GENERAL MEDICAL COUNCIL
FITNESS TO PRACTISE PANEL (PROFESSIONAL CONDUCT)
Thursday 30 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 FOURTEEN)
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: Good morning, can we begin, Mr Tyson.
DAVID PATRICK SOUTHALL
Cross-examined by MR TYSON, Continued
MR TYSON: Dr Southall, we were looking at the letter in the case of H which, just to remind you, is at Bundle C2 at (i). Last night we were discussing this letter in the context of it being of overall care, that being the expressed reason on the letter for the involvement of a local paediatrician.
A Yes.
Q You have accepted that it was unsatisfactory in that context in a number of respects, in that there was no covering letter; that is right, is it not?
A Not necessarily a covering letter, but there is no evidence here that I can find that I contacted the local paediatrician before sending it. That does not mean I did not, it means there is nothing to show whether I did or not. There is also nothing to be sure that it actually went there. I know it went to Great Ormond Street; you pointed that out.
Q Perhaps you could answer my question. Just in terms of it being a referral letter per se, it is unsatisfactory is it not in that there is no covering letter to the person you are referring, explaining the background. That is right, is it not?
A It is not a referral letter. If it is anything it is a copy letter to inform the local paediatrician of our concerns.
Q It is meant to be a referral letter, is it not, in that you have said it is vital for the child that his overall care is managed by a local paediatrician.
A Yes, that was part of the regime which we put to the parents, but in terms of the letter, as you quite rightly say, in its own right just looking at this letter it is not adequate to act as a referral letter to a paediatrician in the Royal Gwent, not on its own.
Q Not on its own. We dealt with this yesterday; it would require discharge summaries and a covering letter of some sort.
A It would require something. Equally, it could be that the way forward would be for Dr Dinwiddie to refer to the local paediatrician of course, because he was the main person involved, and perhaps on seeing this letter he may have felt that was something he should actually do.
Q That was what I suggested to you yesterday, in that you were making recommendations to him and it was not within your purview to have involved the local paediatrician without involvement of him, but we covered that yesterday.
A Yes, we did cover that.
Q Could I just move on to another aspect of this letter in the concept of it being a letter to provide overall care. You agree it would require consent to involve a local paediatrician in the overall care, parental consent.
A Yes, I think for anything to work the parents would have to agree to involve the local paediatrician in the management, yes.
Q Do you agree that it is asserted in the letter that the parents did provide such consent?
A Yes, it is asserted.
Q Do you accept that if they had agreed to consent to such a course they would never have agreed to a letter in those terms being sent to the local paediatrician in the context of overall care?
A No, they would not.
Q As it is asserted that the parents gave consent to the involvement of a local paediatrician, they could not have consented, could they, to have involved the local paediatrician in child protection matters?
A No.
Q There is an inconsistency, is there not, between consenting to involvement in overall care.
A Yes.
Q And consent to involvement in child protection matters.
A Yes, there is, definitely.
Q Turning to child protection matters now, for very similar reasons to why this letter is unsatisfactory as far as overall care is concerned, can I suggest to you a number of reasons
why it is unsatisfactory for child protection matters also. Firstly, it was not to a named paediatrician.
A Agreed.
Q Secondly, you have told the Panel how important matters of sensitivity and confidentiality are in child protection.
A Yes.
Q To send a letter like this to an unnamed person, at a hospital which you did not know, risked grave matters of lack of confidentiality, did it not?
A I agree with you, yes, which is why I am not sure it went at all.
Q On the assumption that it did go and you intended it to go, and you copied in a consultant paediatrician, it was a gross breach of confidentiality, was it not?
A On the assumption that it went in this form it is not ideal. It is not a gross breach of confidentiality because hospitals receiving this should have looked after it, but I accept that especially in light of the arguments I have given before it is not ideal from a confidentiality point of view to send it to an unnamed consultant, and I do not think I did but I cannot be sure because of the length of time – that is the problem.
Q We know that it was sent in that form because we have seen it received in that form at Great Ormond Street.
A I do agree with you, yes, you showed us yesterday.
Q You told us yesterday and indeed throughout your evidence how important confidential matters are in relation to child protection, and I repeat my question to you: this broke all the rules that you have been asserting to the Panel throughout your evidence.
A If it went in this form then it is not ideal. It is not gross, what would be gross is not informing local consultants of concerns, that would be wrong, but not sending it to a named paediatrician is not good practice and I accept that if it went in this form, hoping to find a consultant paediatrician to receive it, it is not appropriate, but at this stage I do not know whether I telephoned or what I did, I just cannot remember.
Q On the assumption that you sent it in this form and without a telephone call or a covering letter and identifying a particular person, it is a gross breach of confidentiality.
A I would say a breach, not a gross breach, but I accept that on all those assumptions you have a point, definitely.
Q You remember that Dr Weaver replied to this letter, so can we look further on in this bundle and go to (n).
A Is it to Helen Morgan?
Q It is a letter to you from Dr Weaver.
A I have one at 2(o) from Dr Weaver to me on 3 April.
Q Yes, go to (o). One of the aspects of Munchausen’s cases is that the mother often does “Hospital shopping”, if I can put it that way, it is one of the characteristics.
A Yes.
Q If we read the first paragraph of this letter from Dr Weaver together:
“Thank you very much for sending me a copy of your letter to Dr Dinwiddie.”
That is the letter we have just been discussing.
A Yes.
Q “Everything I receive from specialists about this little boy confirms the
impression which I had made within five minutes of meeting him, that is that they are a very unusual family! I notice that you also sent a copy to the paediatrician at the Royal Gwent.”
Just pausing there, that was on her copy as well.
A Yes, it was.
Q “… so I imagine that the parents have involved yet another paediatrician in [the
child’s] care – there are now three district health authorities in South Wales who have some involvement with them.”
It is quite clear, is it not, that she has picked up the wrong end of the stick here, she has assumed that the parents were requesting further involvement rather than you suggesting further involvement.
A Yes, exactly, I agree. In fact, it is a bit more complicated than the picture you are painting over Munchausen’s by proxy in that what parents tend to do is to go for hospitals which are very famous and in tertiary care, rather than involve their local district general hospital. Although doctor shopping or hospital shopping is a component, so is going only to somewhere like Great Ormond Street with its reputation.
Q I understand that, but you have agreed my substantive point.
A I do agree your point, yes.
Q Would it not have been fair to Mrs H and this family for you to have responded to Dr Weaver saying you have got the wrong end of the stick here, it was my suggestion rather than the parents’ desire?
A I may have spoken to her. I had lots of discussions with Dr Weaver over the telephone, which are not recorded. Nowadays they would be, but then they were not, about the whole picture, and I think, looking at it a different way, the fact that she received this letter was the starting point that enabled the protection of this child, because she was very proactive in helping to do that.
Q Can we move on to another matter in relation to Mrs H, and that is this: it is recorded in the letter at (i) that we have been discussing that the parents wanted to go for the trigger ventilator approach.
A Yes, that is right.
Q I suggest, and you demur, that that was put to you by the mother in the subsequent telephone call, where the advice was rejected – your hospital’s advice was rejected.
A It is possible, yes.
Q She gave evidence, which I do not think you can contest, that she had taken advice from Dr Dinwiddie and wanted to go down the trigger ventilator approach rather than your monitor and using what she called experimental drugs approach for the asthma, or whatever.
A I certainly accept that Dr Dinwiddie continued to support, to a degree, her involvement with a trigger ventilator.
Q According to the tests that you carried out, you would say, would you not, that that eliminated completely the possibility of the condition known in the jargon as Ondine's curse?
A Yes, the recordings that we did ruled out that condition.
Q Do you accept that Dr Dinwiddie was discussing triggered ventilators with the mother, both before she was admitted to you and indeed after?
A Yes, I do.
Q Do you accept that Dr Dinwiddie was saying before she saw you that this child had Ondine’s curse?
A I cannot remember him saying that. I would have to be shown it, I am sorry. I am not saying it did not happen. I would need to go to it if you want that checked.
Q And indeed was saying that after the child had been with you, even after he was asserting that this child had Ondine's curse?
A Again, I cannot recall that bit. I recalled afterwards that he was continuing to support the mother in her request for a triggered ventilator, yes, which seems, if you like, incompatible with acceptance of our diagnosis that there was not.
Q Can I take you, please, to assist you on this matter, to C16, which is in the bundle of documents produced from correspondence from the other hospital.
A I have it.
Q Can you go to tab 5? Dr Southall, tab 5 is correspondence taken from the original correspondence file held at Great Ormond Street for this child.
A Yes.
Q Do you recall that the original referral to you from Great Ormond Street was in March 1989?
A Yes, it was.
Q We have seen that but for the benefit of the transcript that is at C1, 2(a) where the original referral letter was dated 17 March 1989.
A Yes.
Q Can we look, please, at the first document within tab 5 and we see this letter from Dr Dinwiddie dated 16 March, so that is a few days after the referral to you at the request of the parents?
A Yes.
Q He has produced this document.
“This letter is to confirm that [the child] attends this hospital and that he suffers from Ondine’s curse”.
A Yes, I see that.
Q He describes what that is in lay terms.
A Very lay terms. It is not precise, but, yes.
Q Then over the page at page 56 comes the letter in question, if I can put it that way.
A Yes.
Q Can I ask you to look at page 58? There is a letter from a manufacturer to Dr Dinwiddie relating to the request by the mother about using a triggered ventilator from that manufacturer?
A Yes.
Q And saying, in the penultimate paragraph:
“If you decide this is a path you recommended please let me know….”
A Yes.
Q Then there is a letter in June 1990 from the GP to Dr Dinwiddie saying that he finds himself in something of a piggy in the middle in relation to the child.
A Yes.
Q And what is your opinion.
“Following your colleague Dr Southall’s examination of [the child] the spectre of Munchausen …. has again been raised. [The mother] states that you [Dr Dinwiddie] advised her that definitely the diagnosis is Ondine’s curse and he would benefit from intermittent ventilation.”
He says:
“From my end [the child] is a delightful and outgoing little boy with good social skills but marked communication problems….”
He indicates that he wants to know what the answer is.
A Yes.
Q Then there is a letter at page 83, which is the next one in the bundle, which is a reply to the manufacturer that we see at page 58.
A Yes.
Q It says in the second sentence of the first paragraph:
“We are hoping to provide him with [a product] ventilator which can switch on intermittently….”
A Yes.
Q He goes on to ask the manufacturer technical matters, asking if it would be possible “to construct a switching device which could connect to the ventilator and trigger it after a predetermined period of apnoea”, et cetera?
A Yes, indeed.
Q It asks, and this is in October 1990, way after he has received your letter which should have told him that there is no need for such ventilation?
A Sure.
Q Then in November 1990, at page 84, he, Dr Dinwiddie, approaches yet another manufacturer saying,
“I am writing to ask if it would be possible for you to investigate the practicality of having an… ventilator triggered by either an apnoea alarm or the….. oxymeter.”
A Yes.
Q So he is still pursuing the question with other manufacturers in November 1990?
A Yes, he is.
Q If you turn to page 85, that is an acknowledgement by the second manufacturer that he will see what he can do to construct it and get his R&D people on to it. Then at page 87, there is a letter to the mother from those manufacturers indicating how much it would all cost and copying in Dr Dinwiddie to that correspondence?
A Yes.
Q Then there is a letter at page 88 from Dr Dinwiddie to the GP indicating, and this is January 1991, in the last paragraph:
“I am currently in negotiations with [the manufacturer] to provide a patient trigger ventilation system for him but this is still at a fairly early stage of development and I do not expect it to be available in the immediate future.”
There is Dr Dinwiddie, some 10 months after you have told him that there is no need for this kind of thing, still informing the GP that that is what he is doing?
A Can I just make a note about this letter, just to point to you something on the bottom where it says copied to Community Physician by Dr Dinwiddie.
Q Consultant not Community.
A No, no, no. Underneath, there are two copies: one to Dr Weaver and one to Community Physician --- no name, no hospital, nothing. This just shows you that these things happen. It is the same kind of thing that you have been addressing to me now happening with another consultant. It does not mean there is anything wrong with it. I am not criticising him. I am just saying that these things happen.
Q But not in the context of deeply confidential matters and asserting matters of Munchausen and matters of child protection. There is nothing in the child protection about this. This is a standard clinical letter.
A I accept that point.
Q Then, in January 1991, Dr Dinwiddie is writing to another clinician at well known children’s hospital in Liverpool.
A Yes. Now this is starting to involve more hospitals, which are hospitals not local to the child but distant, a long way distant; this is miles away.
Q But this is nothing to do at the mother’s instigation, is it? This is Dr Dinwiddie writing to this consultant paediatrician saying,
“Dear David.
When we met recently you mentioned that you were using a very simple ventilating system for children at home on ventilation. I have a patient with Ondine’s curse who might need such a system….”
The point about this letter, and it is an important point, do you not think, is that here to another paediatrician, Dr Dinwiddie, still asserting that his diagnosis is correct. He is not, as it were, tagging along with the parents’ desires. He is not running with the hare and running with the hounds, as it were.
A No, that is the point.
Q Here is a situation where he himself of his own volition and at his own initiative is involving another paediatrician. That is right, is it not?
A We do not know, I would say, that this is on his own volition. We would have to ask him the question: was or did the mother suggest the distant hospital.
Q That does not follow from the terms and the wording of this letter, does it?
“When we met recently you mentioned that you were using…..”
There is nothing there about the mother, is there?
A No, there is nothing about the mother.
Q It is two clinicians meeting, one mentioning that he has a system, and so there is no evidence at all in support of your assertion that this was mother-generated?
A I did not assert it.
MR COONAN: I am sorry, this is not this witness’ document. It is a document involving two other consultants. The witness has said he simply does not know and I do not understand how my learned friend can take it any further. Moreover, the second matter in my objection is that there does not appear yet to be a question being put. It is all comment.
MR TYSON: It is right, is it not, that some 10 months after you have told Dr Dinwiddie in terms there that Ondine’s curse was a non-runner, he is still writing to other clinicians asserting that he has a patient with such a condition?
A I understand the point you are making. The child did not have Ondine’s curse, as shown by subsequent investigation and treatment, but, you are right that Dr Dinwiddie was continuing to go along with that diagnosis in various different ways you have illustrated.
Q Because he did have his own treatment plan and he was the clinician commissioned with overall charge of this patient. That is correct, is it not?
A He did have, yes, and I think if he was here he could explain it, but, as I repeat, and I have to repeat, this child did not have that condition because if he did, he would not have been able to have his tracheostomy closed and not be needing ventilation or anything else thereafter with his breathing problem.
Q I understand that is your view, Dr Southall, but it is also right, is it not, that it would appear from this correspondence that it was not Dr Dinwiddie’s view?
A I do not know that we can infer that. That is what I am trying to say. It is not a view. This is something that, as you know, in the future, and I do not want to go into it because it is not appropriate, this was made certain by the actions that occurred in the future. Now, the reason why Dr Dinwiddie is going along with this is complicated and relates to – you would have to hear it from him. We have heard something about how he felt he had to keep the mother on board.
Q I have to suggest to you that if he is asserting to another clinician that he has a patient with Ondine’s curse, that is his view, is it not, that he did have a patient with Ondine’s curse?
A Well, as I said, I cannot interpret his view on the basis of just one letter like this. It appears to be, I agree with you there, it appears to be his view.
Q There was a follow up to that letter, was there not, to the other clinician at page 91?
A Yes.
Q Where in effect Dr Dinwiddie is sending a chaser to this clinician?
A Yes, he is sending a chaser.
Q Where again he has asserted that “our patient with Ondine’s curse”.
A Yes.
Q The overall pointer I seek to put to you, looking at this correspondence, is this: that you were referred by Dr Dinwiddie at the parents’ request.
A Yes.
