting problems.
Q The problem with that is it is difficult to derive some of those words from the referral letter from Dr Dinwiddie.
A Is it?
Q If one looks, please, at C1, subsection 2 at (a), can you help us where we get the words “self resolving cyanotic episodes” from this letter?
A Sure. Basically I think this is a nurse filling in the computer, so she is going to interpret things, but in the first paragraph:
“He has been having an unusual number of apnoeic attacks particularly associated with hypoxaemia …”.
Cyanotic episodes means episodes of going blue due to low oxygen, or hypoxaemia, so it is there in the first paragraph, that bit.
Q Not those words?
A No, not the words.
Q Nor the fact that they are self-resolving?
A They have got to be self-resolving. You cannot not have self-resolving ones.
Q Where do we find the words “upper airway obstruction”?
A That relates to the tracheostomy.
Q I am asking you, where do we find the words, “upper airway obstruction”?
A You do not, but as I said to you, the nurse, when she was filling these in, when she saw a tracheostomy would know that that meant an upper airway obstruction problem, which it was.
Q You are doing this slightly on the hoof, are you not? But you are going to fall out when we get to developmental delay.
A I am doing it on the hoof, you are right, in response to the question. I am going to lose there because there is nothing on developmental delay in the referral letter, so I would have to look at the admission note. We do not know when this patient – in the beginning she fills it in immediately after admission of the child, but of course by then the doctor may have done the admission clerking, which was on 27th. So you will find probably in there something to do with development. Yes, you do,
“History of present complaint: thereafter his development regressed”.
Q The complaining symptom there, the presentation symptom, you told us it was the presentation symptom on admission and the presentation symptom on admission was difficulty in breathing since birth.
A That is the way it is interpreted by the doctor admitting the child.
Q In relation to the previous patient we dealt with, you said that is where we take the “diagnosis” from, which is the admitting complaint.
A Yes.
Q Well here we have the admitting complaint as, “difficulty in breathing since birth”.
A Not quite. I mean what happens is --
Q It is not an important point. I would like to move on.
A I would like to explain. It is just that what happened was that this patient data form was set up soon after admission of the child to help with the process of monitoring and so on. The nurse would go to whatever was available then -- namely referral letter and/or admission -- and produce these points. What is written is “diagnosis” and I accept your point that that is not a good word, but that is what we had. There is nothing at all incongruous between the two of us. I think it is there.
Q If this is going to be an important document to be used for your – to use a neutral word – “clinical audit”, it is important to have a proper diagnosis not occasional words pulled out of the ether sometimes from the history of complaint, sometimes from a referral letter and sometimes from somewhere else.
A I agree and the whole idea of this was – for instance, if we wanted “upper airway obstruction”, we would search for “airway”, for instance, or “upper”, and then you might pick it up. That was the whole idea.
Q It is essential to have an accurate diagnosis and these last two have been shown to be inaccurate diagnoses, merely the history of complaint on admission.
A No. They still would be very helpful in finding the patient. Just because they are not word for word the same, they still have the function of helping to provide a clinical database. Trying to get people to write things down is always difficult.
Q Again I make the point in relation to this patient, and I am up for any suggestion that
I have got it wrong, that I could see nothing about birth weight and gestational age for this patient.
A Is that the reference to the hospital notes?
Q Where it says, “birth weight” and “gestational age”.
A I am saying, is it right to look at C1 for that?
Q Yes. You say it is the duty of the admitting doctor, which is C1 at Section 2(b).
A I have that. If we go to page 6, we see birth weight 8lb 4oz.
Q At (b)?
A No, at (d). Birth weight 8lb 4 oz and then 37 over 40; that is 37 weeks gestation at
X hospital.
Q So it was not there on the first admission but it was there on the second admission.
A Can I just think about that a minute? There is something important here. There is one patient data form, is there? I think there is one patient data form and two recording result forms. If I remember rightly you only need one patient data form which follows the child around.
Q Yes, but you gave evidence that this was filled in on admission, and this was the first admission in September 1989 and it is not there.
A I am just refreshing my memory. I think I am right, there is only one patient data form per child, even though there might be two recording results forms. The birth weight and gestation age are not included in the first hospital admission note but they are in the second.
Q Yes, but what I do not understand is how that fits in with the evidence that you have given, that both diagnosis as there listed, and the birth weight and gestation age are filled in on admission.
