Cot death, infanticide & child protection

GENERAL MEDICAL COUNCIL

FITNESS TO PRACTISE PANEL (PROFESSIONAL CONDUCT)

Thursday 15 November 2007

Regent’s Place, 350 Euston Road, London NW1 3JN

Chairman: Dr Jacqueline Mitton

Panel Members:

Mrs Leora Lloyd
Mr Alexander McFarlane
Mr Arnold Simanowitz

Legal Assessor: Mr Robin Hay

CASE OF:

SOUTHALL, David Patrick

(DAY TWENTY-ONE)

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 JOLLIFFE 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

CLOSING SUBMISSIONS BY MR TYSON (Continued) 1

PLEASE NOTE: Copies printed from e-mail may differ in formatting and/or page numbering from hard copies

THE CHAIRMAN: Good morning. Thank you for waiting while we catch our breath.

MR TYSON: Madam, I gave you a rather rash promise last night that I might be free by lunchtime, or you might be free by lunchtime. Overnight, as is inevitable, I had some further thoughts about matters, but you will certainly finish today, or I will certainly finish today.

Madam, I now come to the second part of my submissions that relate broadly to our allegations of Dr Southall’s inappropriate behaviour towards individual complainants. In relation to the M case, that encompasses head of charge 3-6 and head of charge 17-18 and Appendix 3. In relation to Child H, the heads of charge are 7-9, and in relation to Child D we are dealing with head of charge 17-18 and Appendix 3. Madam, I will deal with these, if I may, in reverse order.

If we can deal, please, with Mrs D, and if I can use a bit of shorthand we are talking about the corridor incident in December 1994 at North Staffordshire Hospital. Madam, the raw material, if I can put it this way, from the transcripts relating to this incident is as follows: Mrs D gave evidence in-chief about it on Day 6/67E-70A. She was cross-examined on Day 7/9E-17D. She was re-examined on the topic at Day 7/22F-24B, and Panel questions on this aspect are at Day 7/26B-G (Mr Simanowitz) and at 27B-28E (the Chair). Dr Southall’s evidence on the corridor incident is in-chief at Day 11/41C-43C, in cross-examination at Day 14/17B-27D and in re-examination on Day 15/37E.

Madam, can I make five preliminary points about this matter before we deal with the evidence. First of all, I readily accept that this incident happened twelve years before evidence was heard about it. Secondly, I readily accept that Dr Southall has no recollection of this incident at all. He told you he deals with thousands of patients and this particular incident had not impregnated itself with his memory of it. Point 3 is the important aspect, we submit, that whilst this incident does not stand out in Dr Southall’s recollection, important aspects of it are vividly in Mrs D’s mind. She used the word in a number of points of her evidence that it was imprinted in her mind. Fourthly, you might think this is not surprising, she was concerned about her son, and to her this was to be, and was in fact, an important discussion to receive the results of the overnight monitoring which her child had just had, and in particular to find out whether or not she was going to get the monitor, which was the reason why she had attended in the first place. Thus, you may think it is to be expected that a patient who sees a doctor once or twice will have a much better recall, we would submit, than a doctor who sees thousands of patients. The fifth point is largely a forensic point. You will recall that Mr Coonan did not ask for this allegation to be struck out as an abuse of process based on the time element. He did make a submission on the corridor incident, but this submission you rejected.

Madam, dealing with the evidence, you will recall that Mrs D herself had been described in almost flattering terms by clinicians over time who had dealt with her son’s allergic reactions, and for the purposes of your note we can see that the GP described her good care of her child at C2/4(a); her consultant Mr Connell did so twice at C2/4© and C/2(d); and Professor Strobel from Great Ormond Street equally described her in good terms at C2/4(e). Madam, all that was in 1989. Then the GP again at C2/4(f) in October 94, which brings us right up to the date of the incident, again describes her good care of her child.

Madam, remember also, I would ask you, that this referral to Dr Southall was at her instigation. We can see that from the GP referral letter that I have just referred to, which is C2, tab 4 at (f). There were no child protection concerns prior to Child D’s admission into North Staffs in 1994. Perhaps I should just take you to the GP referral letter. As I say, it is in C2 at tab 4, dated 6 October 1994, addressed to Professor Southall from the GP:

“Dear Professor,

I would be very grateful if you would see the above child who is the most allergic patient I have ever known. His mother is a SRN and copes very well.

There are relationship problems in that his father has an alcohol problem. He attends Dr Stoebel at Great Ormond Street Hospital.

His mother is very worried about him at night as he gets frequent episodes of becoming [pale], shut-down and query [hypothermic].

Would he be suitable for a P.O. Meter?”

THE CHAIRMAN: Sorry, Mr Tyson, I got as far as C4, but I did not hear the rest of it.

MR TYSON: Sorry. C2, tab 4 at (f).

THE CHAIRMAN: Thank you. Madam, it is quite clear from the evidence that Dr Southall formed an adverse view of Mrs D. This is clear, we would submit, on the basis that he made it clear that Mrs D was wrong to ask nurses to take the child’s rectal temperature and to take blood sugars; also, that in his (Dr Southall’s) view all the recordings were normal despite alarming incidences during the child’s sleep. Further, Dr Southall was of the view that this was an MSBP case. Lastly, again a matter which would form an adverse view of the mother, we would say, is not only was that his (Dr Southall’s) view, but it was also the view of Professor Strobel of Great Ormond Street, because there is a clinical note to that effect in the notes.

All these matters that I have just set out arise from the report that Dr Southall wrote about this child, which is in the medical notes, and in your notes at C2/4(i). As we are at C2/4, can I ask you to look at just one note in the clinical notes, which is C2/4(g), and within (g) the last page at 611. Madam, I just draw your attention to the clinical note on 15 December, which is on the same day as the “corridor incident”, and this is Dr Southall’s own manuscript note, where he says he discussed the matter with Professor Strobel. Pausing there a moment, that is the Great Ormond Street clinician that was dealing with the allergy problem.

“Agreed that Mum is exaggerating symptoms
Example of fabricated illness”.

Just pausing there for a moment. So this is, as it were, two limbs of MSBP being alleged here; first, the exaggerating limb, and, secondly, the fabricating limb:

“Needs [Social Services] strategy meeting
To invite”,

and he sets out the people there mentioned.

“[Child] to go home in the meantime.”

Madam, it is quite clear in terms of chronology that Dr Southall had had that conversation with Professor Strobel before the corridor incident, because, as Mrs D told you, she had this conversation with Dr Southall right at the end, in fact she was waiting to go home and was anxious to see him before she went home in order to get the results of the monitoring. Thus, to use an expression I have used in other contexts in this case, one has got to look at Dr Southall’s mindset. His mindset was that this was a mother who was an MSPB mother, if I can put it this way, and that had been confirmed by the fact that all the recordings had been normal, and it was a mother who had in a sense misbehaved at the hospital, in the sense that she had been asking nurses about rectal temperatures and blood sugars and the like. So that is Dr Southall’s mindset.

Looking at the other point of view at Mrs D’s mindset, you may think that this was influenced by the fact that there had indeed been alarming incidences overnight at the hospital relating to this child. We can see what happened on the first night, if you go back to C2/4(g). The doctor’s note in relation to the first night is at page 604. You will recall in this section, the numberings are not chronological. It is about four documents from the back. 604 at the bottom, there is an entry for what we learnt was 13 December 1994:

“Review
Well
Had episode of cold, pale, [I would think that probably says] D sat [short for D saturation] last night.
Tape saved needs analysis”.

In relation to that medical note, we see it picked up in the nursing Kardex in the next section at (h) at page 620. If we see about two thirds of the way down heading in the left hand column:

“0600 14.12.94 settled night slept throughout. Monitors applied by technician at beginning of [the] night. [Then] PO2 [down to] 16/19 temp[erature] 34, SaO2 97/99, looked pale. Mum says also puffy. [Query] causing pool perfusion settled by 2 a.m. and observations stable for the rest of the night.”

It was a sufficiently serious event for, as we have seen, Dr Suchak to be called. Then we have the second night, which is the night before the corridor incident. We see that at the bottom of page 620 in the Kardex, where it says, in the last two lines:

“Saturated well throughout. However during early part of the night TCPO2 [down to] 9. Temperature via monitor 33.5 35.5 throughout, although when taken via axilla approximately one degree higher. Seen by Registrar last night when temp[erature falling] and very ‘clammy’ to touch, nil ordered, to observe only. Mum resident.”

We have a situation where on both nights there were incidences overnight where doctors had to be called and, in particular, on the last night, we have a situation where the temperature went, you may think, very low indeed. The PO2 monitor, which the night before, when the registrar was called, went down to 16, and on the last night it went down to 9. This is informing Mrs D’s mindset, we would submit, that overnight there had been two incidences and on the last night a particularly alarming incident. I would ask you to accept, therefore, Mrs D’s account of the conversation in the corridor or certainly those parts of which are imprinted on her memory.

Madam, her account is this, she stood in the corridor, outside the play room. Madam, for your reference, there is a little sketch she did for you of the location at C11. I will not take you to that. She stood in the corridor as she was anxious not to miss Dr Southall, with the results, before she went home. It was, she told us, a normal conversation to start with. Dr Southall stated that he wanted Child D to be seen by Professor Warner, a renowned allergist. Pausing there, madam, she must be right about that, that there was a discussion about Professor Warner, because there is nothing in the medical notes at the time of this admission about Professor Warner at all. We do know that Dr Southall did in fact refer the child to Professor Warner but we only know that if we go into the SC file. The referral to Professor Warner, we see at C6/305, which was in the March of ‘95, after this admission in the December ‘94. She must be right about Professor Warner because there is nothing about it in the admission notes.

Going back to the narrative. As I say, Dr Southall stated that he wanted the child to be seen by Professor Warner and Mrs D told you that she agreed to this proposition. The conversation went on and then Dr Southall said words to the effect that everything is normal with Child D. Mrs D demurred. She challenged or sought clarification as to how her child could be normal. She pointed out to Dr Southall the last night’s incident, where the child’s temperature had gone right down, monitor alarms were ringing and the registrar was called. Mrs D’s account is that Dr Southall in a sense bridled at this challenge to his statement by a woman who he considered was a Munchausen woman. She said that he, Dr Southall, turned to go and said with a loud voice, words to the effect that there is no such thing as a delayed reaction. Putting that into context, in the notes you will see there is a reference to Mrs D’s assertion that there had been a delayed allergic reaction to the child’s third immunisation and it was Dr Southall’s professional view that there is no such thing as a delayed allergic reaction. That is the context when he says there is no such thing as a delayed reaction. Then, she told you, Dr Southall walked away, making a sort of dismissive gesture, with his right hand, leaving Mrs D to infer that she was not going to get the monitor and, as she told you, feeling sick in her stomach. Again, of course, as he had walked away with this dismissive gesture, she had no opportunity, we would say, and she does say, to ask him any questions about the future or indeed past care of her child.

Madam, I would ask you to accept that the exchange went along the lines that I have set out. It seems to make sense, in my submission, in the sense that Mrs D did not get the monitor. She was referred to Professor Warner at Southampton and Dr Southall did in fact by then believe that this was a Munchausen’s case. Madam, I would ask you not to be influenced by any submission that I would anticipate may well be made casting doubt on this account by reference to whether or not Mrs D’s partner was present or not. That, in my submission, is irrelevant and a complete red herring. You have heard her account. Also, madam, I would ask you not to be influenced by the fact that in previous written accounts, Mrs D had not elaborated on this incident. As she told you repeatedly in evidence, those written accounts were about her concerns relating to her son and his past and future care and diagnosis. They were not about her. When she was asked about her and how she, as opposed to her son, had been treated, then she was able to give the full account which she gave at interview and in evidence.

Can I take you therefore to head of charge 17, relating to this incident. Head of charge 17 of which only (a) and (b) apply to this patient, head of charge 17 says:

“In the cases set out in Appendix 3 you failed to treat the respective children’s mothers in the way set out below, or any of them,

“(a) Politely and considerately

“(b) In a way they could understand

THE CHAIRMAN: Mr Tyson, if I may stop you there. In appendix 3, you kindly pointed out the other day where it says 14 it should say 17 but in Child D breach column, only the letter (a) appears.

MR TYSON: That is an error of mine again. It should be (a) and (b).

THE CHAIRMAN: It should be (a) and (b).

MR TYSON: It should be (a) and (b) and you deleted ©.

THE CHAIRMAN: We did. Mr Coonan, do you accept that this is a typographical error or does this present a problem for you?