Q You were asked for recommendations and suggestions.
A Yes.
Q It was a matter for Dr Dinwiddie, having received your recommendations and suggestions, it was a matter for him and the parents whether to accept them or not.
A Yes.
Q I put it no higher than this, that it would appear from the correspondence both with manufacturers and with other clinicians that, notwithstanding your views, it would appear that Dr Dinwiddie carried on considering that this child had Ondine’s curse.
A The question is why? That is the big question which only he can answer.
Q My simple point is it does appear from the correspondence---
A I agree, it does appear, I accept that.
Q ---that he carried on---
A I completely accept that.
Q Just as if, in terms of any referral, you get some advice, then it is up to you whether you accept it, reject it, deal with it, or not.
A Agreed.
Q Just one last matter relating to this patient. As you know, it is asserted in the heads of charge, there is an aspect about accessibility of these parallel files, the SC files.
A Yes.
Q Perhaps we can deal with this fairly quickly. Could you look, please, in C2 still at (k)? Do you have that?
A Yes, (k).
Q We see that it starts on page A1 at the top with a request in November 1991 for medical records.
A Yes.
Q If we can turn to page A3, you see that the Unit General Manager has written to you asking for your consent.
A Yes.
Q You say “Consent Given”.
A Yes.
Q As he has asked you for disclosure of the child’s medical records, that would only involve, would it not, the medical records held by the hospital on their main files?
A Yes.
Q You are not thereby giving consent to disclosure of the SC file?
A I cannot remember, but there is something odd about this letter, but maybe it has been added later, the SC number is on the top in handwriting, it is not my handwriting, I do not know what it means or why it is there.
Q Would you accept as a simple proposition that you have been asked to give consent to disclosure of the medical records, and that the consent given would be for the medical records held by the hospital in the medical records department?
A Probably, yes, probably.
Q Turning to the other side of this file, which is Mr Chapman’s documents, so moving from (k) to (l) for a moment just to carry on with the history, can you just turn to the next tab which is (l).
A Yes.
Q You see that the request for medical records was repeated in June 94.
A Yes, I do.
Q At page 11 within that (l) Mr Chapman wrote to you indicating that he could see records in the Brompton files, but could not see one aspect of them, which was the involvement with the local authority.
A Yes.
Q That was in the July. Can I ask you, please, to turn to page 15 within that, which is a letter from Mr Chapman to the hospital’s solicitors, dealing with the issue of disclosure, and on the second page, at page 16, indicating that he has yet to receive a reply from you about that other matter.
A Yes.
Q Can I ask you, please, to go back to (k), and look, please, at the letter at A4 on the top right hand corner.
A Yes.
Q This is a letter by your Research Manager, Office Manager, with your reference “DPS”.
A Yes.
Q It is a letter to the local authority, and doubtless precipitated by the Chapman request, if I can put it that way.
A Yes, I expect it is.
Q It says:
“Following the current legal communications regarding the above family, Professor Southall has asked me to request copies of any records you may be holding on the … family. I have to say that subsequent to the move from the Brompton …to North Staffordshire, we can find no trace of relevant paperwork on this family.”
A Yes.
Q Are we to understand from that that the SC file had disappeared?
A It is vague this memory, and I cannot be sure, but I have a feeling that it went to the court at their request, but I cannot be sure, and it had not come back. I just have a vague memory that it was returned, but I cannot be sure.
Q Why would the SC file go to the court, and what court?
A Well, as you well know, there was a Family Court involvement in this case, heavy involvement of the Family Court, so this was the Social Services Department were involved in that Family Court matter, and so all I can think is that, as part of the Family Court proceedings, they have requested medical records, we gave them our file and it had not come back. It obviously did come back eventually because we have got it, but I do not know is the answer.
Q You have told us, or let me put it another way, the SC file was not a file that you ever disclose, is that not right, unless you are specifically asked for disclosure of that file?
A Well, yes, but if---
Q That is right, is it not?
A Yes. If a Family Court asked for it, I would give it to them.
Q There is no evidence that the Family Court asked for your SC file in this case, is there?
A No, there is not, but this letter makes me wonder, because it is obvious that it has gone, and we know it has come back, so – I have seen somewhere something about this, but I cannot remember where I have seen it, about me demanding it back and asking for it to come back.
Q It is right, is it not, that the SC file did in fact contain the medical records, statements and the like?
A Well, you have seen it. It has got a lot of stuff.
Q Yes. So you told the Panel earlier that you regarded these files as something so sensitive that they had to be kept under lock and key in a special place.
A Yes.
Q Here it appears to be saying by your Research Manager that it has got lost in the move.
A No, that is not what it says. I am sorry, it does not say that, does it? It says “subsequent to the move”; that is not the same thing as a consequence of the move, which is what you are saying.
Q “…we can find no trace of [them]”. So it would appear, would it not, that your assertion that this file was so important that it had to be kept under lock and key, it would appear that at least on one occasion it got lost?
A Well, I suspect, I cannot prove it to you, but I suspect it went to the Family Court and this was me trying to get it back.
Q Do you recall Professor David’s evidence that when he became involved in this family for the solicitors that we have seen first mentioned at A1, that when he was looking at the fruits of disclosure he himself never saw the SC file?
A That is what he said, but if a Family Court judge or the Social Services Department ask me for a file containing confidential information about social services matters and child protection matters, I would of course release it immediately.
Q This is important, is it not, that if a family asks for all material on a child, and they make a legitimate request seeking all the medical records in order to take advice - as is their right, you accept?
A I accept it is their right.
Q If the fruits of such disclosure are then sent to a distinguished paediatrician to comment on the medical records, which is what happened in this case, is that right ---
A Yes.
Q --- it produces a slanted picture, does it not, if the paediatrician is not able to comment on all the medical records, but only some?
A It depends entirely on who is “employing” the paediatrician you are talking about.
Q Why?
A Because, if there are matters in there – if you remember first that the concept is that it is the child’s records, not the parents or the family’s, it is the child’s records – if the child is subject to a court order and the parents do not have parental responsibility, as was the case here.
Q For a short time.
A For a considerable period of time, it depends on your definition of short.
Q Can we pause there. Professor David was instructed by the parents and the child.
A In which case if the guardian ad litem for the court was requesting records for Professor David to look at, I have absolutely no problem with that at all, but if the parents’ solicitor were requesting the records, it would have to go through the system and that system would include social services if they had parental responsibility.
Q Let us backtrack. The family asks on behalf of themselves and the child for the hospital medical records in order to take advice. Let us assume that is the position?
A Yes.
Q They ask for all the relevant medical records on the child. Are you with me so far?
A Yes, I am.
Q The hospital gives all the medical records that it, the hospital, has; with me so far?
A It might not. It might only release those components of the medical records that it feels are appropriate. In fact there would be legal proceedings on there that if there was a child protection case. We frequently had that at our hospital and the solicitors advised us, “You can release this document but you cannot release this because it belongs to social services”.
Q Let us assume by the time that Professor David was involved in this case that those child protection matters were over; let us assume this?
A Okay.
Q The child protection issues lasted for, I think, a couple of years?
A That is correct.
Q Certainly by 1992 it was all over?
A I cannot remember without looking.
Q Let us assume Professor David was involved after 1992, in fact was instructed, I am instructed, in 1994?
A Okay.
Q Through his solicitors, the solicitors obtain disclosure, having asked for it, of all the medical records.
A Again they would have to go through the system, but some might be protected some might not.
Q They went through the system – sorry can you pause for a moment. (Short pause). Just follow me through this scenario, will you. Professor David is instructed in about 1994?
A Now I have a bit of a problem because, if the child protection proceedings have finished, the guardian ad litem for the child would not probably still be involved, so how could he request the notes if he was not involved? In other words, a guardian is involved to protect a child, or to support a child, through child care proceedings.
Q You are putting a smoke screen on this. Can I ask my questions instead of you positing various solutions to questions I have not asked. Messrs Huttons, as we have seen in the documentation I have just put to you at C2 at (l), were instructed in June 1994 on behalf of the parents and their son. We see that in the first line of the first page.
A Yes.
Q They write to the Chief Executive seeking disclosure of the medical records in the Brompton Hospital. You see that?
A I do, yes.
Q The things they ask for include – at page 6 – all matters there and at page 7, you have noted (23). Do you accept this is what they asked for?
A This is what they are asking for as part of negligence proceedings, not child care proceedings. That is the important point.
Q But in relation to the their concern was because that, let us go to page 2, bottom paragraph:
“We anticipate that the allegations which will be made against you on our clients’ behalf after we have had access to all of the relevant documentation and we have obtained independent expert medical evidence will include those that (i) you, your servants or agents wrongly and negligently diagnosed that Mrs H was suffering from Munchausens syndrome by proxy and that she was either exaggerating or fabricating symptoms of illness in [the child] or else deliberately causing harm to him.”
So you can see exactly what the allegations against you and the hospital were.
A It goes on, does it not; there is more. There is a group of allegations and
Q We are directly concerned with your management of this case. That is right is it not?
A Yes, it is and I am happy to answer the questions about it
MR TYSON: In connection with your management
MR COONAN: Let him finish.
A I am happy to answer the questions because, as you know, during Mrs H’s evidence she addressed this number (iii) point here that, “[me] or [my] servants or agents carried out research”. As you know, Mrs H accused me of treating her son as a laboratory rat, which I thought was relating to what you are now bringing up here. This was the basis for the negligence claim.
Q No.
A That is what it says here.
Q That is one of the bases.
A Yes, it is one of the bases, yes.
Q Number (i) is that you misdiagnosed Munchausen’s?
A That is one of them, yes. There is a load of them, including
Q In connection with those issues, including your negligent diagnosis of Munchausen’s.
A Alleged negligence.
Q Alleged negligence, yes. The hospital was asked to produce all the matters in the schedule at pages 6 and 7?
A Agreed, yes.
Q Including your own files relating to the treatment of the patients and the type of treatment generally?
A Yes.
Q You were involved in that in the way I have taken you, and I have taken you to the letter at page 11. You were told that the hospital was providing all the records that they had, but there was a slight gap involving the local authority. Do you see that at page 11?
A Can I just
Q Look at page 11, the letter requests disclosure to the solicitors:
“...of the medical records, x rays, reports and correspondence relating to the treatment and care of [the child] and additionally correspondence with [the local authority] in respect of the care proceedings that were brought against his parents. Royal Brompton Hospital holds the medical records but no correspondence with [the local authority]. Royal Brompton Hospital holds the medical records but no correspondence with [the local authority] has been found. I write to ask therefore that if you possess a file within the Academic Department ... with such correspondence would you please send it to me as soon as possible.”
A I did not reply to that letter and I cannot answer why, except to point out the address is wrong. I do not know whether that matters. The actual address of the Academic Department is a different post code – ST4 6QG. I am not saying that is the reason, but I have just noticed that it is the wrong post code.
Q Are you saying that because of the wrong post code it would not be delivered?
A No, not at all.
Q Is your answer not inconsistent with the letter that we have seen in February 1995 that you wrote to the local authority seeking matters. It is clear that you received that letter?
A No, it is not clear. It is probable, but I cannot be sure I did. I am just pointing out that there is a problem with the address. There are different addresses on Mr Chapman’s letters at different times. However, I usually respond to letters, you have seen that I do. The fact that I did not respond to it, it is possible that, even if I did not receive it or I pointed out earlier that I was working in Bosnia in July 1994, it is possible that it was received and for some reason I did not even notice it or get given it. There are all sorts of possibilities. I normally do respond to letters. I think you can agree that from what you have seen. The fact that I did not respond is unusual.
Q Perhaps explained by the letter that we have been looking at five minutes ago in February of the next year where you wrote to the local authority saying that you had lost the file?
A I would have responded to Mr Chapman. Can I finish. I would put on record that I do know Mr Chapman from when I used to work at the Brompton, not in his current role. I always got on very well with him and I would never ignore a letter from him deliberately, so I would have written to him saying, “Dear Mr Chapman, I cannot find the file”, that is what I would normally have done.
Q There is no such letter, is there, on the file?
A Oh no.
Q The simple fact is that disclosure – the solicitors brought proceedings for disclosure of the medical records. You recall that?
A Yes.
Q An affidavit was sworn by your hospital solicitors indicating that they would give disclosure of all the medical and nursing records?
A Yes.
Q We heard evidence from Mr Chapman about that. All the records that the hospitals had were then disclosed pursuant to that agreed order in the High Court?
A Yes.
Q That disclosure did not include the contents of the SC file, did it?
A According to all this no, because there were problems with it, as you know.
Q The problems included the fact that you did not disclose to Mr Chapman that there was an SC file?
A Well, there is not a written response to this letter.
Q You have the evidence from Mr Chapman that, up until 2000, he was not aware of the existence of anything like an SC file?
A No, he was because in the other case he did know, did he not?
Q His evidence to the Panel was that he had not heard of an SC file until May 2000.
A I cannot recall everything, but I thought I had written a letter to him saying we kept separate files and I thought that was in the mid 1990s.
Q It is a matter for the evidence.
A Okay. I was trying to answer the question a minute ago and
Q The disclosure in this case, I suggest, pursuant to the court, did not include the SC file?
A By the sound of it no.
Q It should have included the SC file, should it not?
A If there was a court order, there would be no problem in it being provided. What I am getting at is maybe that was the reason why I asked my secretary to write to the Family Court; maybe, I do not know.
Q You are asserting that an SC file is a medical record.
A I am.
Q The problem with your SC files, of course, is that the Brompton did not know about them so they could not disclose them pursuant to an order, and that is the crucial issue in this case.
A The Brompton Hospital did know about them when I moved. The problem is that Mr Chapman became employed as the main administrator, but he did not know about them because somebody at the Brompton had not told him.
Q There was nothing in the medical records to indicate there was a parallel file.
A There were references to it, but there was not a tracer card, as we have earlier discussed.
Q The parents got incomplete records that did not include medical records which were important medical records relating to the child; that is the result, is it not?
A The records that I held in the special case files were mostly child protection related, but they are medical records.
Q They are medical records and they are absolutely on the issue that the solicitors wished to obtain advice upon.
A I understand that.
Q Which they instructed Professor David upon, and when Professor David had to advise he did not have the SC file – that is the evidence he gave last week.
A You also said he was instructed by the child, is that right?
Q The parents and the child.
A The parents and the child, okay.
Q Could we move on, please, to another case, that is all I need to talk about in relation to this case. Can we go, please, to the case of Mrs D?
THE CHAIRMAN: Mr Tyson, I have had an indication that members of the Panel might need a short break. It is an issue of concentration and perhaps the same would be true for Dr Southall. Would this be convenient, you were about to move on to a different topic.
MR TYSON: This is perfectly convenient.
THE CHAIRMAN: We will take a 15-minute break now and we perhaps would be able to take another break later to break it up for Dr Southall and the rest of us. The usual warning applies.
(Short adjournment).
MR TYSON: Dr Southall, do you have the heads of charge?
A Yes.
Q Could I take you, please, to head of charge 17? Do you see that it says:
“In the cases set out in Appendix 3 you failed to treat the respective children’s mothers in the ways set out below …”
A Yes.
Q And in relation to Mrs D that is (a) politely and considerately and (b) in a way that they could understand.
A Yes.
Q If we look at Appendix 3 together, you will see that the allegations are the four allegations there set out in Appendix 3.
A Yes.
Q That is the area that I am going to ask you about now. To just give you some background, could you look, please, at C2, section 4? The first point I wish to deal with is the question of clinical perception of the mother and that she was in fact described well by other clinicians, was she not?
A Yes.
Q We can see that at tab (a), how she is described by her GP in 1989: “Mother is a nurse who is coping really well with the child’s problems.” That was the view of her GP. Can we go to ©, please? This is a letter from the consultant paediatrician at the hospital there mentioned.