A They must have got it from somewhere when they filled the form in.
Q Just before we finish this topic, can we move to the next and last one of these computer records that come out of the SC file?
MR COONAN: Could I just rise – I am sorry to interrupt – just before you leave page 5 –
I do not want my learned friend to take a bad point and it seems timely to raise it – but that document refers to both admissions, if you look at the bottom of the page.
MR TYSON: That is a perfect re-examination point, with respect.
MR COONAN: It seemed timely to deal with it now.
THE CHAIRMAN: Mr Tyson, I suspect you want to just complete this section, and then it might be an appropriate time to have a break.
MR TYSON: Yes, madam. Can we look, please, at page 12? Again, I make the same point, no hospital number; a diagnosis that – I may be wrong but I could not see from the Crawley referral letter.
A Do you want me to look or not?
MR TYSON: Rather than make a bad point, I will look and check with you after the tea break. Again, I do not want to make any bad points about birth weight or gestation either, so subject to that, this might be a good time to break.
THE CHAIRMAN: We will break for about 20 minutes, and the usual warning applies, Dr Southall.
(The Panel adjourned for a short time)
MR TYSON: Just finishing off the matter that we were looking at, Dr Southall, we were looking at page 12 of C10.
A Yes.
Q I referred you to the referral letter which we see at C2, Section 5 at (b)(ii).
A Yes.
Q I for one was unable to find the reference to brachycardia there, the express reference to it.
A I agree, I could not find it also. I have looked and cannot find it.
Q Similarly, if we look at the birth weight and gestation age section, we need to go into Section C just following, and at (i) is the doctor’s admission note where we can see on the first page there that there is a reference to the gestational age.
A Yes, 34 weeks, but no birth weight. It should have been filled in and has not been.
Q Just to assist you similarly in the Cardex, which is in the following section, (ii), if we go to page 33 of that. We have been looking at C1, which was the clinical notes and C2 is the Cardex.
A I have got the Cardex.
Q There are some page numbers at the bottom.
A I have got those.
Q The third page in appears to be page 33, for reasons which are not quite clear to me.
A Nor me.
Q The third page in of the Cardex does record under, “clinical observations”, “birth weight if under one year”, but that 8 kg weight is the weight on admission, is it not?
A That is definitely not birth weight, no.
Q That would be quite a large baby.
A It would. It has got, “birth weight if under one year”.
Q Yes, but it is made clear that the 8.42 kg is the weight at the date of 10.9.93, the admission date.
A But the baby is under one year so they should have put the birth weight in.
Q But it is not there.
A No, that is twice they have done that.
Q There are two errors on the weight, one not there and the other one not there.
A Right.
Q The final matter I need to put to you about the computer system is that a further problem about the computer records is not only in the manner that they neglected or did include matters not on the hospital medical records, but also that in relation to two out of the patient data, these forms are not in the paper SC file either.
A Right, yes.
Q Just to make it clear about that. If we look at page 1 in relation to the patient data in relation to Child D, I accept that that printout is in the SC file, but it is not in the child’s hospital medical records.
A Okay.
Q Of concern, I would suggest, the patient’s data on page 5 is not in the SC file, this printout.
A Okay.
Q And the patient’s data in relation to Child B on page 12, that printout is not in the SC file. So you see, the potential difficulty there, Dr Southall, in relation to those two matters is that there is information in these computer printouts that is not on the hospital medical records, not on the paper SC file and only discernible when we get the printout here.
A I would argue that 99 per cent of the important data is in the medical record, the basic medical record.
Q But it is the 1 per cent I am pursuing you on.
A Yes.
Q That is not, is it?
A The 1 per cent?
Q That is not there, either in the paper SC file or in the main hospital records.
A I accept that.
Q I am now going to turn to Patient H, and the Heads of Charge relating to, if I can put it globally, the unknown paediatrician on the Heads of Charge. So you can remind yourself of the allegation that is put in relation to that patient, you will see it is in Head of Charges 7 and 8 and 9. You have admitted a number of matters in relation to that so we can see where the dispute lies.
Head of Charge 7(a) you have admitted, which is the initial referral of March 1989. Head of Charge 7(b) is admitted, which was the two admissions that this child made in September 1989 and March 1990. Head of Charge 7© is admitted, that on or about 22 March you were informed by the parents that they did not want you to be involved any more.