MR COONAN: It probably is. It is just that I do not have and never have had, I think, the version of the appendices that you have. I have always been working off the document that I was served with, which was the original appendix, which was then subsequently amended, and that document did have, if I can take you to it, in relation to Child D in appendix 3, it originally said 14(a). My learned friend, quite rightly, following a discussion, I raised the point with him, whenever it was, Monday morning of this week, we agreed that that should be a reference to 17 and it should now read 17(a). I do not think there is a problem about that. Then in the next block I think, again, that should read 17(a), (b) and ©.

THE CHAIRMAN: That is correct. The problem, Mr Coonan, is that Mr Tyson has just told us that in respect of Child D, (a) and (b) apply, 17(a) and (b), whereas only 17(a) appears in the appendix.

MR COONAN: As I say, I do not have your version. I have to confess, it is the first time I have spotted that or I have had it spotted for me by you.

THE CHAIRMAN: I just wanted to check whether it presented any problem for you, whether you were expecting to answer 17(b) in relation to Child D.

MR COONAN: I can deal with it but I do not want to interrupt my learned friend. He can deal with it and I shall deal with it when I have considered it but I do not think it is a fundamental problem.

THE CHAIRMAN: So we accept that this is essentially a mistake.

MR TYSON: If and in so far as I have to formally apply to amend the head of charge, I do so formally apply, to add, under appendix 3, 17(a) and (b).

MR COONAN: Can I say straightaway, it does not cause him any prejudice.

THE CHAIRMAN: Thank you. I just needed to check that with you.

MR TYSON: I am grateful for that.

THE CHAIRMAN: Would it be helpful if we took this as a formal application to amend this?

MR TYSON: Madam, it is.

THE CHAIRMAN: It is. You have not opposed it, Mr Coonan, I understand.

MR COONAN: I have not. I am just looking again at the text of paragraph 17 of the heads of charge and 17(b) is set out precisely. I am not prejudiced and I do not object to the amendment.

THE CHAIRMAN: Thank you. I look to the Panel who accept that this amendment should be made. We are all agreed. Thank you.

MR TYSON: I am grateful to you all, madam.

Indeed there was a discussion about the meaning of the word “understood” in this context, because you, madam chair, raised it with the witness, because you asked her what she meant by the word “understand”, did she not, as it were, understand what she was being told. You elicited from her that understanding is put in the sense that she could not understand why she was being treated in that particular way, why she was being treated and addressed in that particular way. Madam, there was a specific passage in the transcript to which I can take you but I will just give you the quotation about it. It is Day 7/27B 28E where you personally elicited that; what understand means in this context, in relation to this particular matter.

Madam, in relation to head of charge 18,

“Your failures under paragraph 17 were (a) inappropriate; and (b) were in breach of your duty to establish and maintain trust between yourself and the children’s mothers whilst they were acting with parental responsibility.”

The concept of establishing and maintaining trust comes from the December 1993 blue book which I think is in your little booklets, and it is the first one. It is paragraph 47, Madam, under the global title, amongst other things, “Professional confidence”. Paragraph 47 reads:

“Patients grant doctors privileged access to their homes and confidences and some patients are liable to become emotionally dependent upon their doctors. Good medical practice depends upon the maintenance of trust between doctors and patients and their families, and the understanding by all that proper professional relationships will be strictly observed. In this situation doctors must exercise great care and discretion in order not to damage this crucial relationship. Any action by a doctor which breaches this trust may raise a question of serious professional misconduct.”

That is why 18(b) is put in the way that it is, Madam, bearing in mind that paragraph 47 deals with both patients and their families.

Madam, in my submission head of charge 18© is self-evident if you accept Mrs D’s evidence. She told you that she felt, in her words, “sick in the stomach”.

Madam, can I now turn, in shorthand terms, to the unnamed paediatrician letter in relation to Mrs H? Here we are dealing with head of charge 7, which is all admitted, head of charge 8, of which head of charge 8(a)(i), (ii) and (iii) is admitted; head of charge 8(b) is not admitted, for reasons which currently escape me but which I will deal with at the end,

“You copied the letter mentioned at (a) to an unnamed consultant paediatrician at the Royal Gwent Hospital even though no one there was involved in Child H’s care.”

and then as far as 8© is concerned the stem is admitted,

“You did not seek, nor obtain, Child H’s parents’ consent (i) [ which is not admitted] to the fact of involving a local paediatrician in Child H’s care or (ii) to any letter being sent to an unnamed local paediatrician.”

Madam, neither (i) nor (ii) are admitted but (iii) is admitted:
“You did not seek nor obtain Child H’s parents’ consent to the letter mentioned in 8(a) and in those terms being sent to an unnamed local paediatrician”.

Then there is the consequences paragraph at head of charge 9

“Your actions … were (a) inappropriate, (b) in breach of Child H’s and his parents’ confidentiality.”

Madam, the evidence and the evidential material in support of this issue is, firstly, the letter itself, which we will look to in some detail later, but just for notes it is at C2, tab 2, i. The transcript material relating to this letter comes from Mrs H in chief, Day 6, 12E-22C; she was cross-examined on the letter at Day 6, 38D-42G; she was re-examined on the point at Day 6, 46D and the Panel asked her questions about it, Day 6, 46G-50H.

Professor Southall dealt with the letter and this patient on Day 11, 43F-54G; he was cross-examined on it on Day 13, 58D-70B and again on Day 14 at 1A-4B; he was re-examined on the letter on Day 15, 33C-37E.

Dealing with the facts leading up to the letter, you will recall that Mrs H went to see Dr Southall with Child H at her request, so just like Mrs D Mrs H requested the referral to Dr Southall as, as she told you, she had seen him on daytime TV where he was discussing monitors and the like and she felt that he may be able to help. She discussed the referral with the child’s clinician, who at all material times was Dr Dinwiddie at Great Ormond Street and Dr Dinwiddie agreed with the idea of a referral and did in fact refer her at her request to Dr Southall, and we can see that referral at C1, right at the back, under tab 2 at A.

Madam, that is the original referral letter, dated 17 March from Dr Dinwiddie, from whom incidentally we did not hear, addressed to Dr Southall. It starts:

“I would be most grateful if you could please see Child H at his parents’ request. He has been having a number of unusual apnoeic attacks particularly associated with hypoxemia and they are very keen to know if any of your new monitoring equipment would be helpful for him.”

It is a referral at the mother’s request but it is rather a barbed referral, if I can put it that way, because we see in manuscript at the bottom of the third paragraph that Dr Dinwiddie has added the words in manuscript “the question of Munchausen by proxy has also been raised”, so it was as it were a two-pronged referral, you may think, the principal prong being the mother wanted to see him. The request is what we would say is a classic referral letter; the request was, in the last paragraph,

“I would be very interested if you could see him and arrange the necessary further investigations and advise in any other treatment which you think might be helpful in this situation.”

Madam, in view of the context of the letter which we are going to examine, the unnamed paediatrician letter, this is what a referral letter should be. It should identify the doctor, i.e. Dr Southall, it should give the reason for the referral, i.e. please see child H at his parents’ request, and the issue is “whether any of your new monitoring equipment would be helpful”. So you get the identity of the doctor, you get the reason for the referral, you get a full history relating to the child and, as you see here, this history was not only referred to in the letter but, as we see in the second paragraph,

“His history is very long and complicated and I think it best to enclose copies of the case summaries from his numerous admissions here.”

We have not got them in the bundle, but there were, as it says on the face, numerous case summaries from his numerous admissions, and so you get lots of discharge summaries, you get this letter, you get the history, you get the discharge and then the question to be answered is set out in the bottom paragraph, could you arrange the necessary further investigations and advise on any other treatment. That is a standard referral letter and a textbook referral letter, you may think.

You may also think, as is Mrs H’s case and is clear from the last paragraph of this letter, that the child remained Dr Dinwiddie’s patient. Dr Dinwiddie was merely looking for Dr Southall’s advice on a specific aspect of his care. The child had been, as is made clear in the second paragraph, with Great Ormond Street for a long period of time and, as we can see from the last paragraph, Dr Dinwiddie sought Dr Southall’s help on one specific matter and, as it were, asked him to come back with the result of any investigations and advice. The care of this child was not being transferred to Dr Southall, Dr Southall was merely being asked to investigate, using his elaborate monitoring equipment, and then advise on any further treatment which might be helpful, advise on further treatment not carry out further treatment.

Madam, in due course the child did attend for overnight monitoring at the Brompton Hospital and he returned for further overnight monitoring in March 1990, so the initial overnight monitoring was September 1989 and then he returned for further monitoring in March 1990. It is clear that in the March 1990 admission the parents saw Dr Samuels. It is also clear by omission that at that March 1990 admission the parents did not see Dr Southall, there is no mention whatsoever that he did see the parents on that March 1990 admission and, indeed, that is Mrs H’s firm evidence to you throughout.

May I ask you to put away C1, never to return on this aspect of the case, and go to C2, please, at tab E, the first tab in C2. It is the nursing Kardex, which we have seen before, but I take it from 16 March where it is recorded:

“Up and about. All care given by parents. Seen by Dr Samuels, to go home with PC02 monitor.”

It is also clear, if you turn to tab h, which we have seen in another context, which is admittedly Dr Samuels’ note, that he records, as you can see just at the second hole punch mark, something entitled “Parental view”. It is, in my submission, clear beyond peradventure that that parental view was acquired by Dr Samuels at his meeting with the parents that we see in the nursing Kardex took place on 16 March 1990.

Madam, I make that submission and when I put it to Dr Southall in evidence he accepted that the words “parental view” meant clearly that Dr Samuels had obtained that from the parents. Dr Southall accepted that proposition at Day 13, 61D. Just looking at the headings on that manuscript note, you can see the history is set out at the top of “Apnoid instance, wheezing and cough”, the previous treatments are set out, there is a discussion about the tracheostomy which the child had at that time and there is discussion about cyanotic episodes and the fact of bagging, and then he sets out the parental view. Then he sets out his impression, i.e. his view, and then he sets out under the word “Needs” the format as there set out including the words which read – and I hope you have written into this note the missing bit which we found, number 4 should be “neuro opinion/local paediatrician”.

Madam, for what it is worth I rely on the word “Needs” there, it does not say “Agreed” or words to that effect. There is nothing in that note to indicate that the parents agreed with those needs.

What Mrs H told you about this meeting at Day 6, pages 12 and 13, is this: she accepts that the overnight monitoring results were discussed with Dr Samuels and that Dr Samuels put a treatment plan to her which involved essentially, as she said, experimental drugs for the child’s asthma, her being sent home with home monitoring equipment with the ability to add oxygen if required and, ultimately, the removal of the tracheostomy. Those three things, she accepts, were discussed and she told you that she was surprised at these suggestions because they did not accord, as it were, with the Dr Dinwiddie treatment plan which was for a triggered ventilator for the child, i.e. a ventilator which would see that the child needed oxygen on any particular occasion and trigger the requisite amount of oxygen as and when required – quite a sophisticated bit of kit.

Mrs H told you that she was surprised at the suggestions and she asked Dr Samuels if she could discuss them with Dr Southall. You will recall her evidence, she said that she learnt that Dr Southall was too busy to discuss the matter with her because, apparently, he was appearing on Sky TV or something like that. In the end, she told you that she conditionally accepted the package, conditional in the sense that she made it clear to Dr Samuels that she wanted to discuss the package with Dr Dinwiddie, the child’s paediatrician. She did agree that she would take the monitor home and try it out, and for that purpose, she told you, she was trained in its use by Dr Southall’s staff.

She also told you, and this is important, she told you this on page 14, that at this meeting with Dr Samuels there was no discussion or mention at all of the involvement of yet another paediatrician in the child’s care, whether in Wales or elsewhere. Mrs H said not only was there no discussion with Dr Samuels about involving another paediatrician, equally there was no discussion with anybody else at the Brompton about the involvement of another paediatrician. On her behalf, madam, I would ask you to accept that evidence; neither then nor at any time was she asked at the Brompton about the involvement of a local paediatrician in Child H’s care. Also, and it is of course related to that, her consent to such involvement was never asked for. First of all, there was no discussion about the involvement of yet a further paediatrician, and, secondly, she never gave her consent to such a course because of course she was never asked.

Mrs H told you that she tried the monitor overnight and it went off all the time, and in a sense it was, as it were, unsatisfactory. Accordingly, she told you, the next day she rang Dr Dinwiddie, told him about the Dr Samuels discussion, told him about her experiences with the monitor, and she told you that the advice from Dr Dinwiddie was to return the monitor to Dr Southall and to continue with his (Dr Dinwiddie’s) treatment plan. Accordingly, she told us (Day 6/16B-C), and again I would ask you to accept, that, having had the telephone call with Dr Dinwiddie, she then got on the telephone and spoke to Dr Southall, told Dr Southall of Dr Dinwiddie’s advice and was asked by Dr Southall to therefore return the monitor. Madam, the tone of that call is not a matter in the heads of charge and I will not deal with it. The request that the monitor should be returned was made and was in fact carried out.