A Yes.
Q If we can go to the second page the view of that consultant was, in the second big paragraph,
“I think in practice his parents have done extremely well and it struck me that they have an extremely well-balanced and sensible approach to the problems of the child’s diet.”
A Yes.
Q It is quite unusual, is it not, for a consultant to as it were praise parents to that extent, to use the words “extremely well-balanced and sensible”?
A It is not unusual.
Q It is certainly a view to take account of, is it not?
A Yes, it is.
Q That was his view in August. Can we go to (d) now where, in November, he is writing to the professor at the department of immunology at Great Ormond Street?
A Yes.
Q He has used similar phrases on a consultant-to-consultant basis. If we turn over to page 3, do you see the second main paragraph:
“His mother has an extremely sensible and balanced approach to the problem and copes with him very well.”
A Yes.
Q That remained that clinician’s view. Can we go over to (e); this is a response by the then Dr, soon to be Professor, Strobel back to Dr Connell.
A Yes.
Q We see in the second paragraph of that letter that the view of Dr Strobel was: “The mother seems to cope very well with managing his diet.”
A Yes.
Q We have the three clinicians who have been involved in this child to date all praising the mother for coping well and being sensible.
A Absolutely.
Q Then there came a time after this when some five years later the child was referred to you. Can we come, please, to (f)?
A Yes.
Q This is a letter from the GP to you where it says in the first paragraph: “His mother is an SRN and copes very well.”
A Yes.
Q So the principal clinician involved in the care of this child, the GP, who had been the same GP since birth, still is saying some five or six years later that he is of the view that the mother copes very well.
A Yes.
Q There are two other interesting things about this letter: it is right that this is not a tertiary referral, this is coming straight from the GP.
A No, I would classify it as tertiary because it is outside his referral practice. He lives wherever and we are 120 odd miles away, so this is a tertiary referral.
Q But it did not come from another hospital; it came from the GP.
A You are right about that, usually tertiary referrals come from consultants but in this case it was the GP. That was perfectly okay, we were happy to take it.
Q The other aspect of it is that the referral to you was at the mother’s suggestion.
A Yes, it was.
Q The other aspect that is important, is it not, is that there were no child protection concerns that had been expressed to date.
A No, none.
Q It was a simple request by a GP, at the mother’s behest, to see if the child would be suitable for an appropriate monitor.
A Yes.
Q Dealing with another subject, which is the anaphylactic reactions, can we come please to the clinical notes at (g)? It is right if we look at the note at 602 that she is describing anaphylactic shocks to a variety of food items.
A Yes.
Q If we go to 607, at the bottom, he had had six life-threatening reactions in the last year.
A Needing adrenalin.
Q Needing adrenalin.
A And prednisolone.
Q She is describing at 607, if we can go back to that, in relation to the third immunisation injection, about halfway down, some sort of delayed reaction to that injection because it appears to say it was about one hour after.
A That is what it says.
Q At 610, the note on 15.12, do you have that?
A I have it.
Q Do you see where it says “Mum is concerned because he does this when he is about to have an anaphylactic reaction”?
A I think it is “worried” but I may be wrong. It is the same thing anyway.
Q He has delayed anaphylactic reactions.
A Yes.
Q Dealing with another aspect of the background, he was admitted for at least two nights.
A Yes.
Q Dealing with the first night can I suggest to you that there does appear to be an event of some sort on the first night? Can I ask you to look at the cardex under (h) at 620 where we see at six o’clock on the 14th,
“Settled night, slept throughout. Monitors applied by technician at beginning of night. PO2 down to 16/19.”
A Yes.
Q “Looked pale, mum says puffy.”
A Can I just mention Sa02 there, can you see that, oxygen in the blood, normal 97-99. That means the oxygen is normal.
Q The PO2 meter went down, did it not?
A That is because the PO2 meter measures two things: one, oxygen and one, skin blood flow, and it can drop if either of those drop, but because the oxygen in the blood was normal it means that it dropped because the skin blood flow dropped.
Q I am not asking for a technical analysis, but it does appear to be “an event” that night which is recorded by the nurse.
A What I am trying to say is it is not a life-threatening event.
Q I accept that. The issue was that there was some sort of event.
A Yes, an alarm event.
Q Alarms would have gone off.
A An alarm went off, that is the thing.
Q Indeed, we can see that in fact a doctor was called as a result of such alarm, if we go back to the clinical notes at (g) on page 604.
A Yes.
Q At the bottom of the page, “Had episode of cold, pale …” Is that desaturation?
A Yes, that is incorrect of course because the oxygen did not drop.
Q But that is how it is described.
A Yes.
Q “Last night. Tape saved, needs analysis.” So in the mother’s perception there would have been an event on that night.
A Yes, definitely.
Q Again, on the second night there would have also been an event which would have sounded alarms. If we can go back to the nursing cardex at (h), again at 620, just a few passages below the one that we were looking at before; do you see the last two lines?
A I have it, yes.
Q This is the next night,
“Very settled night. Saturated well throughout. However during early part of night the TCP02 monitor down to 9.”
A Yes.
Q “Temperature via monitor 33.5 to 35.5.” Pausing there for a moment, what would you expect to be the temperature of a normal healthy child?
A This is the skin temperature so this is okay.
Q Could you tell me what the normal range is?
A That would be within the normal range. It depends on how warm you are in bed. If you have a lot of clothes on you might be higher than that.
Q We see the previous one, the PO2 monitor went down to 16.
A Yes.
Q But on this occasion the TCPO monitor went down to nine, so again alarms would have gone off.
A An alarm would have gone off, yes.
Q Over the page, “Temperature via monitor 33.5 to 35.5 throughout, although when taken by axilla approximately one degree Centigrade higher.”
A Yes.
Q “Seen by registrar last night when temperature low and very clammy to touch. Nil ordered, observe only.”
A Yes.
Q In the mother’s terms there had been an event on each night.
A Yes.
Q And alarms had sounded each night and a doctor had been called each night.
A Yes.
Q Your view was that there was nothing wrong with this child, is that right?
A We then looked at the recordings, you see. We would look at the recordings and see what happened to the heart rate, the breathing, the oxygen in the blood as distinct from the skin, and when we had done that we found that there was nothing to worry about with this, and so I would have told the mother that on the ward round.
Q You would say and did say that the recordings were normal.
A Yes.
Q You also took a view by the last day about the mother that she had been wrong to ask nurses to take the child’s rectal temperature.
A Yes.
Q Did you not also take the view about the mother that she had been wrong to ask the nurse to take blood sugar measurements?
A Yes.
Q Building up a picture of your view of the mother, she had been wrong in those two respects and you were also of the view that the recordings, notwithstanding the alarms, were in fact normal.
A Yes.
Q By the last day you were also of the view that this was a Munchausen’s syndrome by proxy case.
A As I indicated earlier, at the lowest severity level. It is on the spectrum.
Q You were also of the view that you had the support of Professor Strobel in that diagnosis.
A I telephoned him to talk about all this.
Q You recorded in the clinical note that we can go to that he agreed.
A Contemporaneously I recorded that note, yes.
Q That he agreed.
A Yes.
Q So we build up the picture, do we not, that here is a Munchausen’s mother, to use shorthand.
A I do not like that.
Q Right. There is a mother whom you have diagnosed with Munchausen syndrome by proxy here.
A I would prefer to say here is a mother with evidence of exaggeration of her child’s symptoms and signs. No doubt this child had severe allergy, no doubt about that, but she was exaggerating and requesting inappropriately invasive procedures such as a rectal temperature and taking blood off him, when it was not indicated.
Q But you did apply the label that this was an example of fabricated illness.
A Yes, as I keep saying it is at the lowest level.
Q You have a reputation, and perhaps you would like to comment on this, as a passionate defender of the rights of the child.
A Thank you. I try, yes.
Q It is a label that you are proud to have?
A Yes.
Q Also, you are passionate, and would you like to comment this, about child abuse and the evils of child abuse?
A That is where I would not go quite with you. I do not l like the word ‘evil’ because that implies something about the parent doing the abuse that you cannot ever judge. Nobody can know what the motives are of the parents involved, so I do not like the word ‘evil’ and I think that is wrong.
Q Without the adjective ‘evil’, would you accept the proposition that I put to you that you are passionate about the examination of child abuse?
A Yes, I think that as a paediatrician when you look at child abuse issues, they are some of the worst things that can happen to a child, worse than illnesses.
Q And you feel, as it is one of the worst of illnesses, strongly about it?
A Yes, I do.
Q And you wish to examine the extent to which it is present, if you suspect it?
A Well, I think it is important that if it is suspected proper procedures are undertaken to see whether or not it is or is not the case.
Q You have no hesitation in ensuring that the procedures as you feel appropriate are carried out to investigate it. Is that right?
A Yes, to try to be fair to everybody because if it is abuse, then it is very important to detect it, and, if it not abuse, it is very important it is not diagnosed incorrectly.
Q You have already come to a diagnosis here of fabricated illness?
A Yes.
Q And as such that reflected, if I can put it neutrally, rather poorly on the mother, does it not?
A No, I do not think we could go that far either. That is a perception I think that needs to be dealt with because what we are talking about is a complex family event. Now, there are completely different types of reasons why parents ill-treat their children. I have written papers on this so I know a bit about it. There are some where the parents are doing it for gain – they are gaining from what they are doing and this is one issue. In others, they are doing it because they are very unhappy and pressured into it, for whatever reason. So you cannot ever put a blanket term on it. It is too complicated.
Q Let us look at it another way, and, to use your expression, this is an example, is it not, of ill treatment of children?
A Yes, it is. It is a form of ill treatment.
Q I have to suggest to you that these are matters in general which we are discussing and then matters in particular that were informing your frame of mind on the last day of admission in this case, that you were of the ivew that here was a mother who was ill-treating her child and had further acted inappropriately in asking for rectal temperatures and blood sugar measurements?
A Yes.
Q Would lit be fair to say that as a result you were not particularly well disposed towards this particular mother?
A No, you cannot go that far. This is part of the job. Sometimes in certain cases I have been very upset about what parents have done to their children but when you get into this complicated psychological arena which we are talking about now, it is something that has to be understood and the reasons behind it looked for so that it can stop without the issue of blame. I think what you are trying to say is that I am sort of somehow blaming the mother for what she has done.
Q I was not putting it that way. I was saying that as a result of your recent diagnosis – I think you only made the diagnosis on that day ----
A Well, it I was building up.
Q Having examined the overnight recordings, and your discovery that day that the mother had inappropriately asked nurses to carry out these two tests, I am suggesting to you that that informed your view of the mother and was in your mind of the mother that she had been ill-treating her son?
A Yes.
Q And that that was your frame of mind, I have to suggest to you, at the time that you met the mother on the last day of her two-day stay at North Staffordshire?
A Yes.
Q I take that ‘yes’ as an acceptance of the proposition.
A It is an acceptance of what you are saying.
Q We come now to the incident that the mother described, which is the subject of these heads of charge. You told the panel that you only had the vaguest memory of the incident with the mother?
A Yes.
Q Would you agree that on the other side it was an important meeting as far as the mother was concerned because she was going to learn the results of the two-day stay?
A Yes, definitely.
Q And she would be anxious to take on board that which you were going to tell her?
A Yes.
Q Will you accept that because it was a vital conversation to her and because she wanted to know about the child?
A Yes, from her perspective, definitely.
Q So, whilst you may have only the vaguest memory, for her this was an important conversation and, to use her own expression, will you accept it was imprinted in her memory?
A Absolutely and I can accept this completely. Probably I saw 15 children on that ward round, so she was only one of them and most of the others were not tertiary referrals but, even so, it is still the same principle.
Q Would you accept it follows from that that challenging her actual account is not easy for you?
A Well, I cannot. It is really difficult.
Q I understand what you are saying but I formally have to put to you aspects of the conversation so that you are able to comment on it. The mother told the panel that this was a normal conversation to start with and that you indicated to her that you wanted the child to be seen by the well-known allergist Professor Warner?
A Yes.
Q Was it your view in fact that Professor Warner should be involved?
A It was.
Q There is nothing in the notes about it.
A No, no; it was in my subsequent report. He had written a paper on the allergic manifestations of Munchausen’s syndrome by proxy. I also knew him from the Brompton. Remember that we had worked together there.
Q That was going to be my supplementary question. Is it the same Professor or Dr Warner who we see as the admitting consultant?
A Yes, he went to Southampton.
Q He went to Southampton and you went to Keele?
A Yes.
Q So she is likely to be right about that, is she not, that there was a mention at that conversation about the possible involvement of Professor Warner?
A Yes, it could well be.
Q And she could well be right if she told the panel that you told her that everything was normal?
A Yes. I am almost certain I would have done that.
Q I have to suggest to you that in response to that she challenged your description of everything being normal, pointing to the events of the last two nights where alarms had gone off and registrars had had to be called?
A I think that it is very likely that she would have done that.
Q I have to suggest to you and do suggest to you that you bridled at being challenged so openly when the mother challenged your view?
A I did not. That is not the sort of thing I would do.
Q You cannot say whether you did or did not on this occasion?
A No, but it is not the sort of thing I would do. That is all I can say.
Q It is in fact your view, is it not, particularly in relation to injections, that there is no such thing as a delayed reaction?
A When there is an injection, usually if there is going to be an anaphylactic response, it is pretty quick.
Q The mother then told the panel that you said to her in terms that there was no such thing as a delayed reaction. Let us break that up a bit. It is quite likely that you would have said that, is it not?
A Yes. It depends on the context. If she said “in response to an injection”; she would have had to have qualified it.
Q I have to suggest to you that you came out with this out of the blue in response to her challenging that everything was not normal with her child?
A Possibly. How can I answer this? I cannot remember it.
Q And that you said those words “there is no such thing as a delayed reaction” in a loud and rather angry voice?
A It is not what I normally do. Normally when you tell a mother in a tertiary centre with all this expertise that there is nothing wrong with her child during these events, they are pleased. It is the sort of thing that a mother would be really delighted about. It is not life-threatening; there is nothing seriously wrong. So all of this does not quite fit somehow.
Q It does quite fit, does it not, because the mother had witnessed and been there for two events, in inverted commas, the night before?
A Yes, but supposing she was coming to me to find out whether these events were life-threatening because she was really worried that they were life-threatening, and I tell her that they are not life-threatening, they are harmless. That sort of thing is what should result in the mother being delighted, not upset. That is what I am talking about.
Q But the issue is that she asked you for an explanation of the normality, pointing to matters which appeared to her abnormal, and the accusation against you, Dr Southall, is that you did not provide explanations; you shouted to her that there is no such thing as a delayed reaction.
A Well, I did not. That is not how I behave but I cannot remember what happened in this precise case. I do not do that, so what can I say?
Q And that you accompanied that raised voice allegation by walking away with a dismissive gesture of your hand?
A I do not do that.
Q Thus leaving, I have to suggest to you, the mother with no opportunity to talk about the future of her child and whether or not she was getting a monitor?
A The thing is that I would look at it like this, that she said, “I felt sick”, remember. My own interpretation is that ---
Q Just pause there. It is not open to you to speculate, is it, if you say that you have no memory or only the vaguest memory of this matter?
A But you are speculating. I am just replying and saying what I think she might have felt.
MR TYSON: I am not speculating. I am putting evidence to you.
MR COONAN: With respect, I think he is entitled to respond in a way in which he is attempting to.
MR TYSON: All you can tell the panel is what your normal reaction would be to a conversation like that?
A Which I have done, yes.
Q You cannot assist the panel with this particular conversation because you only have the vaguest memory of it?