A Yes.
Q Head of Charge 8(a)(i), (ii) and (iii) are admitted that on 22 March you wrote to Dr Dinwiddie stating, first, that the child’s parents were not acting in the child’s best long-term interests and you were suspicious of their motives, and you viewed the child’s long-term prognosis with grave concern. That is admitted.
A Yes.
Q You have not admitted Head of Charge 8(b), which is an allegation that you copied the letter to an unnamed consultant paediatrician at the Royal Gwent hospital even though no one there was involved in Child H’s care. It is a matter for you, but that appears to be a surprising non-admission. Head of Charge 8©, you have admitted ©(iii) so it reads,
“You did not seek, nor obtain, Child H’s parents’ consent… to the letter mentioned in 8(a) above and in those terms, being sent to an unnamed local paediatrician”.
But you have denied the allegation that you did not obtain consent for the fact of involving a local paediatrician, or any letter being sent to an unknown paediatrician. So you see where the factual issues are that still remain to be resolved.
A I do understand, yes.
Q If we go to the initial referral letter which we have just seen in another context, for which you will need for a short period C1, and then we go to C2. We start with C1, Section 2, which is towards the back. There are a number of matters I would seek your assistance on in relation to this letter. It is a letter from one consultant paediatrician to another consultant paediatrician referring to a child who was by then aged about three and a half years old.
A Yes.
Q We can see from the first paragraph that it was a referral to you at the parents’ request.
A Yes.
Q That has been made clear because the parents were very keen to know if any of your new monitoring equipment would be helpful for the child.
A Yes.
Q You have heard the evidence of Mrs H that she had seen you on some day time television programme or the like and had mentioned your name to Dr Dinwiddie, who had agreed to refer them. So the principal reason why you were involved was at the parents’ request.
A Yes.
Q As a result of that he asks if you could see the child at the parents’ request and he adds his own bit in the bottom paragraph where he says,
“I would be very interested if you could see him and arrange the necessary further investigations and advise in any other treatment which you think might be helpful in this particular situation”.
A Yes.
Q Essentially Dr Dinwiddie was the child’s paediatrician, who the child had been seeing for a long period.
A Yes.
Q On this one particular issue, he had asked you to look at one particular aspect of the care of this child.
A Yes.
Q The letter here, if I can put it this way, is a typical referral letter in that it identifies you personally as the person who the child is being referred to, and sets out the history, that:
“His history is very long and complicated and I think it best to enclose copies of the case summaries from his numerous admissions here.”
Which I think is a legitimate way, rather than putting it all in the referral letter, to enclose the discharge summaries.
A It is a standard approach, yes.
Q Then sets out, as it were, highlights the main issues which you might get from the discharge summaries that he has set out, and highlights aspects of the child’s medical history, and ends in the way that it does. Can I put it this way, this is a classic referral letter?
A Yes.
Q To a named clinician, dealing with the history of the child, and indicating the reason for such referral.
A Yes.
Q Can I take you, please, to the first admission in the clinical notes, which is in the following section, which is section (b), and just by glancing through it there is no indication from that alone that you personally saw the parents on that occasion.
A No indication.
Q You heard Mrs H say that she did see you on her arrival there, and that you had a discussion with her for a period. You recall that evidence?
A I cannot, but I accept your word for it. I cannot recall it.
Q That was her evidence, that she saw you on the first occasion, where you had a pleasant discussion about the child, and thereafter the child was admitted for the one night’s overnight.
A Fine.
Q On the second occasion, we have the clinical notes at the last section (d) in C1. Just glancing through those, again there is nothing in the clinical notes that indicates that you personally saw the child.
A No, there is not.
Q I think that is all we need from C1, so if we can put C1 away and go to the first tab in C2, which is (e). There is nothing in the Kardex which relates to the second admission which would indicate that you personally saw the child or the parents. That is right, is it?
A That is correct, yes.
Q I have to put it to you formally, Dr Southall, that in fact you did not see the parents at the second admission, and the only time that you had seen them was for a brief period in the first admission.
A I cannot remember whether I did or not. That is why I looked through, to find some information to help me.
Q You had a memory, you told the Panel, that you had seen the mother at some time, and I suggest to you that that memory arises from the introductory discussion, if I can put it this way, that you had at the first admission.