Madam, that is the evidential background to the letter itself. If we just turn it up for a moment, the letter itself is at C2, right at the beginning of the C2 bundle. Madam, just going through that letter, and I would ask you to read it with care at this time, I went through it with Professor Southall and he agreed with me to this extent, that paragraphs 2, 3, 4 and 5 and a half, if I can put it this way, comes directly from the Samuels’ note, follows the logic of it, and I put to Dr Southall that the pure Southall aspects was the first paragraph, and he accepted that, and then picking it up in the second paragraph over the page, when it says “in communication with them today”, from then on, as it were, it is pure Southall, and in between time when the word “we” was used, I note Dr Southall accepted that that was, as it were, the team “we”. (Inaudible question by Mrs Lloyd) The question was where the words “in communication with” start, and the learned Legal Assessor is correct, it is at page 24, second paragraph, second sentence:

“in communication with them today, they have decided to reject this advice and go for the triggered ventilator approach. They are therefore returning the TCP02 monitor to us by registered post.”

Dr Southall accepted that the words “in communication with them today”, that was more likely than not a reference to the telephone conversation that he had had with Mrs H, which I have just described to you.

Madam, can I draw your attention to the bottom of 23, where it starts with “Our suggestion to them was that”, and then it sets out a number of matters on page 23, and we pick it up on the bottom of the top paragraph on page 24:

“We also feel that it is vital that [Child H] has his overall care” – and I emphasise those words – “managed by a local paediatrician.

We put this regime” – i.e. the regime that starts at the bottom of page 23 and goes over to the top of page 24 – “to the parents last week and they initially said that they would like to accept it. We therefore spent 24 hours training them in the use of the monitor. They were discharged with this on Friday night of last week.”

It is clearly being said there, in my respectful submission, that the parents consented to the involvement of a local paediatrician for the child’s overall care. It is asserted:

“We ….. feel that it is vital that [Child H] has his overall care managed by a local paediatrician.

We put this regime to the parents last week and they initially said that they would like to accept it.”

So consent to the involvement of a local paediatrician for the child’s overall care is here being asserted in that letter.

Madam, as you have heard, Mrs H’s evidence, there was no such consent because the concept, she says, of involving a local paediatrician at all was simply not discussed. On a sort of curious note, and you may think it is curious that instead of putting the regime to the referring doctor, Dr Dinwiddie, and allowing he (Dr Dinwiddie), the referring clinician, to discuss the regime with the parents, the parents were in a sense denied that opportunity to discuss the matter with the referring paediatrician because the plan of action, as it were, was being implemented at Brompton rather than being sent back to Dr Dinwiddie to discuss with the parents. In particular, the plan was implemented by the giving of the monitor to the parents, as opposed to a triggered ventilator, the training of the parents in the use of it, rather than going back so that Dr Dinwiddie could discuss with the parents monitors as opposed to triggered ventilators, and thirdly, and most importantly you may think, copying this letter to a variety of doctors, including one named one in the area where the child lived and one unnamed one, and thereby implementing, you may think, the plan which they thought they had been consented, namely that there should be an involvement of a local paediatrician. Looking at the copying list, madam, we can see on the bottom of page 24 there is a copy to Dr Bailey, number 1, that is the GP; it is copied to Dr Weaver, who was a consultant paediatrician at the University Hospital of Wales, who had had previous involvement with the child; and it is copied, number 3, to Consultant Paediatrician Royal Gwent Hospital.

Madam, in case there is an issue about it, this letter was clearly sent in the form that we have seen it. It arrives signed at Great Ormond Street, with the reference to the consultant paediatrician at the Royal Gwent Hospital still there. These following submissions relate to something that Dr Southall said in evidence, where he said, “Well, it may be I never sent the letter”, one of the straws that he was grasping at the time. We can see that it arrives in that form at Great Ormond Street Hospital, and you will recall that there is that individual bundle at C16, and I just give you the reference rather than anything else at this moment, where there is hospital correspondence relating to each of these children. Can I just say for the sake of the record that at tab 5 of C16 we have the clinical correspondence from the medical records held at the Great Ormond Street Hospital, and we have the letter that we have been looking through, looking at C2, in the Great Ormond Street records, signed by Dr Southall with his Christian name, and with the reference to the consultant paediatrician still there. So it arrives in precisely that form at Great Ormond Street Hospital.

It also arrives in that form, again with the reference to the Royal Gwent paediatrician, at the University Hospital of Wales. Dr Weaver receives it in that form. There I have to take you to the SC file, C7, at page 49. This is a letter in response to the unnamed paediatrician letter, and you can see that that is a letter from Dr Weaver to Dr Southall dated 3 April 1990. The importance of that letter in this context is this, it is in the first paragraph:

“Dear Dr Southall

Thank you very much for sending me a copy of your letter to Dr Dinwiddie. Everything I receive from specialists about this little boy confirms the impression which I made within 5 minutes of meeting him, that is they are a very unusual family! I [note] that you also sent a copy to the Paediatrician at the Royal Gwent Hospital in Newport, so I imagine that the parents have involved yet another Paediatrician in [Child H’s] care – there are now three district Health Authorities in South Wales who have some involvement with them.”

So clearly, in my respectful submission, the letter with the mention of the paediatrician gets not only to Great Ormond Street, but also to the University Hospital of Wales. It may well be important that Dr Southall replied to that letter, as we see on the next page, and that is the letter of 17 April to Dr Weaver, and starts:

“Thank you for writing to me following my latest letter concerning this family.”

I need not trouble you with bits until we pick it up at the last paragraph:

“This further outlines our further concern that this mother is going to subject her child to whatever she considers appropriate based on her knowledge of medicine. This really does fit well into the category of Munchausen’s syndrome by proxy and I wondered if something a bit more active should be done to protect this child from his mother’s activity. I look forward to hearing your progress in re-opening the contact with this family.”

Madam, I rely on this letter for what it did not say. It did not say:

“Thank you for your letter. You are completely wrong about the paediatrician at the Royal Gwent. I never sent any such letter.”

As you see, Dr Weaver has made a point about the involvement, and immediately thereafter, within ten days, Dr Southall is responding to that point, and not saying, “You have got it wrong about the Royal Gwent paediatrician”. It follows, and I would ask you, if it is necessary, to find as a fact that this letter was copied and sent to the Royal Gwent Hospital.

Madam, as Dr Southall readily conceded, there are enormous problems with the copying of this particular letter to an unnamed paediatrician on any of the three bases that were canvassed: firstly, as a referral letter for the child’s overall care; secondly, to alert a paediatrician or paediatricians that there was a child in their area who was breathing through a tracheostomy; and, thirdly, whether to alert a paediatrician in the area about child protection concerns. On each of those three bases, there are severe flaws in this letter being appropriate for any or all of those three matters. Dr Southall conceded that, to use his words, “It was not ideal”; he used the words, “It was not optimal” for any of those purposes. He also told us he did not know how many consultant paediatricians there were at the Royal Gwent. Indeed, it was not until we looked at the map which he produced of the local area, and that map is at D18, that we all saw that there was an even closer hospital to where this child lives, and that is the Caerphilly Miners’ Hospital, and we saw that on the map at D17, with, we know not, a paediatric department, an A&E department, we know not, and certainly it was to the A&E department that it was essential that the tracheostomy information was available.

Madam, that might be a convenient time, but I am at your discretion.

THE CHAIRMAN: We would be looking for a break about now, so if it is convenient to you, I am sure it is convenient to us. Thank you very much. So if we can break now until about 20 past 11. Thank you.

(The Panel adjourned for a short time)

THE CHAIRMAN: Mr Tyson, just before you continue, I was responsible for interrupting your flow earlier on, on the matter of appendix 3. Another Panellist raised with me whether, as a consequence of that, did we in fact interrupt your flow to the point where you did not address us on everything that you might have wished to on 17(a) and (b) or did you in fact do so?

MR TYSON: I was fine.

THE CHAIRMAN: You were all right. Thank you.

MR TYSON: That was fine. Thank you very much.

THE CHAIRMAN: I just promised to check with you.

MR TYSON: I am grateful for the opportunity to revisit but I do not think I need to.

THE CHAIRMAN: Thank you. You will continue now with where you left off.

MR TYSON: Yes.

We are at Child H, madam, and we are dealing with whether the unnamed paediatrician letter, if I can put it that way, at C2 at (i), whether it was, if I can put it this way, fit for purpose, either as an overall care referral letter, an alerting about tracheostomy letter, or about a CP concern, child protection concern, letter. Madam, in relation to overall care, in our submission, this is not fit for purpose as a referral letter to a local paediatrician to take over the overall care of this child, not least as no proper history is given, no discharge summaries from Great Ormond Street are enclosed and it does not tell the unnamed paediatrician what is expected of him or her. Furthermore, you may think, that if the overall care of this child was going to be managed as it were locally in Wales, if I can put it this way, the appropriate thing to have been done was to discuss the identity of a hospital and, in particular, a named clinician, you may think: choose a name, and send it to that named clinician. That was an appropriate discussion to have had, we would say, most appropriate discussion to have had with Dr Dinwiddie, but Dr Southall jumped the gun, we would say, and implemented his own treatment plan, without reference to Dr Dinwiddie and did not have any discussion about a local paediatrician, let alone the appropriate hospital or the appropriate name. For all those reasons, it is inadequate as a referral letter for overall care. I pointed out to you earlier the March 1989 referral letter of Dr Dinwiddie to Dr Southall, in these cases, which, in my respectful submission, is a model referral letter.

The second reason given by Dr Southall was that the purpose of this letter was to alert a clinician as to the possibility of an emergency with the child’s tracheostomy. Again we would submit that this is inadequate for that purpose: no proper history of the events leading up to the insertion of the tracheostomy in this child were given; no reason for the child having a tracheostomy was given; and the Great Ormond Street discharge summaries were not included. Madam, the most important omission and reason why this cannot have been a letter to alert people locally about the tracheostomy is, as Dr Southall accepted, if you wanted to alert someone about a potential tracheostomy emergency, the people you alert is the A&E department. It is to the A&E department that this child who had stopped breathing or had an event involving breathing would have gone to. In relation to Dr Southall’s admission in relation to that see Day 15/33E.

Madam, if in so far as it is alleged, thirdly, that this letter is to alert the local paediatrician about child protection concerns, then, again I submit, and indeed Dr Southall accepted in cross examination that there are many failings on this letter on its own as being a suitable one for child protection purposes. Firstly, there is no evidence whatsoever that this letter was accompanied either by a prior telephone call or a covering letter. Secondly, it is to an unnamed paediatrician in a hospital where the parents were not known. In those circumstances, thirdly, this letter could float about at that hospital, been seen by many, but not finding a permanent home with the appropriate consultant who needed to be alerted to the potential problem. Fourthly, it gives insufficient history and indeed suggestions or a plan of what to do if the child did in fact arrive at the Royal Gwent.

Madam, I have made these submissions but in the end you may think that in re examination Dr Southall accepted how unsatisfactory the copying of this letter to an unnamed paediatrician was in any circumstances. Where there was a discussion about the appropriateness of sending such a letter without a covering letter or a telephone call, he said in terms: “It is not ideal or even appropriate”. Asked by Mr Coonan:

“If that be the case, would you criticise yourself for not doing it?

“[And the answer was] Yes.”

Madam, that important exchange you will find at Day 15/33A 34B.

Madam, can I turn to the not admitted heads of charge relating to this patient. I take you to head of charge 8(b):

“You copied the letter mentioned at (a) to an unnamed Consultant Paediatrician at the Royal Gwent Hospital even though no one there was involved in Child H’s care”.

Madam, at first, second or indeed third blush, it is difficult to see what it is that is not admitted in that paragraph. It is plain on the face of the letter that it was copied to an unnamed paediatrician and that it was received in that form by both Dr Weaver and Dr Dinwiddie, and if the issue is one of not copying but sending, I hope that I have shot that particular fox by taking you to the correspondence between Dr Weaver and Dr Southall, where the issue of the involvement of the local paediatrician at the Royal Gwent was specifically raised by Dr Weaver and Dr Southall did not thereafter respond, saying, no, I was not talking about that at all. You can safely assume, if you need to, that head of charge (b) is established both on copying and sending. It is in fact only asserting the copying, however you want to put it, and I would say it means what you says, you copy the letter, that you should find head of charge 8(b) found proved.