A No, but I heard Mrs D give evidence and I heard her say how she felt sick. Now, I understand that because if she is in the state she is in, trying to get some support for whatever reason (and we do not need to go into what it was because there were reasons, but they come out later) but if she was, and here was somebody who she was looking to to help her, if you like, and he is saying to her, “well, there is nothing actually wrong with your child and these perceptions are nothing to worry about”, it closes of an avenue of support for the attention that she is needing. I can understand it.
Q I understand your speculation.
A That is what it is; it is only speculation, just as some of the things you have said.
Q Just lastly on this patient, I have suggested to you that you were angry with her; you were angry that she had challenged you. You have dealt with that. There is further evidence, and perhaps you would like to comment on this, and it is just one aspect of the report that you wrote in this case, which we find at the first page at (i). It is a medical report on the child. You indicate that in August 1989 she was referred by the GP to the outpatient clinic at the hospital there mentioned, saw the paediatrician there mentioned.
“The problem was one of allergies, abdominal pain, eye swelling and skin rashes. It was known that his mother also had allergies, bad eczema and abdominal pains. She apparently is a trained nurse….”
That is pretty dismissive of the mother, is it not?
A No; it is what she said she was, and I had come across a number of cases where a parent had said they were a nurse when they were not. I was just saying that this needs to be checked as part of the whole business.
Q But described by the GP as a nurse, described in all the clinical correspondence as a nurse, and here you dismissively describe her, I suggest, as “apparently a nurse”.
A It is not a dismissive statement. It is just something that needs to be checked, flagged up. It is known also that if you are a nurse --- Sorry. It is extremely rare but overrepresented in factitious and induced illnesses are nurses; they are over represented. You can see that almost from this small sample here. So it is an important issue to address.
Q It is an important issue but if it was that important, why did you not ask her?
A Then she would really have got upset, if I had said to her, “Are you really a nurse?” There is no need to do that.
Q I just suggest to you that it indicated your attitude to this woman and that it is corroborative of the way that she says that you dealt with her that day. Can we move on, please, to the final patient in this matter, and that is Patient M, and M1 and M2? Can I ask you to look in this context at C1? Do you recall the accusations against you or do you want to be reminded through the heads of charge?
A No, I know what they are.
Q Following on from what we were discussing in relation to the previous patient, would you accept that to make a diagnosis of Munchausen’s syndrome by proxy is a complicated matter?
A Yes, I would.
Q And that there are many factors that have to be taken into account?
A Yes.
Q And the factors include looking at the past medical history of the mother?
A Yes.
Q The past medical history of the child and other children, looking at the wider family?
A Yes.
Q Looking at occupations of the people involved.
A Yes.
Q Looking at social services aspects, such as domestic violence.
A Yes.
Q Co-operation with agencies.
A All sorts of things.
Q All sorts of things.
A It is not just mothers either, it can be fathers.
Q All these many social, medical, occupational issues have to be looked at before you can come to a diagnosis, would you accept that?
A It depends. I mean, you look at all of those as part of it, but you can come to a diagnosis earlier if you have clear evidence from one or other of them. In general you would try and put all the jigsaw together, if you like.
Q Before coming to a diagnosis?
A Not necessarily, no. I mean, you could come to a diagnosis earlier. For instance, if it is was a case of poisoning, which none of these are but I use as an example, if you find that a child has been poisoned, it is not necessary to get through all of these others before you make the diagnosis. You could make it earlier, but you would complete the picture later.
Q Yes, but that is a rare matter if you have direct evidence before you that (a) the child has been poisoned, and (b) one of the parents was responsible for that and no other person was. That is relatively clear cut, is it not?
A It is clear cut, yes.
Q The average case is not clear cut and needs a lot of investigation, would you accept that?
A Yes.
Q Amongst the factors that have to be taken into account, can we just look at the beginning of one of the reports that you wrote on this case at 1(z). Do you have that?
A I do, yes.
Q You set out, in the first two pages of your report, eleven factors that you are looking for at that stage in your process of your work on this subject. You were doing a bit of a profile exercise, if I can put it that way.
A Yes, it is a form of profile exercise.
Q So in order to come to a diagnosis you would have to go through all those matters in order to find whether at least three of them existed in order for you to come to a diagnosis?
A Yes, that is what it says.
Q That is what it says.
A Yes.
Q Your first discussion in this case was on the telephone to a social worker. Your first involvement in this case, was it not, was in a telephone conversation with a social worker?
A Actually it was not, but it is not revealed here, it was actually a phone conversation from the Head of Nursing at the hospital to me.
Q Because of your personal connection.
A With her, I think, and she knew of my work, and I said to her, “You must go to social services”, which she did. Then social services rang me. I just wanted to make that clear.
Q Yes. You indicated that there was a personal connection between the Director of Nursing and the Chief Executive of your hospital.
A Previous.
Q Yes. There is no dispute about that.
A No.
Q The first contact with social services was by Ms Salem on 23 January, that we can see?
A Yes.
Q On that occasion you had no documents, you were merely relying on what you were told, is that right?
A By her and by Ann Grey, yes.
Q You are recorded as saying that as a result of what you were told, that you believed there was Munchausen’s syndrome by proxy here.
A Well, she has written this down, not me, but I would certainly have said to her I would be very worried about that possibility.
Q She has said in a sworn statement to the court that that is what you said.
A Okay, fine, but it is not me saying it. That is all I am trying to say. It is her saying what she interpreted me as saying.
Q Just to show you the reference, it is at 1(u).
A Yes.
Q We see that this is a court statement, and she makes the declaration on the first page and she makes the statement “…believing that what I have said ... is true”.
A That is right, yes.
Q Made ten days after the conversation in question.
A Well, she met with me, did she not, she and her team manager---
Q Yes, but it is before the meeting. Can I take you to page 3.
A Yes.
Q The second paragraph says:
“At this time I believed that there was a similar pattern being established with [the youngest child] as there [was with the oldest child]. I was concerned at this and contacted Professor Southall at North [Staffordshire] Hospital to request his opinion.”
I am putting to you that that is the telephone conversation on 23 January.
A Yes, it is, that is the telephone conversation, yes.
Q “He suggested to me that on the basis of the information I had given him, that he believed [Mrs M] had Munchausen syndrome and that this would have serious implications for [the youngest child’s] welfare.”
So I have to suggest to you that at that stage, and on no documentation, you used the words “Munchausen’s syndrome” to the social worker.
A About her.
Q About the mother.
A This is not the same as Munchausen’s syndrome by proxy. I think I have made that clear already.
Q That was your belief at that time.
A I was worried about it, yes.
Q Because if you believed that she had Munchausen’s, and if you coupled that with your belief that this would – not “could”, “would” – have serious implications for the youngest child’s welfare, that would indicate that you were also thinking along the lines of Munchausen’s syndrome by proxy.
A Yes, obviously. They do go together.
Q As you are coupling it there, and the social worker saying “this would have serious implications”, you are clearly making the connection that it is a proxy case as well.
A Well, it certainly is a major issue, yes.
Q Following that telephone call, you got the bundle of documentation from the social worker.
A Yes.
Q Which is set out, if I can take you back to 1(a), the first document in the bundle.
A Yes, I have got it.
Q You got all the material there. You have been taken through that material by my learned friend and I need not trouble you with that, but I just want to pick up aspects in relation to reports by independent people on the mother. Did you note in the material that you received the document at ©?
A Part 8 review, yes.
Q 1©.
A Oh, © in the list, you mean?
Q No, © in the tabs.
A Oh, that is different. Sorry. Yes.
Q Amongst the material you received was this chronology---
A Yes.
Q ---which you have dealt with, concerning the eldest child’s death, or events leading up to the eldest child’s death. You recall receiving that?
A Yes, it is a lot of different things.
Q Did you note in the course of examining that, at page 365, on the entry of 1 October 95, an entry from the learning support record compiled by Mrs Stones, the class teacher, about the mother, who was concerned at the eldest child’s attitude at home, and at the end, “She is obviously very keen to help [the eldest child]”.
A Yes.
Q So there being reported as a, as it were, concerned mother.
A Yes.
Q Similarly, over the page at 366, the entry of 29 November 95, again from the same source, the mother is recorded as being very supportive.
A Yes, I saw that.
Q Similarly, over the page at 367 there is recorded, on the first of the many entries of 3 June 1996, halfway down, here the mother is recorded as apologising on behalf of her child for saying or doing something which he should not have done.
A Yes.
Q So the picture coming through from independent people, is it not, is that here is a mother supportive of both her children, and supportive of the school?
A Those items certainly show that.
Q In relation to the youngest child, can I take you to (d), which is the next tab, and take you to, at the bottom, 372.
A Yes.
Q You will see again this is an entry, going to the first page at 370 of these contact sheets we see that the date is January 1998.
A Yes.
Q So now we are dealing with the younger child rather than the older child.
A Yes.
Q It appears, and I will be corrected if I am wrong, that that date carries on to the next page 371, and the same date carries on to the next page at page 372. We are certainly talking January 98 here. There is a photocopy in which, as ever, we cannot completely see what the dates are on the left hand side, but I suggest to you that it is immaterial what the date is for the purposes of my question, but we are talking January 1998?
A It looks as if it is a continuous record, yes.
Q Did you note when you examined the papers that there was a discussion, which we see from the second line, with a lady from the child’s school?
A Which page?
Q We are on 372.
A Right. Yes, got it.
Q There was a telephone call from someone at the youngest child’s school.
A Yes.
Q Did you note, when you were looking at the papers, about halfway down, just above the second hole punch in my copy, the comment that in December 1997 the mother had contacted the school asking how best to support the youngest child in class?
A Yes.
Q Again, the same picture, would you accept, is coming through in relation to the treatment of the youngest child as with the oldest child, she was supportive of the school and was concerned?
A Yes.
Q Carrying over, again in relation to the material that you received and I asked whether you noted, you also got a number of witness statements that were in your initial pack, if I can put it that way, and that included a witness statement at (i) of the head teacher.
A Yes.
Q Which is a witness statement that starts at page 418 and goes on, for my purposes, to 428. Did you note, when you were looking at the papers, the passage at the bottom of page 428, where the head teacher says:
“…it ….. [seems] to me that [the eldest child] was extremely well supported by [the mother and the father] and teachers and support staff at school”?
A Yes.
Q He made the global comment that:
“It would be helpful if all parents could show the same level of interest and positive support for their child and be ... prepared to work with the school as Mr and Mrs [M].”
Did you note that comment?
A I did note it, yes.
Q Again, going through to (j), we see there was a witness statement by the class teacher Mrs Stones.
A Yes.
Q Which begins at 430, but for my purposes can I take you, please, to 438. Did you note the passage in the middle of the page, where the class teacher records that:
“Mrs [M] was obviously a very caring and concerned parent with whom I kept up a regular dialogue, as we both wanted the best from [the oldest child]”?
A Yes.
Q Finally on this aspect, later on in the statement, and can I take you to page 442, and ask you if you noted the passage at the top of 442, where the class teacher was saying:
“Over the year Mrs [M] was a concerned parent who kept up a continuous dialogue with the school.”
A Yes.
Q So would it be fair to say that the picture that you got when you received the papers from the social worker was of a concerned mother in relation to each of these children?
A Yes.
Q Who was supportive of the school in what they were doing in respect of each child?
A That is what the documents say.
Q Again in the pack, as I put it, all the documents that you received from the social worker in the January, also included what is known, perhaps in the jargon, as a Part 8 report.
A Yes, I did.
Q Can I ask you to look at 1(m), please. Is this the Part 8 report that was being referred to in your enclosures with the letter from the social worker?
A Yes, it is.
Q It was a review carried out, by, as we see at B1, it was a Joint Strategy Group to consider all the reports and to decide whether there was any learning to be obtained as a result of the death of this eldest child.
A Yes.
Q Did you note that on page 2 they set out the facts as they saw them?
A Yes.
Q Including recording at 8C the fact of an inquest and the fact that an open verdict had been recorded. You see at paragraph 8C?
A Yes.
Q Did you note that?
A Yes.
Q Going over to page 3, at paragraph 4 did you note the conclusion – sorry, going back to page 2 we see that there is a heading called “Outcome”.
A Yes.
Q Which is effectively the decision of the Review Panel?
A That is right.
Q They say in paragraph 1, page 2:
“The Joint Strategy Group have reviewed the actions of the several agencies concerned.”
Can I take you to paragraph 4:
“Whilst the number of attendances at the local Accident and Emergency Unit was slightly unusual, none of the attendances in themselves was serious and there is no indication that they were anything other than accidents.”
Did you note that conclusion in the Part 8 report?
A Yes.
Q Over the page, in respect of the conclusions at E, did you note that under E4 that, as far as the police were concerned, there were no issues arising from their involvement with the eldest child and his family?
A Yes.
Q Would it be fair to say, Professor Southall, that remained the police view, certainly up until the time that you became actively involved in this case?
A Yes.
Q The police saw no reason to doubt the open verdict that had been recorded by the coroner?
A That is correct.
Q Also in the initial pack that you got was a list of injuries to the respective children?
A Yes.
Q Can I take you to 1(b). At page 361 with (b), these are the list of injuries you were given in relation to the youngest child?
A Yes.
Q Did you note within those the ages of each admission to hospital?
A Yes.
Q Did you note that of those eight, the last four of those admissions had been when the child was over nine?
A Yes.
Q Did you also get a list of the injuries on the hospital entries in relation to the eldest child at page 362?
A Yes.
Q There were twelve entries there. Did you note the feature, that the last six of those entries were when the child was aged over eight?
A I make it five, but yes, that is fine, yes.
Q I will give you five, too! There are several important issues, are there not, Dr Southall, arising out of those two records. Perhaps I can put them to you and ask for your comment. It is very rare, is it not, for parents to induce accidents or trauma as a presentation of induced or fabricated illness?
A It is not very rare, it is rare. It is more common for them to induce illnesses than injuries, but in my list at the beginning, which you went through, I did point out that physical abuse is also a feature of some of the cases.
Q I think you accept my basic proposition, but for the description “very”, that it is rare?
A There are a number of cases in the world literature where parents were involved in this type of problem. I vividly remember a nurse who was hitting a child with a hammer and breaking a leg on repeated occasions and presenting the child to hospital with injuries, so it does happen
Q I am dealing with the basic proposition that it is rare for trauma or accidents to be a feature, it is much more common for illnesses?
A Exactly.
Q The second proposition, which I wish to put to you for comment, is that another factor which takes this, I would suggest, out of Munchausen’s syndrome by proxy area is that as the children were as old as they were, that, in respect of the last series of accidents, it would require them to cooperate in some way with the mother to produce these accidents or this trauma. It is not an occasion of a mother bashing a young child?
A This is not, no. If it is part of that syndrome, it would require the child to, not so much cooperate, but perhaps be too frightened to reveal what is happening to the hospital. But it does happen and there have been publications on it, but it is not common, it is rare.
Q You broadly accept two of my propositions that militate against the finding of Munchausen’s syndrome by proxy; one is the fact that they were accidents and the second one is the age of the children?
A Yes.
Q Is it not a third factor that militates against a finding of Munchausen in this case, that these injuries there recorded are not typical non accidental injuries, they are more typical of pure accidents, if I can put it that way?
A You have to be a bit careful there because of the burn. Burns are quite a worrying injury and especially – it is not available now, but when later we looked at it there had been a four day delay in presenting the child to hospital with the burn, so that is a worry with any injury. There was also the baby injury, but that is not listed on this either, so at this particular time, which is what we are talking about, the issue that would be – the only thing that would be – particularly needing investigation from what is here would be the burning incident.
Q Basically, looking at these, I suggest that, apart from a slight query as to that, we have here a whole series of accidents that appear to be just that and do not have the hallmarks, of which you are familiar, of non accidental injuries?
A Yes.
Q That, I suggest, is a third factor that a skilled clinician like yourself, looking through, would say, “There are three matters here but not pointing towards Munchausen’s. Is that fair?