A Well, I cannot remember.
Q It is clear, from the notes we have looked at earlier, that the child and the parents were seen by Dr Samuels on both occasions.
A Yes.
Q In a neutral way on this occasion, can we look at the tab within C2, the next tab, which is (h), and that amongst the matters that were recorded by Dr Samuels at the second admission relating to this child was a history of cyanotic episodes and shunting episodes, and the like, and he sets out the previous treatments that this child had had, and he deals with the tracheostomy, indicating that “told still needs it for”, and gives the two words – perhaps you can help me with the first word.
A Laryngomalacia. That is a floppiness of the larynx.
Q Thank you – and “? resuscitation”, and that the child was always admitted to the ENT ward at Great Ormond Street.
A Yes.
Q Then it sets out the cyanotic episodes, and there is the word “bagged” there, and, for the benefit of lay members of the Panel, does that indicate that through the tracheostomy this child’s breathing was assisted by---
A It is a bag that you squeeze and the air goes in, yes.
Q There is a discussion there about the cyanotic episodes. Then there is a further section that deals with the parental view, and I think you accepted when we were looking at this letter in another context earlier that this parental view must have been got by Dr Samuels from the parents.
A Yes.
Q During the March admission.
A Probably, yes.
Q The parental view was that the tracheostomy was needed, and that they saw ventilation as being the answer. We will come to it in more detail in a moment, but it is right, is it not, that through Dr Dinwiddie there was an exploration going on about having a ventilator for this child which was triggered, so that when the machine thought that the child needed some oxygen it was given some oxygen?
A It ventilates.
Q Yes, it ventilates, but what was slightly unusual was it was not one that just gave regular ventilation, it was a particular specialist kind of ventilator that was triggered by the needs of the child.
A Well, it is triggered by the child taking an initial breath. As you suck, it triggers the ventilator to add to the breath if it is not getting enough breathing on their own.
Q It is triggered by a perceived need through the way that the machine is set up that the child needs additional---
A That is it, yes, that is the way.
Q That was, as it were, their “ego fix” at the time. That was what they were keen on and saw that as the answer to the problems of their child.
A They did, yes.
Q It is recorded that the parental view was the child was neurologically normal, but
Dr Samuels’ view was that the child had obvious tremor and ataxia.
A Yes.
Q He records further that the parental view was that the mother did not want this child as a cabbage.
A Yes.
Q Then he records, as it were, his own view – is that a fair way of describing “impression”?
A It is, yes
Q That the mother was used to the child’s sickness in the sick role, that the mother wanted the tracheostomy, wanted the ventilator, and likes the idea that this child possibly has a rare disease or illness.
A Yes.
Q And that despite the fact that the child was about three and a half at this time, I think we have worked out, treats the child as an infant. He then sets out the child’s needs in the way that we have put in.
A By the way, my copy, I do not know if this matters, does not have the bottom line on.
Q Well, I apologise for that. It should have. The bottom line should read “neuro opinion/local paediatrician”.
A Yes, that is right, it is missing.
Q I take no point on that, but your copy, like ours, should have that in. As you say, and I think you agreed with me, on the first line the word there was “needs” rather than “agreed”.
A Yes.
Q Going back to the referral letter, in fact what Dr Dinwiddie was looking for was, as it were, your suggestions and recommendations as to the way forward.
A Yes.
Q You might like to take out the manuscript bit from the note and compare it with the next letter in C2, which is the letter, the subject matter of the heads of charge. If we pick it up there, the first bit of the manuscript starts at the second line of the second paragraph of the page.
A Yes.
Q Broadly, the bit about previous treatments and the tracheostomy are dealt with there. Then the cyanotic episodes are all dealt with in the second paragraph, and also the question that they want a trigger ventilator is again made clear in paragraph 2 of the typescript.
A Yes.
Q What is described as the parental view is set out in paragraph 3 of the typescript.
A Yes.
Q The needs section, if I can put it that way, is set out in the fourth paragraph under “Our suggestion”.
A Yes.
Q We deal there with the PO2 monitor, and we deal there with the nebulised – is it “budesonide”?
A “Budesonide”, yes.