Madam, as far as head of charge 8©, (i) and (ii):

“You did not seek, nor obtain, Child H’s parents’ consent...:

“(i) to the fact involving a local paediatrician in Child H’s care, or

“(ii) to any letter being sent to an unnamed local paediatrician”.

Madam, by Dr Southall’s non admission of ©(i) and (ii), it would appear that he is relying on the patient’s consent to the involvement of a local paediatrician, (i), and to the sending of the subsequent letter, (ii). Certainly that is what is said in the letter, i.e. the parents approved the regime. Madam, there are three problems with that approach. Firstly, Mrs H was firm in her evidence that there was no discussion at all about a local paediatrician. If you accept that of course, no question of consent arises. The important point here, madam, is that it was specifically put to Mrs H that she did in fact consent to the involvement of a local paediatrician. It was put to this witness on two occasions by my learned friend on Day 6/39G H and at 40A B. On instructions, it was put to my client that there was in fact consent to this letter. If there are child protection concerns, I accept that parental consent is not required. The problem with that, in the context of this case, is that Dr Southall cannot have it both ways, in that, as it was specifically put to my client, that she did in fact consent to this letter, and to the involvement of the local paediatrician, it cannot be alleged that the purpose of sending this letter was to alert someone that there were child protection concerns. The important thing is not to alert the parents that there are child protection concerns but to alert a named clinician that there might be.

Thirdly, it is not and cannot be a proper and valid consent if the consent is to the involvement of a local paediatrician for overall care. That consent cannot be used, and it is an invalid consent, if the purpose of the letter includes child protection concerns. If you get consent for one thing, involvement of a local paediatrician, for instance, in overall care, and if you use that consent for another thing, namely to alert a paediatrician for child protection concerns, then the consent that you have obtained is invalid because the consent is only for one purpose and not for the second purpose. I put that concept to Dr Southall at Day 14/2D and he accepted that. In those circumstances, madam, I would ask you to find head of charge 8©(i) and (ii) proved on overwhelming evidence, you may think.

Head of charge 9 (a), in my submission, you are bound to find proved because the letter itself was highly derogatory of the parents and it cannot be that the parents consented to that information going to an unnamed person or clinician in Wales. Head of charge 9(b), in breach of Child H’s or his parents’ confidentiality, madam, I can only establish, and I accept this, on the basis that you make a finding that the letter was not only copied but sent because it is the sending that requires the breach of confidentiality. Dr Southall made a great play in the course of his evidence about the great confidentiality that is required in dealing with child protection matters. Indeed, it was the principal reason, he told us, that documentation relating to child protection matters was kept in his secure SC files, rather than in the child’s hospital patient records. It is submitted, in relation to head of charge 9(b), that Dr Southall cannot have it both ways. This letter was not going into confidential records or certainly not without it being seen by a number of eyes at the Royal Gwent, determining what, if anything, to do about it.

Madam, there are two separate duties here and I want to distinguish them. There is one duty of care and the second is a duty of confidentiality. As to the former, I accept as a matter of law, that the duty of care that the doctor owes is to the child, his patient.

But the duty of confidentiality is different. If one is to mention derogatory matters about a parent I accept that these matters can be expressed in confidence to a nominated clinician – I underline that, a nominated clinician – if there is a good reason, i.e. child protection concerns. In this case, looking at the face of this letter, these matters were not expressed in confidence to a named person for a particular child protection reason. The claimed reason for involving a local paediatrician was for the overall care of this child rather than child protection concerns, and thus we submit that it was the parents’ and by necessary implication the child’s confidence that was being broken by this letter being sent to an unnamed paediatrician, the confidence of course being that those matters learnt in a doctor’s surgery, appointment room, consulting room or whatever should remain in that room unless there is good reason or consent for it to go out of that room.

Madam, at the appropriate time – we are dealing with an incident in March 1990 – the blue book for 1989 was in force, and in your little folders you do not have the appropriately dated blue book. At the next C number I would ask that you look to see the relevant blue book guidance.

THE CHAIRMAN: C23.

MR TYSON: Madam, this is at March 1989, can I take you, please, to paragraph 47, which I have taken you to in another context at another date in relation to Patient D. Again, it is headed under “Professional confidence”.

“Patients grant doctors privileged access to their homes and confidences and some patients are liable to become emotionally dependent upon their doctors. Good medical practice depends upon the maintenance of trust between doctors and patients and their families, and the understanding by both that proper professional relationships will be strictly observed. In this situation doctors must exercise great care and discretion in order not to damage this crucial relationship. Any action by a doctor which breaches this trust may raise a question of serious professional misconduct.”

Over the page at 48, in particular 48(a):

“Three particular areas may be identified in which this trust may be breached.

(a) A doctor may improperly disclose information which he obtained in confidence from or about a patient.”

Madam, further on in the guidance, and we pick it up at paragraph 79 at the bottom of what says page 19:

“79. The following guidance is given on the principles which should govern the confidentiality of information relating to patients.

80. It is a doctor’s duty, except in the cases mentioned below, strictly to observe the rule of professional secrecy by refraining from disclosing voluntarily to any third party information about a patient which he has learnt directly or indirectly in his professional capacity as a registered medical practitioner.

81. The circumstances where exceptions to the rule may be permitted are as follows:

(a) If the patient or his legal adviser gives written and valid consent, information to which the consent refers may be disclosed.”

Madam, talking in relation to child patients, of course, parents with parental responsibility as these had are the people to give the appropriate consent when it is talking about disclosure of matters relating to the child patient.

(b) Confidential information may be shared with other registered medical practitioners who participate in or assume responsibility for clinical management of the patient.”

Madam, that is not the position as far as the unnamed paediatrician at North Gwent is concerned because at the time of writing that letter he or she had not participated in or assumed responsibility for the clinical management of the patient and so the 81(b) exception does not apply. It could possibly be argued that (d) applies:

“If in the doctor’s opinion disclosure of information to a third party other than a relative would be in the best interests of the patient, it is the doctor’s duty to make every reasonable effort to persuade the patient to allow the information to be given.”

That is not the situation here. Lastly, I would submit that none of the exceptions set out in 81 apply and thus we get to paragraph 82:

“Whatever the circumstances, a doctor must always be prepared to justify his action if he has disclosed confidential information.”

Clearly, on the face of that letter, confidential information has been disclosed.

“If a doctor is in doubt whether any of the exceptions mentioned above would justify him in disclosing information in a particular situation he will be wise to seek advice from a medical defence society or professional association.”

There is no evidence before you that Dr Southall took that precaution before firing off this letter to the unnamed paediatrician at the Royal Gwent. Madam, those are all my submissions in relation to Child H and Mrs H and one can thus put away C2, because I am going to come to Child M1 and M2, but you will need to have C1 before you in the course of these submissions.

Madam, in relation to this child, looking at the heads of charge, the matters that I still have to prove are 3(a), which is:

“In January 1998 you were contacted by social workers from a local authority who had concerns about Child M2, and in particular about similarities between current events in Child M2’s life (including apparent suicide threats) and those in his elder brother, Child M1’s life, shortly before Child M1’s death by hanging in June 1996, when aged 10.”

Reminding myself of the reasons why that was denied one can see that when my learned friend was giving his client’s admissions or non-admissions, it was the words “by hanging” in that paragraph that he had problems with and, as I recall – I am looking at him – it was because of the insertion of those two words that his client felt unable to admit to paragraph 3(a). Anyhow, I need to prove it.

Then 3(b) is admitted:

“You gave the social workers certain advice, and on 29 January 1998 Child M2 was removed from home under an Emergency Protection Order.”

3© is admitted:

“Your advice was put into writing in a preliminary report dated 2 February 1998”

3(d) is admitted:

“On 3 February 1998 the local authority applied for an Interim Care Order in respect of Child M2.”

Head of charge 4 is admitted:

“On 17 March 1998 you were instructed by the local authority to prepare an assessment/report for them in the care proceedings. Such report was to cover both Child M2 and his family.”

Head of charge 5(a) is admitted:

“For the purpose of preparing your assessment/report you interviewed Mrs M on 27 April 1998”.

Head of charge 5(b) is of course the one which this aspect of the case is all about:

“During the course of such interview you accused Mrs M of drugging and then murdering Child M1 by hanging him.”

Then the consequences are set out in the non-admitted head of charge 6, which is:

“Your actions were inappropriate, added to the distress of a bereaved person and were an abuse of your professional position.”

Then the interview, the nature and mode of it, is the subject of heads of charge 17 and 18 and all the sub-heads of head of charge 17 apply in this case. You will see that the short particulars given under the M case in Appendix 3 are “accusatorial, aggressive and intimidating questioning and dismissive attitude to answers”. If you find any or all of those proved then the consequences are set out in head of charge 18.

Madam, there has been a considerable amount of evidence in relation to the unadmitted heads of charge relating to these children, and can I seek to assist you by identifying where in the transcripts you will find it. Mrs M gave evidence on Day 2. She was in chief from pages 2-18, she was cross-examined between pages 18 and 43, she was re-examined from pages 43 to 53 and the Panel asked questions between pages 54 and 63.

Madam, Dr Corfield, or Dr Solomon as she then was, also gave evidence in relation to this matter, again on Day 2, and she gave evidence in-chief at pages 66-75. She was cross-examined at pages 75-79. She was re-examined on page 79, and she was asked questions by the Panel on pages 79-82. Madam, Mrs M’s solicitor also gave evidence, Ms Parry, in relation to this matter, and she gave evidence on Day 7, and her evidence in-chief was at pages 29-42. She was cross-examined from pages 42-49, and the Panel asked her questions on page 50. Madam, as far as Dr Southall’s evidence in relation to Mrs M and the M boys is concerned, he gave evidence in-chief about it on Day 12/1-40. He was cross-examined about it on Day 14/27-66. He was re-examined about it on Day 15/39A-44A. Madam, Ms Salem also gave evidence about the matter, and if you give me a moment I will be able to assist you as to when she gave evidence about particular matters. She gave evidence in-chief on Day 17/5-77. She was cross-examined on Day 18/1-43. She was re-examined on Day 18/43-51, and she was asked questions by the Panel on Day 19/1-23.

Madam, you will recall, doubtless, that at the start of my submissions I pointed out the difficulties that both you and in particular Mrs M faces as the complainant in this case as the evidence in this matter has been heard a year apart. Your task is a difficult one because you have to test both memories, or assess both memories, and to assess credibility. You have got to try to remember how the witnesses came over to you a year ago. How did Mrs M come over to you? How did the psychiatrist, Dr Corfield, come over to you? How did the solicitor Beth Parry come over to you? In relation to Mrs M, my submission to you is that she came over as an intelligent woman, clear in her evidence about the essential issues, and truthful in her account.

In particular, she was clear about the matters that she says arose in the course of the interview that took place on 27 April. Madam, the curious thing about this interview is that in fact Mrs M did not challenge many of the factual matters that were written in Francine Salem’s note. What was in fact written there as a factual account was broadly, save as to one entry about the belt which I will come to, accepted by Mrs M, but her evidence to you was that those written words did not present the whole picture, and she said that to you at Day 2/60E. She gratefully adopted, you may think, the chair’s description that, whilst each sentence in the note was not wrong, when you take the whole thing together it is wrong, and that was an exchange between the witness and your chairman at Day 2/60F-H, because her case was it was what was not in the note that was important – the interjections, the hectoring, the aggressiveness, the tone – rather than the words that were in it. Her description, you may think, given to you a year ago, as to why the note did not cover those matters, chimes, you may think, with Francine Salem’s description of her note as purely factual. Francine Salem told you that, as it were, she deliberately excluded any non-factual matters, and so the mood, the persistence, the tone were all absent, deliberately, from Ms Salem’s note, and it is on that basis really that Mrs M was saying that the typed note does not present an accurate picture of this interview as a whole.

Madam, the way I am going to deal with the M case is to approach it from two sides; first of all, to use one of my favourite expressions, I am going to look at it from the mindset of Mrs M, and then I am going to take you after that to the mindset of Dr Southall, coupled with that of Ms Salem.

So I am first going to give you the point of view of how it all went from Mrs M’s point of view. She told you that she was asked to go for a medical. That was the expression she used, she was asked to go for a medical, and she told you that at Day 2/5G. She was asked to go for a medical with Professor Southall to see if she was suffering from MSBP. That is her mindset, she thought she was going to a medical. She thus considered, not unreasonably you may think, that she was going to be asked questions about her youngest child and to be asked about her thoughts and feelings about him, and she told you that on Day 2/22A and at 24H.