A Absolutely fair. As you know, my first report would have had the title “Very Preliminary” because I needed to look into this in a bit more detail. What was more concerning – if you recall a list in my report of the background information – was the violence in this family and the allegations of rape and so on and the very fact that this little boy had died at the age he had in the way he had.
Q I want to take you through a number of contacts which you had with the local authority and with others. Can I explain to you right now what the purpose is. I am trying to get a picture of your mindset, where you are coming from?
A Absolutely.
MR TYSON: The first of what I say is an example of that is that on the first telephone conversation, even without the documents, you are saying that you believed that this was a Munchausen case. Can I take you to your second matter, which I say shows your mindset. I have dealt with 23 January, can I take you to 28 January and ask you to look at the contact sheet at 1(v), page 96.
THE CHAIRMAN: Mr Tyson, I think we should probably not run through until 1 o’clock without a short comfort break, if you could suggest a point.
MR TYSON: This is as convenient as any.
THE CHAIRMAN: We will take ten minutes.
(The Panel adjourned for a short while)
MR TYSON: I was exploring with you, continuing to explore with you, your mindset leading up to the interview you had with the mother. Can I take you, as I was about to, to 1(v) at 96. Can I take you to the entry on 28 January 1997 where it says, on the fourth line down:
“Clive Bartley and myself visited Professor Southall...”
A Yes.
Q “... to discuss this case”. By that time, presumably, you had read all the material that you had been sent
A Yes.
Q by the social worker. It says:
“...now that he has the full information, having considered all the information available he is still of the opinion that mother has a Munchausen syndrome and that this would lead to [the child] being at serious risk of harm from her.”
Can I emphasise the word “still” there to you. You were in fact confirming, according to the social worker in her contemporaneous note, that this mother did in fact have Munchausen’s?
A Okay, perhaps I could just come in now because I just want to be clear about something. In my preliminary report, my “Very Preliminary Report”, I did not mention Munchausen’s syndrome. What this is about is that, as you know, Munchausen’s syndrome and Munchausen’s syndrome by proxy have been changed to fabricated or induced illness. There are reasons for that, and I was involved in all that. What we are looking at here is the possibility of life threatening child abuse; that is the possibility. That was the encompassing concern that social services, the court and I had. When it is written here that the mother has Munchausen, that is not my words. My words would be that with all the background in this case, all the concerns being raised, there is a worry, a serious concern, of the possibility of life threatening child abuse. That would be my phrase rather than the word “Munchausen”, which is not my word.
Q Can I suggest to you, and if I have an opportunity I will suggest also to the social worker, that that is precisely the word that you used and that is precisely why she wrote it down contemporaneously at the time.
A Obviously you must do that, but the word “Munchausen’s syndrome” I still felt at that time that the mother might have Munchausen’s syndrome, the mother. I think by then I had heard from the Family Court
Q No you had not, this is before the Family Court?
A Is this before the judge?
Q The judge was March, this is now January.
A You are right about that, absolutely.
Q All you had was the material you were given at (a), that is all you had.
A Okay, I am getting mixed up with later.
Q We are talking 28 January. What I am suggesting is that you used the words to the social worker on 28 January that the mother still had Munchausen’s?
A That does not mean Munchausen’s syndrome by proxy.
Q I accept that.
A There are a number of features that were there then, more later, but there were quite a lot there then suggesting that that might be correct.
Q I wanted to take it further, that you were suggesting, and told the social worker, that mother did in fact have Munchausen’s syndrome?
A How can I answer that?
Q I have to put it to you so you can comment. That is what I do, I formally put to you that that is what you told the social worker on 28 January, that the mother did in fact have Munchausen’s.
A That is funny because I did not put it in my report. It is possible that that is how she heard me. Certainly I was concerned about the mother having all these features that could fit that.
Q If we could move on. As a result of your diagnosis, I suggest that you said that, “This will lead to...” the social worker’s notes goes on, “This will lead to the youngest child being at serious risk of harm from her”.
A It would if that was the case.
Q Do you not think, if this note be right, you had leapt to a conclusion based on insufficient evidence to come to that conclusion at that time?
A That is a matter of opinion. Obviously I had a lot of experience, unfortunately, as you know, in these kinds of cases; probably more experience than anybody in this country, so I was basing it on my experience. You can say, “Well, is that not a bit too premature?”, and that is an opinion which I can see where you are coming from with it, but
Q If it be correct that this note is right?
A You did say that, which is fine, which makes it fine, yes.
Q On that hypothesis, it is far too soon and you have not covered the appropriate investigations for you to come to that firm diagnosis?
A Of Munchausen’s syndrome in the mother, in the mother only?
Q Yes?
A Not as a firm diagnosis and that is why I had not put it into my preliminary report.
Q Can I take you to the witness statement that the social worker made as a result of that meeting. We go back to 1(u) in the fifth paragraph down, “On 28 January, myself and my team manager visited Professor Southall”. Do you have that passage, it is on page 3 of the witness statement?
A Yes.
Q
“On 28 January myself and my Team Manager visited Professor Southall who had opportunity to read all the relevant documentation. He confirmed his belief that [the mother] had Munchausen syndrome, and that she presented a high risk to [the youngest child], it was his opinion that we should remove the youngest child the same day.”
A That is true.
Q Again, I would suggest support for the proposition in this legal document that you had used the word “Munchausen’s syndrome” in relation to the mother to the social worker.
A It looks – almost certainly I did, but that is in relation to the mother, not in relation to the whole picture.
Q It does, does it not, make it in relation to the whole, because you made the important link that, as a result of that, she presented a high risk to the child?
A It is not just that, it was all the other things that were worrying. In fact the police had said, had they not, that they wanted an EPO even before this?
Q You did not know this at this time. I am dealing with your knowledge?
A I did not know that, but I did find out subsequently.
Q I am dealing with what you said so the social worker, and you were putting the link that this was not only Munchausen, I suggest, but Munchausen’s syndrome by proxy because you are saying to the social worker, “The mother has it and thus she presented a high risk to the child”?
A You just put the word in that matters. He confirmed his belief that Mrs M had Munchausen’s syndrome and...” not “thus” she presented, “...and that she presented”. It is because of all the other information as well. You put that word “thus” in there and it is not there, is it?
Q It is in the contemporaneous note. Move on to (v), which we were just looking at, at page 96.
“Having considered all the information available he is still of the opinion that mother has Munchausen syndrome and that this will lead to [the youngest child] being at serious risk of harm from her.”
When I say “thus” I take the thus from the contemporaneous note of the social worker.
A That is this note. I accept that that is what she said there.
Q And I suggest that that is what you said to the social worker at the time.
A I might have said a lot of things. This is her interpretation of it and you will have to ask her what she thought, but I thought there was a constellation of issues including the possibility – strong – that the mother had Munchausen’s syndrome, that placed this child at risk. The biggest issues were to do though with domestic violence, the fact that the child was allegedly ---
Q Just pause there a moment, this is not what is said in this report, is it?
A No, I agree, it is not.
Q At this time, on 28 January, you were saying because the mother has Munchausen’s syndrome this will lead to the child being at serious risk of harm.
A I was not saying it, this is a report of somebody else as to what I have said. That is completely different. I am not denying that there were elements of this which are really correct, but what I am saying if you look at my report is that I was looking at a bigger picture involving all the other issues which I was just giving you then, which I will repeat again.
Q You can repeat them if you like, but I am going to move on. I suggest to you two things that it is important you should know: that this was an over-hasty diagnosis of the mother.
A I know you are suggesting that.
Q Secondly, I put to you formally for your comment that you were saying that as a result of the diagnosis of the mother you led that to be inevitably causing a risk of itself to the child.
A Of itself, Munchausen’s syndrome in a parent does raise the risk of life-threatening abuse, but in this case I was concerned about all the other things as well, which were arguably more serious and it was why I put them into my report.
Q The note here is that of itself this will lead to the child being at serious risk of harm from her.
A Yes, this is Francine Salem’s notes.
Q Can we move on, please, to your report at (t)? Again, I want to pick out two passages within (t) to show your mindset. You will see that that is your report and it starts at page 177.
A It is, yes.
Q Can I take you, please, to page 181? You set out in the second paragraph a description of the mother’s account of the death of the eldest child.
A Yes.
Q Can I take you to the third paragraph, please? You say:
“Reading this history I am struck by how extremely unlikely a story it is. I just could not imagine Mrs M had not heard some sound as a result of [the child] hanging himself. I would also like to know a bit more about how he could actually have tied this belt around the curtain rail in such a way that it would be strong enough to resist breaking or the knots coming undone. He was only 10 years old. In my experience 10 year old children do not kill themselves, especially not in this way.”
A Yes.
Q On a mindset point of view you were already, at this early stage in January, challenging the account of the mother that she gave as to the circumstances of the death of the eldest child. That is fair, is not?
A It is fair, yes; I was.
Q Just dealing with the last point, “In my experience 10 year old children do not kill themselves, especially not in this way”, subsequently did you have the opportunity of reading reports by others prepared in these proceedings?
A Yes, when I wrote this one I had spoken to Dr Bentovim who is an expert on this as well.
Q Could you please answer my question, did you subsequently see the reports prepared in these proceedings?
A Later you mean.
Q Yes, subsequently, by Dr Black.
A I did.
Q And by Professor Stephenson.
A Yes, I have seen those.
Q You were instructed only by the local authority.
A That is right, yes.
Q Professor Stephenson is a consultant paediatrician instructed by all the other parties in the case.
A Yes.
Q He was instructed by the mother; who was in turn separately represented from the father.
A That is right.
Q Who was in turn separately represented and the child was again separately represented.
A That is right.
Q It is right, is it not, that Professor Stephenson was instructed by those three other parties: the mother, the father and the child.
A I think that is correct, yes.
Q We will come to this report in more detail later, but do you remember the comment made by Professor Stephenson where he said, based on research, that suicide in 10 year olds is extremely rare, but if suicide at such a young age does take place, hanging is apparently a quite common mechanism?
A Yes, this is mostly from the United States of America, and I expect it, it is a very good opinion actually, but from my experience it was extremely rare.
Q Not in this way, “especially not in this way” is not supported by the research, is it?
A Not by the research, no. I accept that.
Q Again, just dealing with your mindset, here you were doubting the mother. Can I take you further within the report to the last paragraph of the report itself at page 184, where you said:
“Information about [the child’s] death needs to be identified, in particular the post mortem report. For example, was any toxicology undertaken, was there any skeletal survey undertaken? All of these issues are potentially very relevant to the current situation.”
A Yes, that is correct.
Q You were focusing, I have to suggest to you, on the cause of the death of the eldest child.
A I was, yes.
Q Because you believed, did you not, that if it could be shown that the mother had harmed the eldest child there was a serious risk that the youngest child would also be harmed by the mother.
A Exactly. The issue on the accident side and the suicide side had already been very extensively investigated and so I was left to deal with this ---
Q You did not know that at the time, we are still dealing with your state of knowledge in January.
A The Part 8 Review had been done, which did discuss the bullying issue, it did discuss those issues.
Q Your mindset ---
A I accept that my role, if you like, was to look in particular at that third scenario as the cause of the death of the first child, because of the very reason you said, which is it could, if it was true, place that living child at great risk.
Q That was your particular focus, is that a fair assumption?
A It is my particular focus, it is my particular expertise, that is why I was involved in it by the people who involved me.
Q There came a time, would you accept, when it ceased to be the local authority’s focus? Whereas it might have been yours, it was not the local authority’s focus. Can I take you, to support that proposition, to the judgment of the judge who looked at the matter in March. Could you look at the document at C4, please? Just to help you, for technical reasons you were unable to appear at this hearing, is that correct?
A No, I could not be there.
Q If I could take you through passages of the judgment, you are aware that the local authority, supported by the children’s guardian, were seeking the child to remain with foster carers and the parents were seeking the return of the child, that was the issue.
A Yes, they were seeking an interim care order.
Q As part of the interim care order they were seeking to retain the child with the foster carers.
A Yes.
Q To come to the end, before I deal with the beginning, the local authority and the guardian did not succeed in their application for an interim care order.
A I agree, they did not. That is what they wanted.
Q And the child was in fact returned in March on the date of this judgment.
A That is correct.
Q Picking it up at page 3, between F and G, the judge set out ten matters which the local authority were initially relying on.
A Yes.
Q Those ten matters are all set out on page 4. Number nine is just above G where it says, “Ninthly, the assertion that the circumstances of Lee’s death are questionable”?
A Yes.
Q Do you see the judge’s comment in relation to both 9 and 10 where he says: “These last two points were not pursued in evidence”?
A That is right.
Q If we go over the page at 5 we see recorded just above B the matters which Mr Bartley, Ms Salem’s manager, relied on; the judge sets those out between B and D and then at D he sets out the matters that Mrs Inwood, who I think was the children’s guardian, relied on.
A She was the guardian.
Q You will note what the judge says just above F where he says:
“Notable for its absence in those lists of grounds on which it is said that the threshold is crossed is the suggestion, which was a significant part of the local authority’s case when the Emergency Protection Order was obtained, that it was suspected that the mother suffers from Munchausen’s syndrome … by proxy.”
A Or the syndrome.
Q Yes, from the syndrome or the syndrome by proxy. You note the fact that the judge said,
“Notable for its absence [from the] grounds … that it was suspected that the mother suffers from Munchausen’s syndrome or the syndrome by proxy.”
A Yes. As you know, I was unable to give evidence there and the evidence would have been along the lines that you are talking about perhaps, nine and ten anyway – particularly nine. The guardian pointed out under three the mother’s medical history which may lead M2 to be preoccupied with such matters.
Q Can you carry on answering my questions, please? You note that the judge went on after G:
“There cannot be any doubt realistically that this was at the forefront of the local authority’s mind when the Emergency Protection Order was sought, in particular because they sought to consult and did consult, Professor Southall, although he does not make reference in his report to Munchausen’s.”
A That is right.
Q “It must be for this reason that the application for the Emergency Protection
Order was made in the terms that there was a fear that Dale could suffer at the hands of his mother, and Mrs Inwood’s report dated 27 February, but written earlier, gave prominence to this aspect.”
A Yes.
Q Can I ask you now, please, to turn to page 7, just below C?
“I do have a written report of Professor Southall which is expressed by him to be ‘very preliminary’, which to me sounds a note of caution. This report was not prepared for litigation but by way of advice to the local authority before they sought the Emergency Protection Order. It was prepared at a time when the local authority perceptions of the problems were very different from what they are now and his advice was given in the context that it was feared at that time that [the youngest child] was at risk ‘at the hands of his mother’. Things have moved on since it was written.”
It is right, is it not, that by March 1998 things had moved on as far as the local authority were concerned and they were not pursuing the concept that the youngest child was at risk at the hands of the mother. That is plain, is it not, from the transcript itself.
A That is what it appears to imply, yes.
Q It is in this context that one has to look, I would suggest, at the instructions that you were given. Can we look, please, at 1(x), page 3? Whilst keeping that page open could I ask you to look at another C document that I am going to produce.
THE CHAIRMAN: This will be C18. (Document C18 distributed).
MR TYSON: This is the report that I referred to earlier from Professor Stephenson?
A That is right, yes.
Q Go to what you were asked to do, and we see this on page 3 of C1:
“In preparing your report could you particularly address the following issues:
1. The implications of the family’s (including both parents and [the eldest child’s]) medical notes in the context of the functioning and history of this family and the possible implication for the care of [the youngest child].”
A Yes.
Q You are being asked to look from a medical point of view at the implications of the family’s, including both parents and the eldest child’s, medical notes in the context of the functioning and history of this family and the possible implications for the care of the youngest child. This was a medical investigation that you were asked to carry out by looking at the medical notes?
A Yes, the medical notes were important to make sure that there is not Munchausen’s syndrome by proxy.