Q Which is the second need. It deals with the closing of the trachea, which is on the second typescript page, and it deals with the neurological opinion, and it deals with the involvement of a local paediatrician in these forms as we see in the last sentence of the top paragraph on page 24:
“We also feel that it is vital that [the child] has his overall care managed by a local paediatrician.”
A Yes.
Q To that extent this document, the manuscript document, is reproduced broadly in the body of the letter.
A Yes.
Q Perhaps we can put the manuscript back into the section before, which is (h), and we will return to the letter at (i). The first paragraph and the last two paragraphs, if I can put it this way, are pure Southall rather than Samuels?
A Ah, that is a good point. I do not know. The trouble is it is a long time. What I do recall, because I have been trying to think about this, is meetings between us as a team over patients, where we would sit down and talk about patients, particularly difficult patients like this, and there is no date on that manuscript thing, I have no idea if there was a meeting or not, but the royal “we” throughout this, you know, “our regime”, suggests it is a mixture of us talking.
Q Or it suggests, does it not, that it may well be a discussion between you and
Dr Samuels that leads to the “we”, but what I put to you formally is that it is not a discussion with you and the parents that produces the “we”.
A Well, that is where I just cannot help either way. I just do not remember whether there was or not.
Q If we pick up, can I put about it being a team “we” rather than a royal “we”, is if we look at the second paragraph on the second page and the second sentence, when we see “We therefore spent 24 hours training them in the use of the monitor”, that would be a team “we”, would it not? That would be members of your staff who spent the 24 hours training them on the use of the monitor?
A Yes.
Q So what I have to suggest to you is that the “we” here is a team “we”, this is a view of the team rather than any of your personal involvement with this child at the second admission. You understand the point I am putting to you?
A Yes. I mean, I would not be involved in the training.
Q What I am suggesting to you is that the first time that you personally became involved in this matter was when you were rung up by the mother post discharge, when she indicated to you that she had discussed the matter with Dr Dinwiddie and was going to return the monitor.
A I understand, yes.
Q That, I suggest, is correct, that that was the only time in March that you personally had any involvement with the mother, which was subsequent to discharge when she telephoned you after?
A It does not fit with the affidavit.
Q I am suggesting to you that that is correct?
A I am just saying I cannot, I mean I cannot remember.
Q You cannot remember one way or the other. That is fair, is it not?
A I cannot remember one way or the other, but the affidavit that she wrote suggested she did meet with me during that admission. So, I do not know.
Q That is a matter for the Panel, but you yourself personally cannot assist us, can you, because you have got no memory at all, except a vague memory of having met her at some time?
A Yes, it is vague.
Q That is fair, is it not?
A It is vague. That is all I can do, yes.
Q Let us assume for the purposes of my following questions that I am right and the only contact that you had with the mother was when she rang you up afterwards saying she was going to return the monitor?
A Okay.
Q Just so that we can try and establish a factual basis for that, do you accept there was in fact a subsequent telephone call where she did ring you up and say she was going to return the monitor?
A She said so. That is all I can accept. I cannot remember.
Q Are you assisted in that aspect if we look at the third sentence in the second paragraph on page 24, where it says:
“In communication with them today, they have decided to reject this advice and go for the triggered ventilator approach”?
A It does not say with who, that is the trouble.
Q I am suggesting that that was a direct call by the mother to you?
A That is what it suggests, definitely.
Q And that in that call she said that she had discussed the matter with Dr Dinwiddie,
I suggest, and presumably you cannot remember one way or the other?
A No.
Q She said that she was going to return the monitor as a result and that you were cross about that?
A Yes, that is what she said.
Q And that you put the phone down somewhat abruptly?
A Slammed it down, she said, yes.
Q We are assisted, are we not, in that evidence given by the mother if we look at the first paragraph of this letter and at the second sentence.
A “… wasted a lot of valuable time.”
Q Yes.
A That phrase, yes.
Q
“The upshot of it was that we wasted a lot of valuable time, at the end of which the parents decided they would like to continue along their own route basically with the parental belief that [the child] has a severe rare illness which warrants intensive care treatment at home.”
A Yes.
Q I suggest that you were irritated. You were irritated that you spent a lot of time with this family, or the team had spent a lot of time with the family, and that they had not accepted the team’s advice?
A When I spoke with Mr Coonan yesterday I indicated that this was actually not unexpected, given the nature of what we were dealing with. I cannot remember whether
I was irritated or not, but it is not likely that I would be really irritated with them about that, especially as I put in the last paragraph a phrase:
“I have left it with the parents that should they change their mind …”.