Her outlook and expectations were doubtless influenced by the fact that she had a week or so earlier attended another medical with another of the court appointed experts in this case, namely Professor Black, who she had found not to be intimidating and whose questions to her were put quietly. She was not aware, she told you, that in fact the two professors that she was seeing – Professor Black and Professor Southall – were of different disciplines, that one was a child psychiatrist and the other a paediatrician. So her mindset, you may well think, was focused on medical rather than forensic matters.

She arrived for her medical at the Academic Department, North Staffordshire Hospital, and who should she see in the room, not only the court appointed medical expert but also her social worker, Ms Salem. She told you, amongst other things, that no social worker had been present during the Professor Black medical. She told you that she was not expecting to see Francine Salem. She told you that she had not been told that Francine Salem would be present. She told you that no explanation was given as to why she was present. Indeed, in evidence both Professor Southall and Francine Salem admitted that this was so. She told you, and this is also accepted, that she was not asked for permission whether the social worker could attend. She also told you that had she known that Francine Salem would be present, she would have taken a solicitor or someone else on her behalf. Madam, these matters were all canvassed on Day 2/6.

So she is, in the light of those factors, we would submit, on the back foot already. As she described the interview to you as very aggressive compared with Professor Black’s, throughout her evidence to you she used words to describe it such as “jolted”, she was jolted by the questions, and she said that on page 25; that Dr Southall was “like a steam roller”, she said that on page 29; or that “He kept interrupting”, and she said that on page 30.

Madam, in the course of her evidence she was taken to the typed note of Ms Salem, which is now a familiar document to us all, but just to remind you it can be found at C1, tab (gg) at page 23. Madam, can I take you to page 23 and the penultimate paragraph, where it was stated in the note:

“Mrs [M] stated that the belt [M1] used to kill himself was a brown leather belt, it was his own and was a belt to his jeans. This was returned to Mrs [M] following the inquest.”

Madam, in relation to that exchange, what Mrs M told you was that Professor Southall told her that he did not believe that it was her son’s belt as it was too long, it was an adult’s belt.

Madam, over the page, page 24, you will see between the two punch holes are two lines that said:

“There was then a discussion about [M1’s] height and weight. Mrs [M] indicated that [M1’s] feet were not far from the floor when he was hanging.”

Mrs M told you in relation to that discussion that Professor Southall interjected and said that in those circumstances, knowing the height and weight of the eldest child, the pole should have broken.

Madam, just two paragraphs further down, right by the second punch hole, are the two lines that say:

“Mrs [M] stated that her husband ….. had taken the curtain rail down and put it in the bin ….. with the curtains – he had to use a hammer to get it down.”

Madam, in relation to that conversation, there were a number of interjections and observations made by Professor Southall. Mrs M said it did not come down because it was firmly fixed to the wall, and Professor Southall clearly disbelieved her and made comments to the effect that, “I do not believe you. You are even heavier than your son”, bearing in mind the evidence was that she had tried to pull him down. As to tone, Mrs M told us that as he was saying, “I do not believe you. You are even heavier than your son”, he was being aggressive about this and sarcastic about it.

Madam, it may or may not be in relation to that observation, or the one that I talked about for the curtain pole, because at page 25 you see in between the two hole punches there is a second little sentence relating to the curtain pole, where it says:

“Mrs [M] stated that she had tried to pull the rail down when she had found [M1] hanging but she couldn’t, she ….. stated that the pole had never come down before.”

It was probably in relation to that exchange, we allege, that Professor Southall said, “I do not believe you. You are even heavier than your son”, or words to the effect.

Madam, you can see just above that paragraph, the paragraph that says:

“[Professor] Southall asked Mrs [M] about her knowledge of syringes and injections. She said that she didn’t know how to inject someone, she had never seen it done, in theatre she was at the other end of the patient from the anaesthetist.”

The evidence that Mrs M gave you in relation to that was that Professor Southall made it clear that he simply did not accept that she had never seen injections, that she was just trained to clean the operating theatre, and he expressed that disbelief to her in aggressive tones.

Mrs M told us that there was a heated discussion about the belt, and this is a discussion that we can see at the bottom of page 25. The nature of the discussion is that Professor Southall wanted to know how the belt physically had been attached to the curtain rail, and thereafter round the child’s neck, that was the issue that was being explored here. Mrs M admits that there was a heated discussion about this, with both parties having, as it were, a full and frank exchange of views, prompted by Professor Southall saying that this was crucial information, and if she did not tell him how it was tied, then she must be guilty. Mrs M told us in terms, page 15E-F, that at this point she became angry and there was a discussion, during which she told Professor Southall that her solicitors had told her not to talk about the belt, to which Professor Southall responded that her solicitors had given her wrong advice.

He added words to the effect that: “If you will not tell us, it is obvious you have got something to hide”. He also added, as a further inducement to get her to demonstrate the matters: “Child protection matters take preference over criminal cases”. Also he said to her: “It is a vital piece of evidence to help prove your innocence as there has been no toxicology report and M1 had been cremated”. In view of that combination of threats and inducements, Mrs M’s resistance crumbled and she felt forced to tell and then to demonstrate how the belt was tied round the pole and the neck. You will recall she said it was something like used a pencil and a shoelace. When she demonstrated it, she told us that Professor Southall told her, “Ah, that is very clever”, in a sarcastic voice.

Madam, you have seen that Professor Southall and Francine Salem took nearly contemporaneous notes of this matter but there are also in your bundle reasonably contemporaneous notes from Mrs M when her solicitor asked her for her comments on the typed note. Madam, I am hoping – I put it no higher than that – that you will find this typed note with Mrs M’s comments scrawled over it at C1/(aa). Madam, I would ask you to note those when you retire but in particular I would like to take you to the bottom of page 3, where there is her manuscript note commenting about how Francine Salem had stated the belt issue was discussed. What Ms Salem said is that Mrs M initially declined to talk to Professor Southall about how the belt was tied around M1’s neck:

“Mrs M stated that she would be pleased to talk about it if it cleared her name but she had been advised not to by her solicitor. Professor Southall told Mrs M that he felt this was a crucial piece of information that was needed. Mrs M did tell Professor Southall that as she felt she wanted to prove her innocence and that she could do this through explaining how the belt was tied”.

You will see under the first sentence: “Mrs M said that she would be pleased to talk about it if it cleared her name”. You can see that she has made a note, which is consistent with her evidence that she gave to you, that she did not say that, he said that, i.e. it was in Professor Southall’s phrase talk, about clearing her name. In relation to Mrs M saying that she felt she wanted to prove her innocence, in fact the evidence was the other way round, in that it was Professor Southall who was talking about proving her innocence, rather than vice versa. That is made clear by the manuscript, you may think, where it says:

“No I did not. Forced to tell them. Professor Southall said that a child protection case took preference over a criminal one and if I was not prepared to tell him, then it must be that I had something to hide. And because there was no toxicology report done on M1 and that M1 had been cremated, it was a vital piece of evidence that could prove that I did not murder M1, and that I was given the wrong advice by my solicitor to stay quiet. He accused me of murdering M1. Professor Southall said it was a crucial piece of evidence, not me”.

Madam, that is exactly in accordance with the evidence that she told you, so it is not a recent invention, expanded and exaggerated over time. It is precisely what she was saying about this interview in 1998 when it occurred.

Madam, later I will take you to further corroboratory evidence about what was said, both corroborating and contemporaneous evidence about what was said at this interview, when I deal with the evidence of Dr Corfield and Mrs Parry.

Madam, Mrs M also gave you an account of what are called the three scenarios – this is not her word – as to how the three scenarios were dealt with. She did not see them as scenarios at all. She dealt with them and particularly the last one. She told you at Day 2/14 exactly how the matter went. It was in these terms:

“Professor Southall said ... ‘I put it to you that you killed your son by injecting him, hanging him up, leaving him there to die and then ringing the ambulance’.”

Mrs M told you that Professor Southall said that in an aggressive and uncaring way, having introduced the topic with these words: “This is what I think happened”. That is what Professor Southall said, according to the witness, that is how he introduced the topic: “This is what I think happened. I put it to you [et cetera], you killed your son”.

Mrs M told you she had a bit of a cry about it, when that startling accusation was put to her. She said she was not hysterical but there was a pause while she cried. After the interview, she told you that she was upset, that she was angry, that she was crying and that she felt sick, as she had been accused of murdering her son. As she told you, at Day 2/17G:

“[This] is something I [will] have to live with forever. I am still quite angry about it.”

You heard her evidence that she went to see her solicitor that day when she got home and gave a brief description of what had occurred. The solicitor, when I come to it, will give evidence to you as to what she did say. She told the solicitor in terms that she had been just accused of murdering her son, that day. Madam, I would ask you to accept that account as an account of truth, both as to the words used by Dr Southall, and as to the tone and manner in which he said them together with other things at that interview. Madam, in my submission, it rings true and in particular it rings true when I take you to what she said immediately thereafter, to the psychiatrist and to her solicitor about it.

Madam, Mrs M did not believe that she was being accused of murder, she did not perceive that she was being accused of murder, her firm evidence to you was that she was in fact accused of murder. She went to this medical believing it to be a medical about M2. M2 scarcely got a mention and she was accused of murder. No wonder, you may think, that she is still angry about it.

Madam Chairman, I now come to the other side of the fence, if I can put it that way, and looking at it from the Dr Southall/Francine Salem point of view. Madam, it is clear from the evidence that Francine Salem managed within three days of knowing about this case, to form a view that she, Francine Salem, did not believe that questions around the circumstances of M1’s death had been answered. Within three days she was able to form a written conclusion that as a result of the circumstances surrounding M1’s death not being properly answered, the possibility of M2 being a victim of parent induced illness could not be ruled out. She told you that when she wrote that interim assessment report, which she did on 23 January 1998, she told you that at that time on 23 January 1998 that the potential risk of harm to M2 included, in her view, the risk that he might be murdered by his mother. She had that in her mind within three days of hearing about the M family generally. Madam, the views that I have just read out come from C1/(b) at 358, which is the last paragraphs of the interim assessment report. That report, which is on its face undated, is in fact dated 23 January 1998. One can see from the contact sheet at 1D375, I am not asking you to look at it, but you can see it, that at 1D375 for the entry of 23 January, we can see words to the effect that she completed her interim assessment report.

Madam, can I ask you please to look at tab (u). This is Ms Salem’s witness statement that she prepared for a court, signing what we know as the statement of truth. On page 1:

“I make this statement consisting of [x] pages believing what I have said in it is true. I understand that it may be put before a Court in family proceedings or proceedings under the Children Act”.

Then we go over the page and we read together the third paragraph:

“I first became aware of the M family on 20 January 1998”.

Madam, it is from that document that I deal with the three day argument. She first became aware of the family on the 20th and she wrote her interim assessment report dealing with matters of harm including murder on the 23rd, three days later. She goes on:

“I first became aware of the M family on 20 January 1998 following a referral from the Director of Nursing at the Orthopaedic Hospitals, Oswestry, Mrs Ann Grey, where Mrs M works.”

This of course is crucial, you may think, that the referral, as she there says, came from Mrs Grey, who, we have heard in evidence was the Mrs Grey who was familiar with and knew about Professor Southall, as her husband used to be the chief executive at the North Staffordshire Hospital. Madam, it does not take much imagination, you would think, to see the link. Ms Salem told you that she had no experience of MSBP cases. One can easily see here that both possibility that this was MSBP case and the potential involvement of Professor Southall to help out, both came from the same source, Mrs Grey, and that the possibilities of both were put into Ms Salem’s mind by the assistance of Mrs Grey. You will recall that Ms Salem was unclear as to how she got the name of Professor Southall and, in my submission, it is beyond peradventure that that is how she got the name of Professor Southall, with whom she was in contact within a very few days thereafter as somebody who could help.

Madam, you may well consider, and it is part of my submissions to you, that Ms Salem’s mindset from the very start was that this was a parental induced illness case that she was dealing with. I gain support for that proposition from what she said in her contact sheet of 23 January at tab (d), page 375. You will see that within three days of her knowledge of the case she was in contact with Professor Southall. She learnt about the case on the 20th and was speaking to Professor Southall on the 23rd, and we can see, as it says in the contact sheet for the 23rd,

“Telephone call to Professor David Southall, North Staffs Hospital and gave him a brief summary of involvement and concerns. David Southall shared my anxiety and felt that I was right [and felt that I was right] in my suspicions that this may be PI illness. He believed that we had a ‘major’ child protection issue here and suggested that we needed him ‘on-board’.”

From then on, in my respectful submission, both Francine Salem and Dr Southall jointly embarked upon one particular track, namely that M2 was at great risk of physical harm at the hands of his mother. As we can see from that contact sheet, Francine Salem had her suspicions and Professor Southall wanted to be on board, as it were for the ride.

