My Lords, it is a great pleasure to follow the noble Lord, Lord Browne of Ladyton, who made some excellent points. I congratulate my noble friend Lady Kramer on this vital Bill.
I was leader of the opposition on Haringey Council when Victoria Climbié was murdered in 2000. “Lessons must be learned” was the oft-repeated answer to all the questions, but no one in authority listened or learned. So it happened again. Again in Haringey, just seven years later in 2007, baby P—Peter Connelly, a 17 month-old toddler—was murdered by his mother’s partner, his mother and one other. By that time, I had become the MP for Hornsey and Wood Green, the western half of Haringey. Again, there had been warnings from whistleblowers.
The particular case I am citing is the story of Kim Holt, one such whistleblower, a doctor in the special clinic run by Great Ormond Street Hospital as
outreach at St Ann’s in Haringey, and the clinic to which baby Peter was taken. Why was Great Ormond Street running a child safety clinic in Haringey? It needed to demonstrate outreach work to gain foundation status. Kim eventually came to me as the only person who would listen to her and do something. Kim and I flagged up the dangers caused by the lack of appropriate staffing at the clinic before Peter was murdered. Between us, we saw the police, Haringey Council leadership, Haringey Council social services, the local PCT, the Great Ormond Street board and CEO, the chief nurse of the NHS, and others, but none of them heard what we were telling them—neither me nor Kim. It was too big to fail; protect the institution; reputations were at stake. I do not have long enough to tell the whole tale or include all those who tried to flag up the dangers ahead.
When baby Peter was killed and the furore arose, the media focus was on Haringey Council and Sharon Shoesmith as the head of social services. But it was also this clinic that failed baby Peter and therefore Great Ormond Street, because it was its clinic, its responsibility, and it had been warned. With a long history of hospital admissions and many, many injuries, Peter made his final visit to this clinic—his last hope. The doctor there did not perform a full examination of Peter because he was “miserable and cranky.” Furthermore, no reports had been provided of his previous admissions and attendances at the Whittington or North Middlesex hospitals for possible non-accidental injuries, nor were they even sought. Had they been, the doctor would have seen the history of the myriad signs of abuse that were taking place. According to the post-mortem, Peter would have been suffering from numerous fractured ribs and possibly a broken spine at the time of that last visit. The broken spine would have left him paralysed and unable to empty his bladder.
Post Peter’s death, the clinic was judged “clinically unsafe” in the Sibert and Hodes report—the report commissioned by Great Ormond Street. “Clinically unsafe” was the actual terminology used by investigators post Peter’s death and independently verified by the Royal College of Paediatrics and Child Health investigators. The report found that, while originally four paediatricians were employed, two had resigned and a third, Kim Holt, was put on sick leave due to the overload, thus leaving only one single doctor in charge to staff the clinic, Dr Sabah Al-Zayyat. She was not properly qualified, was tired and overworked, and the report found that she should never have been employed in the first place. She paid a price for her part in this disaster.
The report also found that there was no named doctor for child protection. The named doctor position is the absolute critical requirement for this service. That crucial information was deliberately withheld. Instead of submitting the full report as an addendum to Great Ormond Street and Haringey PCT’s individual management review, Dr Collins, the then CEO of Great Ormond Street, passed over only a partial and selective version, omitting all the key points of danger. The information that had been expunged would have flagged up the dangerous conditions operating within the child health safety team for which Great Ormond Street had the responsibility. This report was kept secret
and was released only in response to a freedom of information request from the BBC to Tim Donovan, with whom I worked to expose this horrific cover-up for a period of two years.
Dr Holt had escalated her concerns to the chair and CEO of Great Ormond Street in November 2006; she had been to the GMC. I took it to the board of Great Ormond Street, who basically told me to get lost—as I said, it was too big to fail. How dare I question this great establishment? Shoot the messenger—silence the whistleblower.
Kim was ostracised by the senior management team. Her workload had been unsustainable and she had been signed off work with work-related stress in February 2007. Great Ormond Street then moved to remove her from her post, with an offer of a year’s salary and the expectation that she would sign a non-disclosure agreement. Great Ormond Street would not allow her to return to work. The offers of money increased to £120,000, and that was signed off by the Treasury. Kim declined, as she felt that the concerns she raised were important and relevant for the inquiries that had, sadly, begun to happen. She eventually returned to work four years after her initial period of sick leave. Great Ormond Street has since apologised to her for the distress caused. It is too big to fail, as in so many cases. These are the reasons why my noble friend’s Bill is vital.
1.35 pm