If I had been angry and aggressive, would I have written that as well?
Q I am not putting it higher than “irritated.”
A Okay.
Q And that you did consider, as you have said, at the time that you felt that your team’s valuable time had been wasted?
A Fair enough.
Q I move on. You had been referred by Dr Dinwiddie, who was looking for you to come up with suggestions?
A Yes, he was.
Q We are assisted by that not only by looking at his letter to you, but this letter back, where, looking at the second paragraph, you say:
“I would just summarise his past history as we saw it, to try to put into context our recommendations.”
A Yes.
Q The bottom paragraph starts, “Our suggestion to them …”?
A Yes.
Q Is it not right that you make recommendations or suggestions, but it is up to
Dr Dinwiddie as the, clinician of record, as one expression used in this case, to decide whether or not to accept your recommendations or your suggestions?
A It is up to both. It is up to the parents and Dr Dinwiddie, both.
Q But it was not your role, I would suggest, to take action. It was your role to make suggestions or recommendations back to Dr Dinwiddie?
A To both.
Q And the parents?
A Yes.
Q But not for you to unilaterally act in this matter without reference to Dr Dinwiddie?
A If, for instance, the parents had gone along with everything, it would have been quite appropriate to have continued that regime, letting Dr Dinwiddie know, with a different form of letter to this obviously, that we were doing that. He would have been, I am sure, happy for us to continue with our approach, whatever it might have been. If I refer a patient to him, say, the other way round, and he decides he wants to do, say, a bronchoscopy (that is, look down into the lung) then he would not have to seek my consent, me having referred it to him. He would just do it.
Q You were making here recommendations back to Dr Dinwiddie? That is what the letter says in the second paragraph:
“I would just summarise his past history as we saw it, to try and put into context our recommendations.”
A Yes, but there were recommendations initially to the family and then we would have copied and informed him of what they were.
Q Because he was the one who had asked you for recommendations and so you were giving him the recommendations back?
A Okay.
Q It is in that context I would suggest that it was not open to you to copy this letter either to Dr Weaver or a hospital doctor at the Royal Gwent, simply because that was the decision for Dr Dinwiddie and the parents and not for you unilaterally?
A I do not agree with that.
Q He was asking you a specific question; you were making recommendations, to use your own word, back, and not within that exchange did it come for you to do something quite unusual, which was to copy others in to that particular correspondence?
A I do not agree. I think that I always, as a paediatrician, have to act in the best interest of the child. To me there were two major issues that needed to be addressed; the fact that he was not attending a local hospital with his tracheostomy and his resuscitation problem, and that there were child protection concerns. So for those two reasons I felt it appropriate, I still do, to let not just Dr Dinwiddie know, but also the local paediatrician who had been previously involved – that is Dr Weaver – and what I thought was the nearest local hospital with an A&E department to deal with him if he came in having been resuscitated.
Q Can I just draw back a bit before I examine that answer that you have given. I have to put it to you formally, just as I would if I had the opportunity to put it to Dr Samuels, that in fact the concept of involving a local paediatrician, for whatever reason, was not suggested to the parents at all during the March. I can put it to you formally that you, personally, did not discuss, during the March admission, the involvement of a local paediatrician?
A As I said, I cannot remember. It was thought a very important issue clinically that that child have a local hospital paediatrician, not somebody 150 miles away, and so therefore it is a very fundamental part of the regime we were suggesting for that child; but I cannot go any further because I cannot remember whether I put it to her or not. I just cannot remember. Certainly it was in our minds as an important issue.
Q I have laid the track down. I am just saying ---
A Sure, yes, I know. It is difficult for all of us.
Q She says no-one – and particularly as you are in the witness box, you – discussed involving the local paediatrician?
A I cannot remember.
Q Turning over the page, the expressed reason for involvement of a local paediatrician at the bottom of the first paragraph is to be involved in his overall care?
A Yes, that is the overall.
Q That is the overall care.
A But there are components of it.
Q It would be appropriate, would it not, if you were seeking the parents;’ consent to such a course, that there would be discussion as to who the appropriate local paediatrician should be?