Three days later on 26 January there was the first strategy meeting. Madam, it is a matter of observation only, but if I can take you to tab (o) at page 6 we have the introduction of the hypothesis document which we heard about in evidence a few days ago. The first recorded comment when that document is brought in is by Ms Salem.

“Ms Salem informed the meeting that she had grave concerns about the similarities in the boys’ lives. The threats should be taken seriously. The hospital presentations are another concern, are they parentally induced? The presentations themselves are very unusual.

She is awaiting feedback from Professor Southall in North Staffordshire. He is to provide a preliminary report on information already submitted. He has already advised to take the concerns very seriously.”

She is the only one recorded in the minutes and I am not saying that other people added to the conversation and who discussed in terms parental inducement and matters like that.

Madam, that is 26 January and two days later there was a meeting at North Staffs between the social services team and Professor Southall which we can pick up at tab (v), page 96:

“Clive Bartley and myself visited Professor Southall at North Staffs Hospital to discuss this case now that he has the full information. Having considered all the information available he is still of the opinion that mother has a Munchausen’s syndrome.”

Pausing there, if he was still of the opinion he must have given that opinion at the first occasion. Keeping a finger in that and going back two tabs to tab (u), which is the witness statement, I read to you the second and fourth paragraphs.

“At this time I believed that there was a similar pattern being established with M2 as there had for M1. I was concerned at this and contacted Professor Southall at the North Stafford Hospital to request his opinion. He suggested to me that on the basis of the information I had given him, he believed that Mrs M had Munchausen Syndrome and that this would have serious implications for M2’s welfare.”

So we have this witness saying in a formal witness statement that on the first occasion Professor Southall, even without the documentation, believed that Mrs M had Munchausen’s.

On the second occasion, where we pick up at the fourth paragraph,

“On 28 January myself and my team manager visited Professor Southall who had opportunity to read all the relevant documentation. He confirmed [I rely on that word] his belief that Mrs M had Munchausen Syndrome and that she presented a high risk to M2. It was his opinion that we should remove M2 the same day.”

There we have 28 January, Professor Southall confirming, having read some material, that the mother had Munchausen’s Syndrome and having confirmed that, merely in the matter of a telephone call on 23 January, saying that he believed this was a Munchausen’s mother. Bearing in mind how complicated and how complex diagnoses of Munchausen’s are, to be able to make a diagnosis of Munchausen’s on the basis of a telephone call and no information is, in my submission, extraordinary.

THE CHAIRMAN: Mr Tyson, at some point in the next 10 or 15 minutes perhaps you could find a place in your narrative that would be good to break.

MR TYSON: Let us stop there, Madam, we have reached 28 January and I am about to take you to the 30th.

THE CHAIRMAN: Are you sure that is a convenient place?

MR TYSON: Absolutely. The chronology is well-known to the Panel.

THE CHAIRMAN: We will break for lunch for about an hour until ten to two.

MR TYSON: Madam, I can say that I will not be very long.

(Lunch adjournment).

MR TYSON: Madam, 28 January was the last note I had taken you to at (v) 96. Can I take you to one matter that happened on the 29th which is the second strategy meeting, and that we see at tab ®. There is one aspect of that to which I would like to draw the Panel’s attention and that is at page 6 in tab ®. It is in the middle paragraph and is a question that Dr Solomon raised.

“Dr Solomon asked whether the investigation was a joint one with social services under child protection or was it criminal, to which Steve Martin [the officer] replied that it was a criminal investigation. The approach was a joint one but investigation of an offender is done by the police.”

Pausing there for a moment, Madam, Ms Salem gave evidence that it was a joint investigation under section 47; in my submission what the police are there laying down is, yes, it might be joint in name but the investigation of an offender was a police matter and not a matter for social services and, in particular you may think, not a matter for a consultant paediatrician.

Madam, dealing again with Professor Southall’s mindset we can see that the next day on 30 January where he prepares his report at (t). I take you straight to page 180 where he is discussing Mrs M's statement and going over the page we can see in the top two paragraphs he is setting out how Mrs M describes the death of her eldest child. From a mindset point of view I rely on the middle paragraph which says:

“Reading this history I am struck by how extremely unlikely a story it is. I just could not imagine that Mrs M had not heard some sound as a result of M1 margining 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.”

Madam, that is a classic mindset point that you have there disclosed by Professor Southall on 30 January.

At the end of this report, at page 184, one comes to the last paragraph, again on the mindset issue, where he says:

“Information about the eldest 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.”

It is the words “very relevant” that I rely upon.

That is 30 January and the next mindset matter, if I can put it this way, upon which I rely took place on 25 February. That is a discussion between the social worker and Professor Southall recorded in the contact notes at (v), page 99. I take you to the penultimate paragraph:

“Dr Southall wanted us to get the SOCO [scene of crime officer] report and to interview the doctors that actually saw the youngest child at hospital A&E to discuss the precise nature of the injuries. Also that we should endeavour to get the original letter to [a magazine there mentioned ] from Mrs M to see what was written.”

Again, I rely on that passage to show the approach and the mindset of Professor Southall.

Then we come to a document that we did not know about until recently, because we come to 4 March and now I need to take you to D21, which were the documents produced by Ms Salem in the course of her evidence. Within D21 it is letter (e) and here we note that as of the date there mentioned, which is 4 March,

“The police are not reinvestigating the eldest child’s death, they want to speak to my client regarding an ambiguity about the belt and they believe that this did not constitute a reopening of the investigation.”

That was where the police were at this time.

Madam, the next event in time, which I need not take you to, was the interim care hearing in front of His Honour Judge Tonking. I just mention and record, because we are all familiar with the judgment, which is at C4, the passage on page 7 of that judgment, when it is recorded that the local authority’s case had moved on – those are the important words “had moved on”. Indeed, Ms Salem confirmed that it had in fact moved on as a result of other concerns that had come up in the course of the preparation by her of her core assessment.

The next event in time is the instruction of Dr Southall to be a court appointed expert, and this is at (x). Can I take you to the bottom two paragraphs on page 2, please.

“Directions were given on 10 March 1998 when leave was granted for the Court papers to be disclosed to you for the purpose of your providing an expert opinion as a Consultant Paediatrician.”

Pausing there for a moment, that meant that he was not acting qua clinician for one of the parties, he was an independent court appointed expert, and that has resonance in fact as to who he owed duties and the like.

“Professor Stevenson a Consultant Paediatrician has by direction of the Court ….. been authorised to carry out a report on the joint instruction of the parents and the Guardian ad Litem.

To assist I am also enclosing a note of the [generally] accepted principles of what is expected of you as an expert in these proceedings. It is important that the parties are confident of your independent status and that there are no informal unrecorded conversations with any professionals involved in the case. If you do need any further information or wish to interview anyone else then please could you refer back to me and I will then consult the other Solicitors involved. This does not prevent you from having direct discussions with Mrs Inwood” – pausing there, that is the guardian – “as she is in effect the Court’s independent reporter so you may at any time deal direct with her. [The guardian’s] preliminary assessment is set out in her report which is one of the documents herewith.”

Madam, you may think that Dr Southall is being given a very strong health warning there that the only professional that he ought to be dealing with is the guardian, and not, as it were, constant contact with the social worker involved, because, for the reasons mentioned in that paragraph, it may not help the parties being confident of his independent status.

A further point I make in relation to this letter is at page 3, and it is, as it were, a forensic point, that it is clear from all the sudden matters that Dr Southall was asked to report upon, he was not in terms asked to look at Munchausen’s, or the risk of harm to the youngest child at the hands of his mother, but nevertheless it is also clear that both Professor Southall and Ms Salem considered that was exactly what he was instructed to do.

Madam, there is one key passage in the transcript to which I would now like to refer you as to how Professor Southall saw his role. On Day 12/19B Dr Southall said this: “My job was to provide information on the safety of M2 given the circumstances”. Here is a passage that I particularly rely on: “I had to forensically challenge the data”. Pausing there for a moment, forensically challenging, you may think, is a task for the police or indeed for prosecuting counsel, but hardly a regular task for a consultant paediatrician. It is, I submit, an unlikely role for a paediatrician, specialising in the care of children, doubtless trained and an artist in interviewing children, to seek or to have the skills in forensically challenging an adult, but nonetheless that is how Dr Southall saw his task, and it is our case that he did indeed go on to forensically challenge Mrs M at the interview.

Looking at the word “challenge”, of course, you will recall, doubtless, Ms Salem considered that one of Dr Southall’s attributes was that he challenged people, and in particular Mrs M. I would ask you straightaway to reject Ms Salem’s subsequent definition of what the word “challenge” meant to her when she told you it meant to her as meaning “questions asked to open up discussion to enable the discussion to carry on”. Quite frankly, madam, that is just nonsense.

We now come to 16 April, and here we have the important attendance note of Ms Salem’s immediate superior at D21 at (g). You will see in the middle passage, right in the middle, where the team leader had a meeting with a Detective Chief Inspector and a Sergeant, and they said, it is recorded:

“The police now confirm that they will be re-opening an investigation into [the eldest child’s] death.

In the light of new information provided by Social Services Department Dr Southall and a re-examination of their own enquiry (by way of internal review) it is believed that there is evidence that would cast doubt on the cause of [the eldest child’s] death and that it would be everyone’s best interests [for] a full and thorough investigation now took place.

The purpose of this meeting was to inform Social Services Department of this decision and to find out where we were up to in our enquiries

a) So as not to duplicate our efforts unnecessarily”.

Pausing there, madam, I would submit to you that that memo means exactly what it says. It is crystal clear that the police had decided to reopen the investigation as it would be in everybody’s best interests that a full and thorough investigation now took place. Ms Salem said on more than one occasion that that note was simply wrong and the police never did decide to reopen the matter and to do a full and thorough investigation. In my submission, she is wrong about that, and clearly there is a contact sheet of which she seemed to have claimed no knowledge of, though she had a full knowledge of all the other contact sheets in this case, and she was the social worker involved in this case. My submission to you is that that contact sheet means what it says, that Ms Salem was fully aware of it, but nonetheless, even though she was aware of it, it did not stop either her or Professor Southall in their pursuit of the forensic challenge upon which they jointly embarked, notwithstanding that that was going to duplicate efforts unnecessarily. That is 16 April, madam.

I take you to 20 April, and you can read there the contact sheet at (v) 100 as to what passed between the social worker and Dr Southall on the 20th, at the top, where we see there is:

“[Telephone call] from Professor Southall - who rang questioning whether a curtain pole would actually take the weight of a 10 year old boy - he based this concern on the average weight of 30kg for a 10 year old boy, he felt that the police should be looking closer into this.”

So he is, as it were, still on the chase, if I can put it that way, and importantly we can see, if we turn to page 101 within the same tab, and the contact sheet for the day of the interview itself, we have at page 101 the invitation by Professor Southall for Ms Salem to attend Mrs M’s forensic challenge, and on page 102, you may think, the agenda for the forensic challenge.

The following issues would be addressed:

“Who the belt belonged to.
How it was wrapped round the pole.
Was toxicology done.
Question needle mark in [the eldest child’s] arm.”

Leading up to the interview, now the two accounts can marry as it were, that, I submit to you, shows those documents that I have taken you to, coupled with the evidence, shows the mindset of both Dr Southall and Ms Salem when Mrs M attended for what she described as her anticipated medical with a consultant paediatrician. No wonder, you may think, that Mrs M was upset and angry at what took place during her forensic challenge. No wonder, you may think, that she herself was slightly aggressive and assertive, which is what Ms Salem said she was, when she was suddenly faced with a social worker who she did not know was coming and who she had every reason not to like. Professor Southall told you, at Day 14/51B, that he did not think it necessary to explain why Ms Salem was present. Madam, you may indeed may wonder yourself why Ms Salem was in fact present at a medical where highly confidential matters were going to be discussed, in the course of Dr Southall’s investigation for his court ordered independent expert’s report. Any party, you may think, in the subsequent or any subsequent care proceedings, we heard there were not in fact any subsequent hearings, but Dr Southall was opening himself out, was he not, for conflict of interest and lack of independence, where he is having a crucial interview with one of the parties to the proceedings in the presence of a local authority representative. How independent is that? Or how independent can it be seen?

You may be rather disappointed by Ms Salem’s answer as to why she was present, namely it was as it were for her own purposes because it was going to assist her core assessment of Mrs M. Little thought, you may think, was given of Mrs M’s feelings or indeed of Professor Southall’s court ordered role.