Q Equally, you were asked to look as a medical matter at number 2:
“Whether the children’s [and the parents’] presentations at GPs and hospitals are unusual and if so consideration of the impact of the presentations to GP/hospitals on [the both children’s] physical and emotional development.”
A Yes. 1 and 2 go toward the issue of fabricated or induced illness. They are essential components of making sure it does not exist.
Q That certainly became your interpretation of those?
A That is my understanding of what I was being asked to do.
Q Again, you were asked to look at and come up with your concerns and 3, looking at the medical notes and the history of presentations. Then at 4 ---
A I am sorry. I did not take that 3 to mean just the medical notes. It says, “The concerns raised in the papers.” The papers, I took it to mean, are all the papers that are in the court arena, including my own report, which included the concerns I had. It does not just mean the papers from the medical notes.
Q Then at 4 you were asked to comment, if you felt able to as a paediatrician, on the youngest child’s condition. Then he was also going to be examined by a consultant psychiatrist. At 5 you were also asked ---
A Can I just answer? I would not have been able to do 4 without seeing M2, and I do not think there was leave for me to see him, so I did not.
Q That is correct. And 5 follows and falls for the same reason, does it not?
A It does, yes.
Q You were asked to advise –
“on any management plan, treatment and prognosis, including potential for change”?
A Yes.
Q You were also asked to look at the local authority’s concerns that the youngest child’s pattern of medical history shows a similarity to that of the eldest child. It is quite clear, is it, that you were not in terms asked whether there is Munchausen’s syndrome by proxy here?
A The words are not used in this but I understood that one of my main roles was to look for that by looking at the medical notes of the family and so on.
Q You were not in terms asked whether the youngest child was at risk of harm from his mother?
A Hang on, that is the whole basis for this whole case, to make sure that is not the case. That is what my job was, to help the social services and the local authority find out whether or not this child was at risk of abuse. That was what I was there for.
Q You see, I have to suggest to you that by the time that this report was written, the local authority’s initial concerns about the child being at risk of harm from the mother had, in the judge’s words “moved on” and that it is in that context that you have to look at these instructions. I suggest to you for your comment that it is significant that you were not actually asked whether this was a Munchausen’s case.
A As I said to you before, I do not think we should get hung up on the word ‘Munchausen’s’; we should look at the whole picture. My involvement was to find out whether or not there was a risk to the second child at all from the possibility of abuse. It was scenario number three that I talked about because the others had been dealt with.
Q Could you accept from me that you are not directly asked to answer the question which you thought was important? It is a matter of fact, is it not, Dr Southall? You were not specifically asked?
A What? The words ‘Munchausen’s syndrome’ are not used; I accept that. What I am saying, though, is that if you look at 1, 2 and 3 – 4 and 5 you cannot – and 6 and 7, they are all relevant to the possibility, I put it no higher than that, that the child was at risk of abuse and that was what my job was.
Q Can I ask you to look by way of comparison at page 16 of C18, which is Professor Stephenson’s report? You see that in a number of significant risk facts it follows what he was asked to do by all the other parties. To a significant extent, it follows what you were asked to comment on. Do you want to absorb what those matters are? (Pause)
A Well his number 6 is, “Is there any evidence of factitious illness by proxy?” which is the same.
Q He was directly asked to deal with that matter whereas you, I suggest, were not directly asked to deal with that matter because the local authority’s concerns had moved on from March, as we can see in the Tonking judgment?
A That is the judgment of the judge. I think the local authority and the guardian wanted the interim care order because they were concerned and their wishes were not granted.
Q I do not want to go over this again. Their concerns were other concerns about the child, not the concern that the child was at risk of direct harm from the mother. That was not pursued by the local authority and the local authority concerns in that particular respect had moved on.
A Well, I do not believe that they had, from my discussions with them at the time.
Q I suggest to you that it is significant that you were instructed by the local authority not directly to look at factitious illness by proxy because that was no longer a concern of the local authority?
A Why then was Dr Stephenson much later asked to do the same thing if that was not what I was being asked to do?
Q It was what he was being asked to do by the other parties but not by the local authority.
A That does not make sense, does it? Why would he be asked later to do something that I was not being asked to do earlier in the course of this?
Q Can we move on to show more about your mindset, please? You got those instructions at the end of March. I need to take you to 20 April and back to 1(v) at page 100. Do you accept that on 20 April, at the top entry there, you rang the social worker questioning whether a curtain pole could actually take the weight of a 4 year old boy ---
A A 10-year old.
Q Sorry, take the weight of a 10 year old boy and he based his concern on the average weight of 30 kg for a 10-year old boy and he felt that the police should be looking closer into this.
A That is right.
Q Pausing there for a moment, first of all, would you accept that you are again focusing on the death of the eldest child?
A Yes.
Q Are you not in this report providing the solution as to how the investigations into the death of the eldest child should be carried out, notably by a relevant expert, the police?
A I was suggesting that there was some further investigation needed.
Q Was it not actually the police’s function to investigate the death of the eldest child and not yours as a sort of amateur sleuth?
A I am not an amateur sleuth. I am a paediatrician with an expertise in life threatening child abuse. There is a complete difference. I do not go out and do the tests on the curtain pole. I could not do that. I left that to them. I said, “Please can you check that for me so that I know the answer to that question?”
Q Would it not be more appropriate to leave all your concerns, having listed them, for the police to investigate rather than for you to investigate subsequently at an interview with the mother?
A Well, that is not what I have been doing for years, and for years I have been supported in doing the work I have been doing. The results are well known.
Q And, I am sure you would accept, controversial?
A It is difficult to be controversial when you have 32 cases of intentional suffocation documented by covert video surveillance. You cannot say they are controversial insults or abuses. They are factual.
Q You are being focusing on your mindset. There came a time subsequent to this conversation with the social worker where you got the coroner’s material?
A Yes.
Q We see that at 1(y). Looking at the first page on (y), which is page 185, the manuscript on page 185 is all yours?
A Yes. It is.
Q Would it be fair that this highlights the concerns that you had, having read the material from the coroner?
A Yes. The toxicology was most important from there, the lack of it rather.
Q Again you are focusing on this one aspect of the cause of death of the eldest child?
A Yes. This was what I believed my function was throughout.
Q Then, having got that material on, as we see, 23 April, can I take you back to 1(v) again to what you were saying to the social worker a few days later on 27 April?
A Yes.
Q There we find that at the bottom of 101. The day before the interview you contacted the assessment team to request that Ms Salem be present?
A Yes, that is right.
Q She has set out the grounds that she recorded that were going to be discussed on 102?
A If I was not supposed to be doing this, she would have stopped me at that point. If that was not seen to be my function, surely the local authority would have said, “No, Mr Southall, I do not want you to do this. This is not your role and we do not want you doing it”? The fact that she has written it down is further support for the fact that that is what I thought I was supposed to be doing.
Q Who the belt belonged to?
A Yes.
Q How it was wrapped round the pole? Was toxicology done (it is spelt wrongly there)?
A Yes.
Q And questioning the needle mark?
A Yes.
Q You felt that it would be useful if a social worker was present?
A Yes.
Q There are two points out of that note. Firstly, you would agree that all those points are focusing on the cause of death of the eldest child?
A Yes, although I know that I was supposed to be doing more than that because the instructions that I went through earlier included other issues.
Q And secondly, with your considerable experience of child care work, I am sure that you would accept that when social workers who are responsible in some way fro taking a child away, they are not perceived by the parents as being their friend?
A I do not think that is fair at all. I think that many, many senior social workers in this position come to have very good relationships with the families they are involved with, even if there are difficult areas around the question of abuse or ill treatment.
Q That is nonsense, is it not, Professor Southall? The social worker responsible for taking a child away is universally regarded by the parents as being part, if I can put it this way, of the enemy camp?
A It depends. I do not think you can have an overall picture like that. It depends on the family and so on.
Q You have heard how Mrs M herself describes the social worker in this case as, I think her phrase was and I will be corrected if I am wrong, challenging rather like Dr Southall?
A I cannot remember the exact phrase, but I agree with you that in Mrs M’s evidence she was antagonistic towards the presence of the social worker, yes.
Q You gave evidence that one of the purposes of having the social worker there was to protect yourself, amongst other things?
A And support the mother, the two functions, and also just to add in anything if it was needed.
Q The supporting mother role was a nonsense, was it not, Dr Southall? She could not and would not, because of her very position, be in a position to support the mother. She was no friend of the mother.
A Well, I am going to question this. I think you will have to ask her about that, because I am not of the view that all social workers are regarded as the enemy camp by parents in this situation at all, and, after all, the child had come back to the family at this time.
Q She was a leading member of the institution that had taken her child away from her.
A It is a very simplistic view. I mean, I do not subscribe to your view, but I see where you are coming from, but I do not agree with you.
Q I have to suggest to you that you so arranged matters that when the mother arrived, she was faced (a) with you, and (b) with someone who was clearly “not her friend”.
A Well, we have been through that.
Q You said to the Panel that your plan was to see both parents together.
A Initially together, and then individually. That would be the normal approach.
Q Can I ask you, please, to look at what you told the local authority’s solicitor in this context, amongst others, at 1(dd).
Madam, if that is a convenient time, that might be a convenient time.
THE CHAIRMAN: I think it is clear that you are not going to be able to finish this.
MR TYSON: Alas, no.
THE CHAIRMAN: So we should break now. It is coming up to ten past on the clock in here. We will break until 20 past 2, and I can indicate that the Panel is going to take a slightly longer break because we will be, among ourselves, looking at diaries. That is the reason for making it slightly longer.
Dr Southall, I have to warn you about not discussing the case over lunch.
A Sorry, I missed the time that we are starting?
THE CHAIRMAN: 20 past 2.
(Luncheon adjournment)
THE CHAIRMAN: When you are ready, Mr Tyson.
MR TYSON: Dr Southall, I was taking you to the period just before the interview that you had with the mother.
A Yes.
Q I was about to take you to C1 at (dd) at page 71.
A Yes.
Q This is a note taken by one of the legal officers within the local authority, “MGG”, and it appears to be a Ms Garrard.
A Yes, I think so, yes.
Q I think it is agreed between the parties that despite the date on this note it was taken prior to that date.
A Okay.
Q Because it refers to arrangements being made before that date.
A Yes.
Q So there is no dispute about that. You were taken to this note by Mr Coonan, and this was a note of a telephone conversation with you with this legal officer, and you, in the first paragraph, you will see, said that you wanted to see both the mother and the father and the little boy.
A Yes.
Q You were anxious to stress that it was important to get to the bottom of this matter, and “He feels that he will see the parents separately”.
A Yes.
Q Slightly inconsistent to what you told the Panel earlier, is it not?
A Not really. I mean, it says, “(although he didn’t mind if they travelled up together)”. I would have seen them both to start with, preliminary discussion, and then I would have seen each of them individually.
Q Indeed, the matter in the brackets emphasises the point that you really wanted to see them separately so in a sense they did not pollute each other; is that a fair way of putting it?
A Not really, no. It is so that I could hear both of their views.
Q Separately but not together.
A Separately, yes.
Q Thank you. Then, again going back to what I put as the mindset point, it is clear from the third paragraph that you are again concentrating on your concerns about the curtain pole.
A Yes.
Q Then in the fifth paragraph you are recorded as saying you were concerned that:
“if evidence comes from the police investigations that Mrs [M] could have killed [the eldest child] then [the youngest child] will be at risk”.
Pausing there for a moment. Were you not accepting then that it was a matter for the police to determine the issues as to whether there had been a killing in this case?
A I mean, I asked for certain things to be done of a police nature, like checking the pole and looking for the toxicology and so on.
Q Is not, as it were, carrying out the interview with the accused, or possible accused, also a part of the police investigation?
A If it got to a criminal state, yes, but this was not criminal proceedings, these were Family Court matters. Our concern, or my concern – I would say “our” concern really – was the safety of the second child.
Q So as we have seen, of all the references that I have taken you to, that virtually every time you contact a representative of the local authority you are entirely focused on the question of whether the mother killed the eldest child, to the exclusion of any other matters in your remit, are you not?
A No. I was primarily focused on that issue, but I was mindful of the violence that had already occurred in that family on numerous occasions, and I was also worried about the father. I mean, he is the one that had been violent. So I wanted to just try and understand what had happened by talking to her myself.
Q Perhaps you could answer the question. The contacts you had with the local authority were, as we have been through each of them, and I have taken you through them, were virtually entirely concerned, would you accept, with the issue of whether the mother had killed the eldest child?
A Yes, I said that, they were primarily concerned with that, but one could not ignore the other possibilities.
Q Can we come, please, to the interview itself. Can I first ask you why you did not explain to the mother the purpose of the interview?
A Well, I do not know. I mean, I do not know whether I did or not.
Q I suggest you did not, and you launched straight into questions about bullying.
A About – sorry, I missed that?
Q You launched straight into questions about bullying.
A Oh, okay. Well, I am sure I had a preliminary statement, but I would not have written it down, and I cannot remember.
Q Well, that is the evidence of the mother.
A Okay.
Q Secondly, again following from the evidence of the mother, can I ask you why you did not explain why the social worker was there?
A I cannot think, other than to assume that it is not unreasonable for her to have been there, and I was not of the same view as you this morning that that should be a bar to a discussion.
Q Yes. Could you again answer the question. Could you tell the Panel why you did not explain to the mother why the social worker was there?
A Well, I did not think it was necessary.
Q Can you explain to the Panel why you gave the mother no opportunity to have her own friend with her?
A I did not stop her having a friend. I would have preferred to have talked to her on my own, or on our own, but she did not request somebody when she got in there. If she had, that would have been a different matter.
Q You can imagine how daunting it is for---
A Sorry?
Q You can imagine how daunting surely it is for a woman who has arrived for what she considers to be a medical interview and suddenly finds another person there, and she is given no opportunity by you to have the person of her choice with her for this kind of interview. You gave her no opportunity is what I am suggesting.
A There was an opportunity if she wished. She could have said to me, but she did not, “I am not happy with this. I do not like Ms Salem there. I would like to have my solicitor present”, in which case I would have – it was a voluntary meeting; she could have done that and she did not.
Q The fact remains that you did not yourself offer her this opportunity?
A I did not offer her.
Q It appears from both your note of the interview and the social worker’s note of the interview that the first line of questioning was directly into the question of the bullying of the eldest child.
A Can I turn to the note, just to refresh my memory. I am sure you are right.
Q Yes. Your own note of the interview is at 1(bb).
A Right. Yes, that is correct.
Q I am not going to go through the whole of the interview, or indeed even most of it, but would you accept these basic propositions: you were asking the questions and she was answering?
A Yes.
Q The interview was not discursive, it was direct and focused by your questions.
A Yes, I think that is reasonable.
Q Again, you would ask direct and clear questions of the mother.
A Yes.
Q If you were unsatisfied with the answer, you would ask a series of supplementaries.
A Yes.
Q Amongst the matters that you discussed was the height and weight of the eldest child.
A I think so, yes.
Q Perhaps I can take you to 159, in the middle.
A I have got it, yes.
Q Can I suggest to you that when you elicited that information from the mother, you then said to her, “In that case the pole should have broken”.
A I do not remember that.
Q There was a later discussion, do you accept, about the curtain rail itself?
A There was.
Q You asked how she had tried to pull it down.
A Yes.
Q She told you that she had been unsuccessful in pulling it down because, using words to the effect of, “it was firmly attached to the wall”.
A Could well be something like that, yes – “couldn’t pull it off the wall” I have written.
Q It is right, is it not, Doctor, that when she said that, you said, “I do not believe you”?
A No, it is not. That is not correct.
Q You added, “You are thirteen stone, you must have been able to do it”.
A No, I did not comment on her weight to her directly.