A That is where the Royal Gwent might have come from. They might have said, we might have said or I might have said, “We’re concerned about your child having these events. You do not have a local hospital. Which is the nearest?” That might have been the reason
I got the Royal Gwent in my mind, because although I live in Wales now I did not know where Newport was even. Well, I knew vaguely where it was.
Q Let me be specific. If this was supposed to be a letter of referral to a paediatrician to look after the child’s overall care ---
A Yes.
Q -- then it would have been appropriate, would it not, to have discussed with the parents, first of all, local hospitals?
A Yes.
Q And, secondly, if they knew enough about it, local paediatricians?
A Yes, which is what I think probably happened, but I cannot prove it. I cannot remember.
Q It is not there because instead we have a rather scattergun approach where two paediatricians are chosen from different hospitals?
A No, I do not think this was a scattergun as such. Dr Weaver I think we knew had been previously involved somehow, but with regard to the Royal Gwent, I went through that yesterday.
Q She was included as a possible local paediatrician because she was discussed as that when you go over to the previous page, at page 23?
A Yes, that is right.
Q Where you say:
“A nebuhaler was suggested by the local consultant paediatrician in Cardiff,
Dr Weaver.”
A Yes.
Q What I am suggesting to you is this, that surely if you wanted one paediatrician to deal with this child’s overall care, in order for that to be an effective referral for the benefit of the child it would have been much more appropriate to have chosen one rather than two, or possibly more, and to have identified that paediatrician, and to have given that paediatrician an appropriate background with discharge summaries and the like, just as Dr Dinwiddie did when he referred the child to you?
A This is really important, what you are saying, because it raises another thought. Obviously Dr Weaver had been previously involved, that is clear.
Q He is described as “the” local consultant.
A The local paediatrician. Why would I need to have a second local paediatrician, unless she had said, “I do not want Dr Weaver”? We know from other evidence that there were difficulties between her and Dr. Weaver, so it may be something to do with that for all
I know. I am trying to reconstruct something where we are all in the impossible position of time.
Q That is not my recollection of the evidence before this Panel, that she indicated that she knew Dr Weaver through her Church. She knew another paediatrician through her Church, but not that there were any problems with her and Dr Weaver. That is the evidence as I recall it before the Panel.
A I would have to go back and look, but I had a feeling that there were difficulties. If that is so -- if that is so -- that might be why I was looking at Newport, the Royal Gwent. Perhaps she suggested it. I do not know. I did not know where the Royal Gwent was – I do now but I did not then.
Q Looking at it from the premise of the mother, whose evidence is that there was no discussion about a local paediatrician at all in any context, this is a letter where you have chosen the recipients and she has had no involvement in the choice of recipients at all.
A That is a different point.
Q The point is that it is her evidence and it is her case that she is seeking to have the Panel accept.
A Of course, but that is a different point. If we suppose for a moment that my argument, our logic was that that child desperately needed a local paediatrician – I speculate – we put that to the mother and said, “You must have a local paediatrician, it is very important. There is this monitoring as well and all these events requiring resuscitation”, she might have said,
“I do not want Dr Weaver”. She might have said that.
Q But that is not her case and that is not her testimony to this Panel.
A I agree that. But she might have said that and I might have said, “Where else could your child go?” She might then have said, “We are nearer actually to the Gwent Hospital”, because I do not know where I got the name from. This is speculation but it is a possibility.
Q It is entirely as you describe it, speculation, whereas the evidence here in this matter is that there was no personal involvement with you at all over whether this child required a paediatrician let alone over the choice of such paediatrician.
A There is no evidence documented anywhere, I agree.
Q Let us take it one step further and look at it clinically rather than in this speculative way. If you wanted to refer a child with the difficulties that this particular child had to a local paediatrician for the reasons you have set out, this is not a very helpful letter to such a local paediatrician, is it?
A No, I admitted that yesterday openly. This is untidy. It does not address the important issues.
Q It does not enclose, as you had with Dr Dinwiddie, all the previous discharge summaries so you could follow the matter through.
A Of course.
Q Therefore it is a pretty hopeless letter to achieve the aim that is set out there to involve the overall care of this child.
A I accept that it is not a good letter in the way it is written at the end. I think the body of the letter is fine, but the referral bit at the end, I suggested yesterday that maybe – I do not know either – I talked to a local paediatrician. In which case I would have changed the letter that went to include the name. That is one possibility.