Just dealing with another aspect for a moment, both Professor Southall and Ms Salem are highly experienced in giving evidence in court. Professor Southall told you in relation to this interview that he relied upon his memory of that interview principally upon the written note and his own knowledge of what he would or would not have said. So he admitted that he had to speculate as to his actions there, relying on his knowledge of how he acts in those kinds of situations, but he made it clear, being an experienced witness, when he was as it were giving matters that he could recall and when he was having to speculate, relying upon his experience of how he deals with these things generally. That is an acknowledged and good way of an experienced witness giving evidence. Similarly, an experienced witness, and now I have turned to Ms Salem, frequently uses to advantage the words “I cannot recall” when difficult questions are put to her but she showed surprising recall, you may think, when other questions were put to her. Madam, at the end of the day it is your task to make an assessment of the nature and tone of this interview and as to whether in fact Dr Southall did in fact accuse Mrs M of murder. The typed note is broadly accepted. It is matters outside that note that you have to decide upon. We submit to you that there are various pointers in this case that can assist you in deciding that Mrs M’s version is the correct one and to the appropriate standard of proof.

Madam, I am going to give you seven submissions on the basis that premise. The first matter upon which I rely is the 11 points that were decided upon or the 11 courses of action that were decided upon between Dr Southall and the social worker whilst they were still in the room, it appears, after Mrs M had left. We see this checklist at (dd) at page 77. Madam, just for the purposes of your note, we have the manuscript version of this at D21 at (i). Madam, here is the plan of action, we see on page 77, setting out 11 factors that Professor Southall had suggested that should thereafter be dealt with. I make two submissions in relation to that. First of all each and every one of those shows that he was challenging the account that Mrs M had given at the interview and shows that he was not accepting of the matters that Mrs M had stated in interview. In fact, Dr Southall in evidence at Day 13/60F accepted that all these aspects and matters showed that he was challenging Mrs M’s account.

The second submission I make on this document is that you may well think that these were police matters to be dealt with, not to be dealt with by a social worker. Indeed, you may think, that Professor Southall in his role as an independent court appointed expert should be not getting one of the parties to the proceedings to be doing as it were his forensic work for him but he should be informing the police. So, first of all, they are police matters, secondly, they show his mindset.

The second matter and submission I make is the further questions that Dr Southall was asking to be resolved, which we can see within the same (dd), if we turn to page 84. Here we can see the four queries that he set out. 1 was in relation to the curtain rail, second line of 1:

“He found it hard to believe that 30 [I think that is meant to be kilograms, rather than kilowatts] couldn’t break this curtain pole.”

Further discussions in there about the adult belt and the breaking of the curtain rail. Then he went on about the toxicology tests and Professor Southall’s view that it may have been negligent on the part of the pathologist that such tests were not being carried out. Then we deal with, at 3, about:

“The injection in the right arm he does not believe that [the] mother has [got] no experience of administering injections or seeing injections”.

Wants to check with the hospital and the ambulance crew and the like. These are classic questions showing that Dr Southall was still seeking to forensically challenge the data, to use his own expression, and his mindset was going down all one way.

The third matter I rely on in support of Mrs M’s case is the handwritten comments that she herself made at the interview on the interview record. Madam, I have taken you to those, those are at 1(aa).

The fourth matter upon which I rely is Professor Southall’s version of the interview given in his subsequent report at 1(z). Before we get even to his account of the interview with Mrs M, we can see, in my submission, where his mindset is by looking at some of his comments in bold upon the evidence. If we start at page 6, for instance, we see the comment in bold at the second paragraph:

“At this point I would like just to comment on the length of this belt. From earlier and subsequent evidence, given by the mother to the police, this belt [is] supposed to belong to [the eldest child]. However, a belt of 112 cms long is an adult’s belt.”

Again in the next paragraph he makes the comment, again I say this is a mindset point:

“At this stage I have not been able to find out who injected [the eldest child] in his arm. There is no note of this in the hospital records on his admission and I suspect it was the ambulance man. However, it is vital that we have the report of both the ambulance authorities and the medical records as to whether or not this injection site was undertaken as a part of resuscitation.”

Then at the bottom of the next big paragraph:

“There is no note made as to whether or not toxicological studies were undertaken on [the eldest child] by the pathologist.”

Then penultimately, four lines from the bottom, again in bold:

“There is no note here as to whether any injections were made into the child and, again, I think this is an important issue to be answered.”

Then we have at page 8, bottom five lines, the person there mentioned, Mr Black, is the scenes of crimes officer:

“It is very important that we have further information from Mr Black about exactly how that room was laid out. What sort of curtain pole we are dealing with. Where on the curtain pole the belt had been alleged to be hanging and whether or not the curtain pole could have withstood a 30 kg weight, with some force of gravity behind it.”

Then we have, at 10, just below the second punch hole, dealing with the medical records of the eldest child:

“This is a unusual injury and I could not quite imagine how falling out of a bunk bed would produce such injuries. They are more likely, in my view, to have been the result of someone stamping on his foot.”

Then we get to page 27, and we get the notes of a meeting held at the North Stafford Hospital on 27 April. It is quite clear that his source of that is the note, written note, made by Ms Salem, because he loyally follows it in terms of order and the like. Can I please take you to the comments, the bold comments, page 28 at the second punch hole mark:

“With regard to the scalding incident Mrs M said that she was not alone with the children. A Mrs Lorraine Stone was present with her child. Apparently Mrs Lorraine Stone has declined to give evidence about this. I think this should be checked.”

Then dealing below that about the boys who had reported in the coroner’s court about the oldest child’s allegations of taking his own life:

“This obviously needs to be checked”.

Then, at the bottom of page 28, relating to the school bus incident:

“This [should] be checked”.

Then on page 29, three paragraphs from the bottom, dealing with the injection point, and Mrs M denying that she had ever seen these matters:

“She said that she was always at the opposite bed of the bed to the anaesthetist and would be assisting the scrub nurse. She said that she had never seen an injection being given [by] another person. I cannot believe this”.

Then the next paragraph related to the curtain pole, he adds:

“I find this difficult to believe.”

He clearly did not accept the mother’s account on a number of matters, he clearly did not believe it. Our case is quite simply that the matters he is recording here, whether he believed it or not, he made it quite clear to Mrs M in the course of the interview.

Then we have the important passage, madam, at the bottom of page 30, where the scenarios are discussed. It is an important passage, madam, because it was not dealt with in the written note. In the written note, as you will recall, Ms Salem merely puts the three headings with the things Professor Southall then went through the three scenarios: one, two, three. Here the three scenarios are set out in some detail, with, you may think, (a) showing clearly that Mrs M was right when she said these matters were discussed and she would not have got that from the handwritten note and (b) showing, importantly, that there was a discussion about the, as it were, possibilities or probabilities of each and every one of these occurring.

Perhaps I can just pick it up in the middle. Firstly, in relation to the experimentation, we see that Professor Southall felt that this was unlikely to be the case, and it is part of Mrs M’s case that that is exactly what he said at the time, and in relation to the deliberately hanging himself there was clearly a discussion about that because it was my client’s firm view that that was the answer and she was, she felt, supported in that by the coroner’s report.

“The third possibility was that [Mrs M] had killed the eldest child. A discussion ensued about this, including the concept that at ten years old it would be quite difficult to deliberately suffocate or asphyxiate [M1] and then pretend to hang him. Probably some form of sedation would be involved.”

Madam, there it is, there are all the elements that Mrs M said were actually used, not in that form of words but dressed up as an accusation, and I suggest that that is exactly how it was put at the time.

“[Mrs M] assumed that this had been excluded at the post mortem. Professor Southall pointed out that he could not find evidence as to whether or not toxicological analysis had been undertaken on the eldest child after his death. [Mrs M] categorically denied asphyxiating [M1] ...”

That says a lot, does it not? “Mrs M categorically denied asphyxiating M1” – why would she have to categorically deny something unless it had been positively suggested to her?

Ms Salem, as you will recall, had one of her cannot recall moments when I suggested to her that all these matters were discussed, matters of asphyxiation and deliberate suffocation and sedation, but it is quite clear that those matters were indeed discussed and there they are set out in the note.

Madam, can we go on to page 33 and we can see that the mechanisms of death, if I can put it that way, are discussed just above the bottom punch hole and then we come to the bottom paragraph.

“Turning now to the possibility that the [other child] was killed, I am afraid that the information available after the [eldest child’s] death is, to say the least, superficial. There was no toxicological examination undertaken, as far as I can see, on him after his death. This is important because, given his age, one way in which he might have been strangled would be if he had been sedated first. His mother works in a hospital operating theatre, where there is ready access to powerful sedative and paralysing drugs. She would have seen them given on a regular basis to patients in the operating theatre. I do not accept her comment that she had never seen an injection given. The fact that she is so adamant about this makes me concerned about the whole issue. I also noted that at post mortem a needle mark was seen on the child’s arm. It is important to find out where this arose. Was it the ambulance men or was it doctors or nurses at the hospital?”

Then he uses the words:

“I am concerned about [Mrs M’s] allegations that when she telephoned the ambulance department they put the telephone down …

I am worried about the belt …”

Then, “Perhaps of most concern to myself is the question of the curtain rail.” Dealing with that, we pick it up about the curtain rail:

“She then went on in my interview with her to describe how she had also swung from the curtain pole in order to try and break it and pull the eldest child down. This would constitute a further 14 stone plus 30+ kgs and I just really cannot believe this story.”

Madam, that is what he is saying here and that, in my submission, is precisely what he said to Mrs M in the course of the interview.

Madam, that is the fourth of my seven submissions in support of Mrs M’s account.

Fifthly, I have to take you to Mrs M’s reactions immediately after the interview, and here I have to take you to the evidence of Dr Corfield, then Dr Solomon, and of the solicitor Mrs Parry.

I come to Dr Corfield. Dr Corfield knew the M family well in a clinical setting and of course we have heard and seen that her evidence was crucial or certainly instrumental at the March 2007 interim care order hearing in enabling the youngest child to return home. On the day after seeing Professor Southall, Mrs M saw Dr Corfield and Dr Corfield took a note of that meeting. Dr Corfield told you that she recalled the case well – she said that at Day 2, page 71 – and that, to use her expression, she had “a picture in her mind” of Mrs M at this interview. She said that again at Day 2, page 71.

The note that the doctor took is in C1 at (ee) and we can see from page 1 of that that this is dated 28 April 1998, the day after the interview.

THE CHAIRMAN: Mr Tyson, the sheet I have got says the 27th.

MR TYSON: If you look at page 1 of (ee) it says it is the 28th and the sheet at page 2 says it was the 27th. The disparity was discussed in evidence and the witness accepted that it was the date on page 1 which was the appropriate date. Can I pick it up under the second hole punch.

“Re Dora Black [that is Professor Black, consultant child psychiatrist] saw all of them separately including the youngest child. That was okay. Re Professor Southall. [Mrs M] went yesterday. [Mr M] not there because of job. Saw [Mrs M] on her own. She found interview offensive and upsetting. F Salem also present which she didn’t like. Questions like ‘They didn’t do toxicology. Quite possible you drugged him first’. Felt accused of killing the eldest child and it wasn’t about the youngest child at all.”

Subsequently at (ff) Dr Solomon as she then was made a report for, it appears, the court and this is dated 1 May 1998. If we pick it up on page 2 where it says in the third line of the middle paragraph,

“My most recent appointment was on 28 April 1998 when Mr and Mrs M attended with the youngest child.”

Picking it up at the next paragraph:

“They told me they had already met Dr Black and that she had seen the youngest child for an individual discussion. Mrs M told me that she had seen Professor Southall and had found this interview difficult and disturbing.”

Madam, can I take you back to (ee) and the bottom two lines of page 2, in particular the passage after “Quite possible you drugged him first”. Then these words: “Felt accused of killing the eldest child.”

Madam, that use of the word “felt” was the matter of a number of questions in the course of the evidence given by Dr Corfield. I asked her about it and Mr Coonan asked her about it, and indeed you, madam, asked about it and elicited a very interesting answer. Initially, Dr Corfield stated that the word “felt” indicated to her that Professor Southall was testing a hypothesis and she said that at Day 2, 74D. She added that he was clearly testing the hypothesis in, as she described it, a forceful manner, and she said that at Day 2, 78A. Later you, madam, elicited I submit important evidence about this at Day 2, 82A-83B.

At the bottom of 81, the Chairman asks:

“I have a question, if I may. It is going back to this note which is under (ee) on page 2 – your handwritten notes there at the end. It is where you have written, “… felt accused of killing [child M1]”.
[A] Yes.

[Q] I am just trying to explore what this might have meant. I think you said that you perhaps cannot recall exactly what was said, but in the way that you write up notes as a psychiatrist, in doing this would you try and summarise, or put a gloss on the words that the patient was using to you? You have listened to what the patient has said?
[A] Yes.