Q I suggest to you that you added, “I do not believe you. You are heavier than your son”, or words to that effect.
A I cannot remember saying that, but I did not say “I do not believe you”, that is the important bit.
Q I suggest in two circumstances you said you did not believe her in relation to the curtain pole, but you are denying each of them?
A I am denying them, yes.
Q Then there was a discussion, was there not, of her role as a theatre assistant, and that discussion ended up, did it not, by you saying, “I do not believe that you have not seen an injection”?
A I did not say “I do not believe that”, because that is a direct accusation, and I would not--
Q Well, I am being straight---
A I know you are, yes, it is fine. I did not do it. I did not do that. I did put it in my report---
Q You did.
A ---but I did not do it to her face.
Q Can I just take you to your report for a moment, which is at (z), at page 29.
A Yes.
Q You see at the bottom of page 29 what you say in your report.
A Yes, I do.
Q You have added, in relation to the discussion about injections, “I do not believe this”.
A “I cannot believe this”.
Q “I cannot believe this”.
A Yes.
Q That is exactly, is it not, what you told the mother at the time?
A No. It is what I felt, but not what I said.
Q Then again in relation to the curtain pole, which is the penultimate paragraph in that, please:
“…Mrs [M] points out that she is between 13 and 14 stone in weight and, even with the additional weight of [the eldest child] hanging from the curtain pole, she couldn’t pull the pole off the wall.”
A Yes.
Q You say, “I find this very difficult to believe”.
A Yes, that is right.
Q I suggest that is exactly what you told her at the time. Going back to the---
MR COONAN: Can we have an answer to that?
MR TYSON: Yes.
A That is a bit more in the direction of something I might have said, because it is not a direct accusation, if you like, but I would not have said it like “to believe”, I might have said, “Oh, that is a bit unlikely because you are so heavy” – well, “the combination”, not “you are so heavy”, “the combination is very heavy” – but I would not have said an accusation about it. That is the main difference between the way I am talking then and what I write in my report.
Q Again, in relation to the curtain pole, you have made the comment in your report that you found it very difficult to believe, and I suggest that you expressed that directly to the mother at the time of the interview.
A I do not think so.
Q You remember asking a series of questions about the belt?
A I do, yes.
Q Is it right that you indicated to her that it was vital evidence that you required to know?
A I do remember that, yes. I do remember saying that I would like very much to know the answer to this.
Q You explained, did you not, to her precisely why it was important that you knew, because you commented to her that there was no toxicology report in this case?
A I did tell her that. Well, that was in response to her saying to me that this would have – I think it was – her saying to me this would have been checked at the post mortem, because I think that is what most people would imagine would happen.
Q I have to suggest it went the way I am putting it to you, that you said to her that it was vital evidence---
A Oh yes, I accept that bit.
Q You explained why, I have to suggest, it was vital evidence, because there was other evidence lacking, i.e, first of all there was no toxicology, and, secondly, the child had been cremated.
A Well, I cannot remember when I found that out, the cremation business, but with regard to the belt there were two issues: one, the size of it---
Q Perhaps you can just answer my question.
A Well, I am trying to remember it, sorry.
Q The question is that I suggested that you gave two reasons to the mother as to why the issue of the belt was so important.
A Oh, I see. Right.
Q Firstly, that there was no toxicology, and, secondly, the child had been cremated.
A Well, I do not remember that being put in that way. I cannot think of the logic either, because that is not what I was thinking. I was thinking that the belt was too long (it was an adult belt), and I was also trying to think how it might have been put over the pole by a ten year old in a way that was an efficient, if you like, way of doing it so that it would not fall apart. Those are the two issues, not the toxicology.
Q And the cremation. Then I have to suggest that she demurred from telling you any information about the belt on the basis of the advice that she had had from her solicitors.
A She did. I remember that.
Q It is right also, is it not, that it followed that you indicated to her that there were reasons why this was vital evidence and that she should answer. Is it not right that you used expressions such as “A child protection case takes precedence over a criminal case”?
A No, I do not remember that, and I would not have said that either, so I do not know where that has come from.
Q Again, as part of your encouragement, if I can put it that way, of getting her to answer, you indicated that, “If you do not tell us, it is obvious you have got something to hide”.
A No, it was not put in that way. I did want to know the answer, and she did come back to me and said, “Okay, if it clears my name”, or something like that, “I will tell you how it was done”, and she then showed me.
Q I know that is the end result. I am just going through the list of inducements that you gave in order to get to that end result.
A Yes. I cannot remember them in depth, but it certainly would not have been something aggressive like you are suggesting.
Q Well, I am glad you have picked up the aggressive tone, because that is again part of my case, that you were being aggressive to this woman at this time.
A I deny that I was being aggressive.
Q Again, I suggest that, as part of the inducements that you gave in order to get an answer about the belt, you suggested to Mrs M that “Your solicitor has given you wrong advice”.
A I cannot recall that statement. I will just check my notes, but I cannot recall that statement at all, because that is criticising another professional.
Q Can I suggest to you that that is exactly part of your persuasion for her to tell you and to demonstrate about the belt.
A I cannot find anything written, but I do not recall doing that, no.
Q Lastly, I suggest that the, as it were, fifth way almost that you used to induce her to tell you how the belt was tied, you said to her words to the effect, “It is important to prove your innocence”.
A No, that was her saying that, “If it will prove my innocence...”, or words to that effect, “...I am happy to tell you”, not the other way round.
Q Again, that is a dispute the Panel is going to have to resolve?
A Of course.
Q At this stage we are taking it gently, one question by another. I suggest that all these matters were being fired at her in one sequence, “You have to tell us; child protection comes first; if you do not tell us you have something to hide”, one following the other, following the other?
A Sure. That is not how it was. I did not rush it, I was not hammering her for information aggressively as you are saying. It was not like that. I think also, just looking at the notes, it seems as if I was putting difficult areas and then less difficult areas into some kind of, sort of, giving a break every now and again from what were obviously very difficult issues for her as well.
Q I suggest that when she was persuaded by your many points that you put to her as to why, she did in fact demonstrate using, I think, pencil and string or something like that?
A Something like that. I cannot remember what exactly it was, but it was something like that, yes.
Q When you saw the demonstration, you remarked, did you not, “Ah,very clever”?
A I think I did say something like that because prior to that I thought it was very difficult for a 10 year old to think of a way of doing it and I had not easily thought myself of a way. So, when she showed me I was struck by it, yes, and I might have used the word “clever”, I may well have done. It was not sarcastic, it was – I cannot really say – it was just trying to say that, “Okay, that is a reasonable…”
Q You anticipated my next question because it was said, was it not, in a sarcastic manner to this woman?
A I do not think so, no. It was not meant to be. It was meant to be, “Okay, so that is an important – you have shown me something that I could not have understood without you showing me”, that was really it. Also, for a 10 year old, it was, you know, quite something.
Q Can we look at your notes at 1(bb), running from page 158 to 162. Will you accept from me, bearing in mind that I think you have rather clear handwriting, that there is nothing in your notes indicating the putting of the hypotheses, as you would seek to say?
A No, I do not think there is actually. I accept I could go through it, but I do not think there is.
Q This was an important part, from your particular concern, as to your focus in this case to test these hypotheses as you saw them, was it not?
A The three?
Q Yes.
A I was looking at all three, but I knew that my main role was to look at the third.
Q The question I asked you was that, as this was an important focus of your task, particularly the third, why you made no notes of either the question or the answer?
A I cannot answer that, I do not know.
Q Can I suggest to you
A I did put it into my report.
Q That is not what I asked you.
A No, I know. That is what I am just saying. I do not know the answer.
Q Can I suggest to you how it went?
A Yes.
Q You indicated to Mrs M that, “There are three ways that your son could have died”, and the first thing you said was, “It could be experimentation and thus an accident”.
A Yes.
Q Did you not go on, as it were, in answer to your own question, to indicate that you felt that that was unlikely?
A I did.
Q To her at the time?
A Yes. I think I said what was unlikely particularly was any sexual component of that because of his age.
Q Then I suggest it went like this. You said that the second possibility is that he could have hung himself?
A Yes.
Q Again, did you not supply a doubt in your mind as to that by pointing out that there had been no suicide note?
A I had gone through that.
Q I do not think you had as far as I can see?
A I think I had been through the – yes, one of the two boys who reported what he had said had a nervous breakdown shortly afterwards. He moved away and tried to kill himself by cutting his wrists when he got back, and then there is the name. That is reference to the concept of suicide, referring to the fact, something to do with the boys he had spoken to.
Q Can I just focus on the questions I am putting.
A Okay.
Q I am suggesting that you put some doubt as to the suicide possibility to Mrs M by pointing out that there had been no suicide note.
A I cannot remember whether I did or not. It is possible, but I cannot remember.
Q May I suggest that you leapt to the third possibility in these, more or less, words, “And I will put the third possibility to you. I put it to you that you killed your son by injecting him, suffocating him, hanging him up and leaving him to die”. Then you added, “I think that is what happened”. That is how it went, is it not?
A That is the allegation, and I am sorry but it is incorrect. It is also incongruous because my own view on the injection was that it was the ambulance men, and I said that in my report.
Q Equally in your report, just going away from this point for the moment, was that you wanted this checked whether the ambulance men or any of the people in A&E had tried to issue any kind of last minute resuscitation.
A Yes. The other thing is the phrase “strung up”. That is so derogatory that I absolutely reject any concept I would say such a thing to a mother whose child had died.
Q If I used “strung up” that was my own infelicitousness. What she actually said was – from my note, “hanging him up and leaving him to die”.
A I thought she had used that phrase as well, not just you. It was not just you, it was her that used that phrase.
Q You get the point?
A I understand what you are saying. I know you have to put that to me but that is not what I said. That it is not something I would ever say to anybody, all I can do is to deny it.
Q In so far as she was able at this time to answer back, did she not say that all this has been excluded by the coroner?
A She may have said to me that the coroner has done all these investigations and has come up with an open verdict. She may have said to that to me.
Q Did she not say that it was suicide and that it was due to bullying?
A She did.
Q Did you not come back and say words to the effect that there was no toxicology?
A I did come back to her with that phrase, but I cannot remember the question from her which led me to say it. I do not think it was what you have just said. I think it was somewhere else in the dialogue, but I cannot remember exactly when it was.
Q At this time Mrs M was in tears, was she not?
A No.
Q She had had this shocking accusation put?
A No. No, I had not abused her.
Q She was weeping unconsoled by either you or Miss Salem.
A Again, if I had been interviewing, and I have interviewed a lot of parents in this situation before, earlier, with other cases, if they start
Q Not with these kind of facts, I suggest?
A Well, actually, not of the same, of course, but in similar kinds of situation and if they start crying, if anybody starts crying, you stop questioning and you comfort them. Doctors should do that, and if there is a nurse there or a social worker they will help. She did not start crying inconsolably.
Q I am not suggesting inconsolable, you recall the evidence.
A Okay, but she did not cry in a way that I recognised, because if I had I would have either stopped or one of us would have comforted her.
Q I suggest that one of your many breaches of a doctor during the course of this interview, included the fact that you did not console this lady when she started crying?
A That is an accusation and I deny it because I have always, whenever I have been with an upset parent or patient, I would console them; you have to accept that. I am just saying it. That is what happened. That would have happened here if it had happened, but she did not start crying.
Q Can I look at your account of this because I have to suggest that, apart from some key words, there are not many differences. If we look at your report at 1(z), at page 30, do you see the bottom main paragraph?
A I do.
Q I will not go into whether they are the same scenarios or not for the purpose of these questions, just the areas we are discussing:
“Professor Southall also pointed out that there were possible scenarios which could explain [the child’s] death. The first of these was that he had been experimenting with hanging and that accidentally he had died as a result of this. Under these circumstances there are sexual overtones...”
A Usually.
Q
“...Usually under these circumstances there are sexual overtones and yet there was no evidence one way or the other as to whether any form of sexual experimentation was occurring. Professor Southall felt that this was unlikely to be the case.”
A Yes.
Q I think you accepted that that feeling you communicated to the mother at the time?
A It was the sexual bit I was feeling. I am not saying the accident bit, this is the sexual bit.
Q
“The second possibility was that the [oldest child] had deliberately hung himself. However, there was no suicide note.”
Do you accept from that, that that was something that you did in fact put to her at the time?
A It might have been, but I cannot remember it, but it might have been, of course. It depends how it was put, but I cannot remember, but it says it here.
Q It was clear that two of the boys had reported that the eldest child had mentioned killing himself?
A That is the bit I do remember, yes.
Q The third possibility was that Mrs M had killed the oldest child?
A Yes.
Q
“A discussion ensued about this, including the concept that at 10 years old it would be quite difficult to deliberately suffocate or asphyxiate [the child] and then pretend to hang him.”
A Yes.
Q Then there was clearly discussion by you of the concept that she had possibly suffocated or asphyxiated the child?
A That somebody had, but because she was alone with him, there could not be any other alternative person.
Q Except her?
A You know what I mean, although I still remain with some reservation on that point.
Q
“Probably some form of sedation would be involved.”
I suggest that that is exactly what you are putting to her?
A That is what it logically says, yes.
Q Pausing there, it is difficult to imagine, if one could not deliberately suffocate or asphyxiate a child, how could one deliberately sedate a child if he, again, was unwilling?
A You could put something in the drink. The injection, that is another reason why the injection story would not really hold out because, you are right, it would involve a lot of fighting to do it.
Q That is why I put to you that you said you drugged him?
A I know that, but I did not say that.
Q Mrs M assumed that this had been excluded in the post mortem?
A Yes.
Q
“Professor Southall pointed out that he could not find any evidence as to whether or not toxicological analysis had been undertaken on [the eldest child] after his death. Mrs M categorically denied asphyxiating [the child] and reiterated her view that he deliberately killed himself because of bullying by pupils in his school and by [the teacher].”
A So, we were going through the scenarios and she was giving her views as well. This was given by her in a very matter of fact way, not an upset way.
Q That is not accepted as you know. You know that it is uncanny, is it not, that the matters which Mrs M says that you accused her of, the words and the concepts, you do accept were discussed.
A Yes, and they are in my report which she would have had.
Q The whole tone of this interview was accusatorial?
A No.
Q You had this fixed idea that this lady had killed her son and you set out to prove it in a manner of, say, counsel at a trial?
A No, I did not. You can see from my report that I still, at the end of the day, do not know what the answer to this case is. That is clear in my report. I do not say in my report that I believe which of those it is. I say there are unanswered questions.
Q Immediately after the interview, you were still of the same mindset, were you not, you were still pursuing the criminal element?
A I was still worried about the answers to the questions that had been raised as a result of the discussions.
Q Can we look at 1(dd). After the close of that interview, you gave a list of the things for the social worker to check up?
A Yes, absolutely, that is the list there.
Q At page 77?
A Yes.
Q This is the checklist that you gave the social worker?
A It is. I do not know whether he wrote it down there and then, but it certainly is what I was looking for.
Q You have seen the eleven points?
A Yes.
Q Each of them is a point challenging the mother’s account, is it not?
A Yes, that is right, yes.
Q None of the points relating to the youngest child upon which you were asked to report?
A His plan of action, no, they are not relevant, no.
Q I have to suggest that these eleven points are further evidence of your thinking about this matter, that you were pursuing relentlessly the issue that the mother had killed the son and that you were disbelieving of her answer and that is right, is it not?
A I have known from my previous experience with all this that the way forward is to double check everything in a forensic manner. That is how you get to the truth. That is what this is about. Example number 5, the mother had said things about the way the phone call had been answered, I wanted it checked by talking to, looking at the transcript; that is all. These are forensic matters to be checked.
Q Because you did not believe what the mother was telling you in relation to these matters.
A I wanted them to be checked.
Q Because you did not believe the answers you were getting.