Secondly, I did not send the letter at all to the local paediatrician, and I think it is the case that no letter has been found in the Royal Gwent, so that is another possibility.
Q Dealing with that first possibility, you said that this letter here might be a draft.
A It might be, yes.
Q And not an original. Let us shoot that fox immediately and I ask the Panel to go back to C16. It concerns the clinical correspondence from original records. You can see that Section 5 says “clinical correspondence from medical records held at Great Ormond Street”.
A Yes.
Q Going through Tab 5, we see the second letter in is, as it were, the top copy of this letter.
A Yes, so that deals with that.
Q That deals with that, and we can still see the copied people are still there.
A It does deal with that, yes, thank you. It shows that that letter, in that form, was sent to Dr Dinwiddie. It does not mean it was not sent differently to the local paediatrician, if it was ever sent at all.
MR TYSON: Madam, that would be a convenient moment to rise.
THE CHAIRMAN: Are you suggesting, Mr Tyson, that that would be an appropriate time to rise for today?
MR TYSON: Yes, madam. There are other aspects of this letter that I need to discuss but it will take more than 10 minutes.
THE CHAIRMAN: Thank you. Can I simply say at this point on housekeeping matters, is it possible to indicate how much longer you require for cross-examination and re-examination? What is in our mind is whether Dr Southall will be able to complete; his evidence before us at all by Friday. That is clearly an important matter.
MR TYSON: I have a number of matters to ask about Child H still. Child D is relatively short. Mrs M is difficult. Mrs M may take some time. I cannot say that I will, but I hope to finish by lunch time tomorrow, but counsel are notoriously unreliable on timings.
THE CHAIRMAN: Mr Coonan, can you add anything that might help us?
MR COONAN: As matters stand at the moment, I do have some re-examination. It will not be overly lengthy but it cannot be over in 10 minutes. Of course, I do not know what matters might arise tomorrow which might persuade me to ask some further questions in relation to tomorrow’s material. If that sounds rather unhelpful, I am terribly sorry, but I do think one has to factor in some time for me in re-examination, but nothing like the length of examination in chief or cross-examination. I say that as a fact. It is not a case of going over old ground.
THE CHAIRMAN: From the Panel’s side, I am already aware that the Panel would like a considerable period of time to prepare their own questions – understandably after the length of his evidence – and I am sure that this will be in the order of an hour rather than a few moments. I simply raise the matter as it is clearly one that is a little concerning, but obviously matters cannot be rushed.
MR COONAN: Again, I hope I do not trespass on your thinking unduly, but when you mentioned an hour for the Panel, is that an hour for the Panel to consider before the questions are then put?
THE CHAIRMAN: Indeed.
MR COONAN: I was not entirely sure about that, but I think that gives us a reasonable idea.
THE CHAIRMAN: A secondary matter to this is that I did of course take in the point that you made about discussing potential future arrangements while Dr Southall is still giving evidence. As I indicated then, this could become a pressing matter. If we cannot address it at all before he finishes and that is late on Friday, that may give us further difficulties.
MR COONAN: I have reflected on the points you made yesterday, madam, and reflected too on my initial stance overnight. I think again that since matters change, and I am alive fully to the problem which lies behind what you have just said, it may become unavoidable that we have a discussion about timing. It may not necessarily have to involved Dr Southall at all, if you are content with that. Counsel and the Panel could deal with it. If any information were to be sought or required to be sought from Dr Southall, I am quite sure that that can be done in a limited way with the agreement of my learned friend.
MR TYSON: That is precisely why I have risen, madam, in that I have no objections whatsoever with my friend discussing these kind of matters with his client while he is giving evidence. Not only do I agree with it, but I think it is pretty important that it is done.
THE CHAIRMAN: Thank you. That is helpful. It certainly is in my mind that at some time tomorrow there should be a first round in discussing the future management of this case.
MR COONAN: I am grateful again. I will resist the temptation to have a conversation with Dr Southall tonight, but sometime tomorrow might be an appropriate time to raise it.
THE CHAIRMAN: That is very helpful. I need to remind you, Dr Southall, that other than the matters just mentioned, you must not discuss anything about the case overnight. We will reconvene at 9.30 tomorrow morning.
(The Panel adjourned until 9.30 a.m. on Thursday, 30 November 2006)