[Q] Would you be thinking what sort of thing happens in an interview given perhaps by a psychiatrist, although Dr Southall is not a psychiatrist, but that kind of interview, would you then be transferring those thoughts into how you write up the notes?
[A] Yes. I think if something particularly significant is said, you would try to record that verbatim. Also, it is encapsulated the point that you wanted to make overall, so I think that the quotes that I put down there encapsulated the idea of Mrs M’s view that she had been accused of killing the boy.”

She is saying “I put down there encapsulated the idea of Mrs M’s view that she had been accused of killing the boy”.

Then a later question:

“And how the use of words then makes a person feel. I just wondered if you could remember any more about how she had expressed those feelings?
[A] I think her words would have been, ‘He accused me of killing the boy,’ and I would have written, ‘She felt accused of killing him’.”

Madam, thereafter in questions by Mr Coonan and myself, I was trying to bolster that answer and he was trying to unbolster that answer (if I can put it that way) and at the end of the day the witness said she could not be satisfied so that she was sure of precisely what was said, is a fair way of putting it. I do nonetheless rely on that exchange that I have given you.

Seventhly and lastly I come to the evidence of Mrs Parry who is Child M1’s solicitor, and this is the evidence that she gave at Day 7, page 29 onwards. The documents in support of what she told you are all contained in the section (gg) within C1. Madam, Mrs Parry is an experienced child care solicitor and she told you that it was very unusual for a social worker to attend an independent, court-ordered, medical expert’s interview. She had no recollection in her experience of this ever happening.

Madam, perhaps we can put this into context with what Ms Salem said because she said she had attended clinicians’ interviews with children, but that was in the context you may well think of joint section 47 inquiries where the police and social services are looking at whether there have been any as it were non-accidental injuries to make their assessment before deciding whether or not the matter should go to court at all. Here we are right at the other end of the spectrum in this case where the preliminary matters have been dealt with, the section 47 report has been produced, the matter has come to court, a hearing has been held on an interim basis as to where the child should live and then, on 10 March, the court makes directions for the ultimate disposal of this case at care proceedings and appoints its own independent experts. It is at that stage, not the earlier stage with which Ms Salem was perhaps significantly more experienced, that we come to the question of her attendance and whether, even as a matter of principle or law, it was appropriate. Enough said about that.

Importantly, you may think, Mrs Parry told you that she did speak to Mrs M on the very day of the interview. It was a brief conversation and she told you that Mrs M told her that she had been accused by Professor Southall of murdering her child. Mrs Parry told you at Day 7, 44D, she recalled this conversation because, to use her words, “it was so odd”. She also told you that she a full consultation with Mrs M two days later, at which she made a manuscript attendance note, followed by a dictated one immediately thereafter. Mrs Parry recalled, and she told you (Day 7, 35D) that Mrs M was very upset at that interview due to being accused of murder, especially as she had gone expecting some sort of medical examination.

Madam, the manuscript attendance note is between pages 13 and 15 within tab (gg). I would invite you to read these carefully when you return, because it is important information coming from the mother within two days of the interview. You can see matters that are there laid out. Perhaps I ought to read it rather than ask you to read it later, because it is important.

“He got me 1st of all to draw a picture of the upstairs of the house ….. as he wanted to get it clear from my mind how I could see through from the toilet into the bedroom. I did this, he wanted me to tell him where the position of the bed was before + after, how long the curtain rail was + how thick [it] was, how it was fixed in. I said it was screwed in. He then wanted to know if it was my belt [not the eldest child’s]. I told him [it was the eldest child’s], he insisted it was to, I told him it was [the eldest child’s], asking me how many holes. I told him I didn’t know or what width it was. He then x examined me accusing of lying that the pole didn’t break”.

This is within two days of the interview.

“I answered them do best I could, he asked how I got on with Dora Black, + asked if I could get my hands…”

Pausing there, we can see from a subsequent document, that is “hands on drugs”.

“hands @ work, I told him I wasn’t a nurse, asking me if I’d seen the anaesthetist saying I would know how to inject [someone].

He said did I know no toxology report, he mentioned about [Mr M] going to prison after assault.

[M1] was cremated.
He questioned me about the bullying, he said serious [allegation] …..

[Eldest child’s] accident with scold.

He was looking at Francine, who just stood there smirking.
He said if it can’t be proved.

He asked if I’d spoken to any of the other children about committing suicide, I said no, he asked

At end he said you don’t like Mrs Stones.

The only questioned asked about [the youngest child] was about the bruise at 9 months old – I can’t remember.

He said if nobody can prove that [the eldest child] did or didn’t kill himself through bullying
He suggested that I kill him + that I either suffocated him drugged him and then hung him.

He eventually pressurised me.

He said it was very”,

and then the word is “comments”, but, as we see from the subsequent typed note, it says “cleverly done”. There are other matters not about the attendance note.

Madam, the matter was then put into a typed attendance note, and there are various matters there that are not in the manuscript note, including the first line, which is that “She was very upset”. Again, over the page at page 17, matters not in the attendance note are the first three lines:

“He wanted to know what width it was. He was more or less cross examining her and accusing her of lying and that the pole could have broken with her weight and her son’s weight it would have been over 20 stone. She said she answered the questions as best as she could and she said that she was not prepared to show how the belt was tied because of the continuing questions and telling her that her solicitors had improperly advised her.”

Madam, as you can see, time and time again questions here are coming up within two days, which is exactly what Mrs M told you in evidence some years later how the matter had gone. About four paragraphs down:

“She was questioned about the bullying and throughout he seemed to look at Francine Salem who just sat there smirking. He was telling her that it cannot be proven that she did not kill [the eldest child].”

Then two paragraphs from the bottom:

“There were discussions about Mrs Stones and he accused her of killing [the eldest child] alright saying that she killed him either by suffocation or drugged him and then he eventually pressurised her into saying how the belt was tied and he said that it was very cleverly done.”

Madam, it is clear from the evidence, going to page 19, that Ms Parry then complained to the local authority about the attendance of the social worker at the interview. Quite an interesting use of words you may think:

“Our client attended the medical appointment which was requested of her with Professor Southall and from our instructions it would seem that she has been subjected to this medical with your Social Worker Francine Salem being present. We should be grateful to receive a full explanation as to why this was the case.

We also require full disclosure of the written notes that Francine Salem took throughout the medical interview.”

Then the response at page 20, third paragraph:

“I understand from the Social Worker that she was requested to remain in the meeting by Professor Southall at his request. I understand that your client did not object. If you wish to have a formal explanation I can only suggest that you cross examine Professor Southall to explain why the Social Worker was required to sit in on the interview with your client.”

In evidence, when that letter was put to Ms Parry, she said, “I did not regard that as a proper explanation”, and you may well too not regard that as a proper explanation as to why the social worker was present, and why, if one needed a formal explanation, one would have to wait for any subsequent cross-examination of Professor Southall.

Madam, that is all the evidence and my submissions. I would thus ask you, going to the heads of charge in relation to this child, to look at head of charge 5(b). I would ask you, on the evidence, and perhaps based on my submissions on that evidence, to find head of charge 5(b) proved. If you find it proved, in my submission all the subheads of head of charge 6 are material:

“Your actions …..

(a) Were inappropriate,

(b) Added to the distress of a bereaved person,

© Were an abuse of your professional position”.

Then turning to head of charge 17---

THE CHAIRMAN: Mr Tyson, do you have anything specific about 3(a)?

MR TYSON: I am coming back to 3(a).

THE CHAIRMAN: Thank you.

MR TYSON: Head of charge 17, I would ask you to find those matters all proved: failed to treat Mrs M politely and considerately, in a way she could understand, i.e. she could not understand when she was going for a medical and ended up being accused of murder, and it certainly did not respect her privacy or dignity to be so accused. Perhaps I ought to just remind you of what Appendix 3 says in relation to this matter: it says accusatorial, aggressive and intimidating questioning and dismissive attitude to answers, “I do not believe you” being a classic dismissive answer.

Turning to head of charge 18, clearly 18(a) applies. 18(b), “Were in breach of your duty to establish and maintain trust between yourself and the children’s mothers while they were acting with parental responsibility”, here we come, madam, to the Good Medical Practice that was in force at this time, and in April 1998 it was the October 1995 Good Medical Practice which was in force, which is number 2 in your little booklet. There is an issue here as to who the patient is. I need to take you to paragraph 11 on page 4, but before I take you there, clearly in these circumstances, when somebody is requested to attend a medical appointment with a court appointed expert, it is clear we are not dealing with the child as the patient, and I would submit that the best analogy is that it is the mother who attends for such medical who would be, as it were, the patient for the purposes of paragraph 11 of the 1995 Good Medical Practice. If I be right about that, then the guidance given at paragraph 11 is smack on point, because it says:

“Successful relationships between doctors and patients depend on trust. To establish and maintain that trust”,

and you see those words repeated in the head of charge at 18(b), because I, as the drafter of the charges, there is no secret about that, had my eye on paragraph 11 when I was drafting the charges, so hence the repeating of the words of establishing and maintaining trust.

Just the first three bullet points are at point here: Listen to patients and respect their views; treat patients politely and considerately; and respect the patient’s privacy and dignity. If you think those three bullet points have any echo in head of charge 17(a), (b) and ©, there you would find where the echo is. I would ask you to find head of charge 18 found proved.

Lastly, madam, turning to head of charge 3(a). Head of charge 3(a) is not admitted. As I said, it was my understanding that the reason why it was not admitted was due to the use of the words “by hanging” in 3(a). Madam, again, as the admitted drafter of these heads, the words “by hanging” were merely intended to be a non contentious description of the manner of M1’s death, without any indication of whether the death by hanging was either deliberate, accidental or suicide. I took those words, and I take it clear, from the inquest. Can I ask you please to look at (y); C1 at (y). Within (y), look at page 188. You can see that 188 is the evidence to the inquest given by the consultant pathologist there mentioned. Over the page, at 189, he says:

“In conclusion, I consider that death was due to 1(a) Cerebral ischaemia due to 1(b) Compression of blood vessels in the neck due to 1© Hanging.”

We can pick it up again at page 195, which is as it were the pathologist’s pro forma. As we can see it starts at 193 and going through 193, 194 to 195. Again, the pathologist is repeating:

“I consider that death was due to.
1a) ...
1b) ...
1c) HANGING.”

Then the coroner himself giving the verdict at page 223. Again in the first paragraph of his judgment gives:

“The medical cause of death 1(a) ... 1(b) ... due to © Hanging.”

I make it clear to my learned friend, 3(a) was meant to be a descriptive paragraph or head of charge, rather than one having any connotations to it. It is meant to be entirely neutral, merely to describe the manner of the death, rather than anything accusatorial or disgraceful about the use of those words. I make it clear that it is in that context that that word was said.

Madam, that is all my submissions on the evidence in this case, save as to one matter, if I can remind you, if I can put like this, the double negative in the rules because this is of course an old rules case. I have to draw your attention formally to rule 27(2)(ii). Perhaps I can take you to rule (2)(ii), that at the end of the proceedings, i.e. when you have heard speeches from my learned friend and I, and heard wise words from your Legal Assessor, at the end of the proceedings:

“... under paragraph (1) the Committee shall consider and determine:

“(i) which, if any, of the remaining facts alleged in the charge and not admitted by the practitioner have been proved to their satisfaction, and

“(ii) whether such facts as have been so found proved or admitted would be insufficient to support a finding of serious professional misconduct, and shall record their finding.”

In my submission, and turning that on its head, if you find any of the facts proved in this case, they are clearly capable of amounting to serious professional misconduct. These are serious matters, for instance, just even the last matter I have been discussing, but the collection of secret parallel files and the like; and the allegations in relation to Child H and the unnamed paediatric letter; the matters related to Mrs D in the corridor; and the matters relating to computer records; the matters relating to the special cases files; and the matters related to Mrs M; all of them either jointly, or on their own, are, in my submission, sufficient to support a finding of serious professional misconduct. Madam, those are my submissions in this case.

THE CHAIRMAN: Thank you, Mr Tyson. As agreed earlier this week, Mr Coonan is not going to begin his speech until Monday. We would now be adjourning, unless there are any matters that either of you wish to raise, of a housekeeping nature or otherwise.

MR TYSON: Madam, having heard from me for a day and half now, I have no further matters that I wish to raise.

THE CHAIRMAN: Mr Coonan?

MR COONAN: No, thank you very much, madam.

THE CHAIRMAN: We will now adjourn until 9.30 on Monday morning. Thank you.

(The Panel adjourned until 9.30 a.m. on Monday, 19 November 2007)