A Not necessarily, no. I knew some of them were not correct, I knew that number 3 was not correct, I knew that Mrs M had reported the concerns about the allegations of suicide, I knew that was not correct, but not all of them, I just wanted them checked. For instance, did the ambulance men really have a friend who had done the same thing recently? I do not know the answer to that, but it might be helpful if it was checked.
Q Because you were concerned about the veracity of Mrs M and what she was telling you.
A That is exactly my role in this, to find out the truth if we could. I am not saying we could always do so, but that was why I was there.
Q Lastly you continued, I suggest, in the same tone later when you were chased by the local authority’s solicitors for the production of your report. Can we go to page 84?
A I was still waiting for the reports, yes.
Q The report was only preliminary as you had four queries.
A That is right, we were still awaiting a reply.
Q You were still waiting for information about the issue of the curtain rail because you found it hard to believe that the 30 kilograms would not break the rail.
A No, not break it; pull it off the wall. I was clear about that yesterday.
Q I am having to put an alternative view as written by the lawyer here at the time on an attendance note when you were using the word break.
A Was I?
Q That is what the lawyer has recorded.
A Sorry, which lawyer?
Q The lawyer that you were speaking to on this attendance note.
A It is here is it. You see number one:
“…that he was waiting for information regarding the issue of the curtain rail. He found it hard to believe that 30 kilograms would not break the curtain pole.”
A That is not quite right. This is a report of what I am supposed to have said, remember.
Q Yes, a contemporaneous note.
A Yes, of what I am supposed to have said. What I was concerned with was the pole being pulled out of the wall, if she wrote down that I said “break” maybe that is what she thought I said, but I was always thinking of it being pulled out of the wall, not breaking.
Q If we can continue about six lines down, Dr Southall, do you see,
“He also indicated that jumping from the bed to hang himself would also have broken the curtain rail.”
A But I would not have said that because I would have said what I believe, which is that it would pull it out of the wall. It was held on by two screws, one at each end. That is what I meant; the pole itself could withstand that weight if it was properly affixed.
Q Again, the lawyer used the word for the third time, could I take you to this,
“…would also have broken the curtain rail and that mother’s attempts to try and pull him off the curtain rail would also have broken the curtain rail.”
A With her additional weight on top, that is a lot of weight. Again, I was thinking it would be even more unlikely that it would remain in the wall, but whoever has written this was thinking – she had got it into her head – break. I understand that, but that is not how I was thinking, that is all I am telling you.
Q I have to suggest to you that she wrote the word “break” three times because that is exactly what you were telling her.
A That is what she was hearing.
Q You were also pursuing issues about the belt, which we can see in the middle of paragraph one.
A The adult belt.
Q And you were also pursuing number two, the toxicology.
A Yes, it looks as if I still had not had an answer to that.
Q You did have an answer there:
“I informed Professor Southall that I had been told by the coroner’s office that toxicology tests had not been carried out.”
A Yes.
Q “Professor Southall indicated that this may have been negligent on the part of the pathologist.”
A I will check again it says, because it is standard to do that, it is standard to do toxicology in that situation.
Q Bearing in mind the strength of your views on a number of matters, Dr Southall, it is not surprising that you might have expressed the view that the pathologist had been negligent.
A I would have expressed the view – and I cannot say what words I used – that the pathologist should have checked the toxicology in this case. That is all I can say, I do not know whether I said the word “negligent” or not.
Q You indicated at 4 in the second paragraph – the lawyer says,
“I outlined the summary of Professor Stephenson’s report to Professor Southall. He indicated that he could not agree with the summary.”
A She must have read me the last bit of it, yes.
Q Can I show you the summary, please, it is the document at C18, page 21.
A Yes, I have it.
Q First of all do you note what it says at paragraph 7 above the summary?
A Yes, I do.
Q “On balance of probability I do not believe there is evidence of factitious illness by proxy.” That is essentially your scenario three, is it not, deliberate harm?
A No, it is not just that. I did broaden it out earlier on in our discussions, to move not just factitious illness by proxy but other forms of abuse.
Q The summary says:
“I will conclude by making what I see is the three most striking points in this case:
1. I have never seen a case of Munchausen’s syndrome by proxy which involved almost exclusively traumatic presentations to hospital.”
A That is the bit I do not agree with because I have seen it and I have read about it from others who have seen it. Just to finish, that is the bit I did not agree with in the summary that was read to me.
Q Then: “2. The injuries are not typical of inflicted or non-accidental injuries.”
A Can I just stop you there too because there are a couple of issues that I am not happy with on this; one is the bruising to the face at nine months of age and the other is the burn with a delay of four days. Again, I do not agree that inflicted injuries have been ruled out.
Q And “3 Suicide is extremely uncommon in 10 year olds but when suicide does occur in young boys, strangulation is a common mode of death.”
A Yes, I accept that.
Q As a result of what you have learnt in this case is it?
A Sorry?
Q As a result of the research that you were shown in this case by both ---
A Yes, it was very helpful.
Q Dr Black and Professor Stephenson.
A And Professor Stephenson.
Q I will take you to some other points in this report and ask you to comment on them. Do you see at page 6 there is a discussion of the various injuries in relation to the youngest child. We can see it is in relation to the youngest child if we pick it up at page 5.
A Yes.
Q You see the heading at page 5, “The youngest child’s hospital attendances are as follows.” He goes through them.
A I agree, absolutely, in detail, but he has missed out the one at nine months.
Q Can I just say what the professor’s view was at the bottom of page 6 where he said:
“Unless Mr M is colluding with his wife [Mrs M] he can verify that a substantial proportion of both [the eldest child’s] and [the youngest child’s] injuries occurred when he was present and it is therefore unlikely that they were caused by Mrs M.”
A Yes, I accept that.
Q Do you see the point that he made over the page at page 7, where it says in the second line:
“At page 30 of the Bundle, Professor Southall describes this as a ‘holiday of a lifetime’. I would have thought taking the sibling of a child who had committed suicide away for a long weekend at Butlins was a perfectly reasonable way to use these funds.”
A It actually was the GP who told me that. He or she was the one – I cannot remember if it was a lady GP or a man – who mentioned that issue.
Q You say how important it is to investigate and double-check matters. A simple question of Mrs M at the interview would have elicited the answer to that, would it not?
A Yes, it would have done.
Q Would you go to page 14? We see a double line and a star beside it; is it possible or indeed likely that that double line and star are your double lines and your star?
A It is possible, yes. I cannot deny or agree.
Q Do you note the professor’s summary that:
“[both boys’] medical records show a rather large number of GP attendances but all of these appear to be for common childhood symptoms and illnesses. There are no rare or puzzling symptoms which led to extensive hospital admissions or inappropriate investigation. Furthermore, there is no evidence of ‘doctor shopping’ with mother seeking multiple opinions on bizarre symptoms.”
A I absolutely agree with him that this is not the records of Munchausen’s syndrome by proxy, but there were two injuries that he has not discussed which are features of child protection concern. They are the bruise on the face and the serious burn which took four days to reach hospital, so he has not discussed those issues which I think should perhaps have been in there.
Q He has listed them, if we look at page 2.
A That is the burn.
Q What is the other one you were concerned about?
A The bruise to the younger child as a baby. He was nine months old and had a bruise on the face. I cannot see that, but it may be, I have not been through it in detail.
Q Again, going back to page 14,
“Both boys had a large number of traumatic injuries causing attendance to the Accident and Emergency Department but there seemed to be plausible explanations for most of these.”
A Yes, I accept that, I do accept that.
Q I took you earlier to page 16 where he was given the list of questions he was asked by his instructing solicitor to answer. Dealing with “Illness induction” at page 17, this, I have to put to you, is basically your scenario three.
A Yes, it is.
Q He makes three main points.
A Hang on. It is, but with additional components, which we have discussed.
Q He makes three points, can I suggest to you, in relation to that. Firstly, three lines down from the top,
“I have personal experience of over 30 cases of alleged Munchausen’s syndrome by proxy and have never seen a case in which almost all the illness which would have to have been induced by the perpetrator involved injury or trauma.”
A That is fine, that is his experience. I have a different experience, and he is still right, it is still unusual, it is still a very rare presentation.
Q He goes on to justify that by saying:
“The commonest manifestations of Munchausen’s syndrome by proxy have been well documented by Professor Southall himself. The commonest manifestations include apparent seizures, difficulty breathing, going blue, vomiting, diarrhoea, poisoning, skin rashes, bleeding etc.”
A Yes.
Q The second main point he is making in relation to scenario three, if I can put it that way, is in the next big paragraph where he says:
“I also think Munchausen’s syndrome by proxy is unlikely because of the age of the children.”
A I agree with him, it is mostly young children, pre-verbal children.
Q He goes on to agree with you in that:
“The last six hospital attendances which [the eldest child] was involved in happened when he was over the age of 8.”
A Yes.
Q “… and the last four hospital attendances of [the youngest child] happened
when he was over nine. To suggest that these injuries have been induced by his mother would then require that the children were involved in a folie a deux”
A Yes.
Q Then the third point that he is making in relation to your scenario three is over the page, the main paragraph:
“I have had very extensive experience of non-accidental injury in children and none of the injuries to either boy are in any way typical of those seen in the context of non-accidental injury.”
A I do not agree with that, there are two injuries that are, I have mentioned those already.
Q “Rather, these injuries are very typical of accidental traumatic injuries which occur in childhood.”
A Yes, the majority of them are.
Q Then going to page 20, he says in the second paragraph:
“Professor Southall expressed surprise that Mrs M did not hear [the eldest child] struggle.”
He then goes on to say how that is unsurprising in view of the pathologist saying that he thought the loss of consciousness was extremely rapid and painless.
A That is one of the reasons why I wanted to just ask for Professor Green, the forensic pathologist’s opinion, because to me this was a bit unusual, this opinion.
Q It is right in relation to this case that you had your firm views and Professor Stephenson had other views, and Dr Black had her views. The matter in fact never went to court, did it?
A No, in essence we all came to a pretty similar final point which was that what he needed was lots of input from the child and family psychiatry service. That was the final opinion.
Q And the child remained with the parents, having been taken away for a few weeks before the hearing in March.
A Yes, that is correct.
Q The Panel has heard a considerable amount of your evidence in this case and will not have known the full picture. In the case of each of the children that we have been involved with in this case, did you not prepare a report of some sort or another?
A Yes, I have, yes.
Q Is it fair that in each of these reports you raised child protection concerns relating to the mother and the possibility of the mother causing harm to the child, in one way or the other?
A In one there were also concerns about the father – no, actually more than one. In three there were major concerns about the father. Major concerns.
Q I can widen it.
A Yes, you can.
Q In each of these cases you prepared a report, you have agreed that.
A Yes.
Q And I go further, that in each of these cases you prepared a report indicating child protection concerns.
A Yes.
Q And each of the child protection concerns involved a suggestion or an opinion by you that the child was being harmed at the hands of either the mother or the father or both.
A Yes, that is fair.
Q In relation to each child, notwithstanding those reports, it is right that the child ended up back with the parents.
A Yes.
Q None of these children were taken into care and put into foster care.
A One of them never went into care at all.
Q I will deal with that rather than take it globally. Child A remained in the care of the parents throughout?
A Yes.
Q And there was no contested hearing about the case?
A If you actually look at the paperwork, it was me who supported his remaining with the parents because I felt that it could be the best way of sorting out the problem. That is on record actually in Case A.
Q In case A were you not urging separation of mother and parents for some investigations?
A That was in the beginning if they were not prepared to accept the Family Court’s view, but they were; they accepted the court’s view.
Q Your report did say that the two should be separated?
A Only if they did not accept it.
Q In the case of B, the child was fostered for a period but then did return to the parents by agreement?
A That is correct.
Q In the case of M, which we have just been dealing with, the child was fostered for a period and then did return to the parents?
A Yes.
Q In the case of H, the child was fostered for a period and the did return to the parents by agreement?
A I think both children in that family were.
Q In the case of D, there were no family proceedings at all?
A There were family proceedings. There was a case conference.
Q But no court proceedings?
A There were no court proceedings, no.
Q Again, the child has remained with the parent throughout?
A Yes.
Q Globally, so that the panel can be clear, there were no contested proceedings in any of these cases at all, except for the interim care cases in respect of M?
A I do not understand that. What do you mean by ‘no contested hearings’?
Q There were no final hearings on the matter as to whether the child should or should not go into care permanently?
A That is correct. Permanent care was never an option for any of them.
Q And that is notwithstanding that in each of the cases you had prepared reports that were indicating, as far as you were concerned, serious child protection concerns?
A That does not mean that I am advocating taking the child into care permanently in each of those cases. That is not at all the logic. That is not what I was intending.
Q But you were intending in a number of these separation?
A In a number of those, a period of separation was needed, in my view, yes.
MR TYSON: Thank you. I have no further questions.
THE CHAIRMAN: Mr Coonan, would now be an appropriate time to have a short break or do you wish to defer your re-examination until tomorrow?
MR COONAN: I was thinking of the latter, partly because I am very conscious that it is now the end of Dr Southall’s fifth day in the witness box. It is now a few minutes off 4 o’clock. I do have some re-examination and I cannot promise to finish this by the end of the Council’s standard ten-minute remit. I am conscious that I have to do my best to assist the panel too. If you give me the indulgence, I would much prefer to do it at 9.30 when Dr Southall will be fresh.
THE CHAIRMAN: Despite the fact that we are possibly under some time pressure, that would seem to be the fairer way forward as you have requested it. Mr Tyson, do you have any views?
MR TYSON: If the panel was minded to grant my learned friend’s application, which I would support, can I respectfully suggest that the panel could use the time available to consider their own questions. This would appear to be an appropriate time for that to be done at the same time so that we could go straight through tomorrow.
THE CHAIRMAN: I need to consult the panel and check if everybody feels satisfied that they have the appropriate time to do that.
There is also the matter of whether you would be willing, before we depart today, to try to sort out the matter of future dates for this hearing.
MR COONAN: Speaking for myself, the answer is yes. I have not, as you may know, taken any opportunity of talking to Dr Southall about this, but if we were to break now, I am more than happy to raise that with him. He has been sitting here and he is obviously fully aware of it anyway. It is an issue and I would like to canvas it with him, subject to the usual safeguards. I am more than happy if the Committee Secretary were to be present when that is done.
MR TYSON: There is absolutely no need for that. I would not suggest for a moment that my learned friend should be accompanied when he does that.
MR COONAN: The offer is there. If my learned friend does not want anybody present, then I am happy. I make the offer.
THE CHAIRMAN: A further point might be the possibility, if it seemed to be appropriate, of a 9 o’clock start tomorrow. That might be helpful. As I understand it, the panel would be able to be here at 9 o’clock.
MR COONAN: Again, speaking for myself, that is not a problem.
MR TYSON: I endorse that.
THE CHAIRMAN: Dr Southall is nodding. I suggest that we break now. That will give the panel an opportunity to speak together. We need to do diary work. Your re examination will not begin until tomorrow. We will meet back here after about 20 minutes to resolve the other matters this evening. Will you be able to consult Dr Southall?
MR COONAN: I will do that straight away.
THE CHAIRMAN: Dr Southall, you are fully aware of the warning.
A I am, yes.
THE CHAIRMAN: The panel will now retire. Hopefully we will return in about 20 minutes. Let us know if you need a longer time. We will try to resolve these matters before we depart.
(The Panel adjourned for a short time)
THE CHAIRMAN: I have called everyone back because I understand that Dr Southall needs to leave. We have not managed to complete the matter of future dates. However, I would like to say that we will sit at 9 o’clock tomorrow. I need to caution Dr Southall formally about not discussing the case overnight. The session is formally ended now. The panel will remain until we have resolved the date matter.
(The Panel adjourned until 9.00 a.m. on Friday, 1 December 2006)