This item first appeared on the F.A.C.T. website on the 16th May 2005
Judgement handed down by Fitness to Practise Panel (Conduct)
Session dated 25 April – 13 May 2005
St James’s Buildings, 79 Oxford Street, Manchester M1 6FQ
Dr Camille De Sam Lazaro
Dr Lazaro: At the material times you were practising as a Consultant Paediatrician at the Lindisfarne Centre, The Royal Victoria Infirmary, Newcastle-upon-Tyne, where you specialised in the area of child abuse.
You have admitted that in 1993 and 1994 you examined 53 children from Shieldfield Nursery, Newcastle-upon-Tyne, following allegations of sexual abuse at the nursery. Your records in relation to the children included Child Protection medical records, medical reports, statements for use in criminal proceedings, and reports to the Criminal Injuries Compensation Board (CICB). On repeated occasions you provided to the CICB a “generic” report entitled “Report into Multiple Abuse Shieldfield Nursery, Newcastle-Upon-Tyne”, dated November 1994.
Criminal charges were brought against two workers in the nursery, namely Christopher Lillie and Dawn Reed, in relation to six of the children allegedly abused. On 14 July 1994 both were acquitted on all charges on the direction of the Honourable Mr Justice Holland following the exclusion of video evidence and the Crown Prosecution Service’s decision to offer no evidence. Newcastle City Council subsequently appointed a team to review the abuse allegations, the report of which was published on 12 November 1998.
Christopher Lillie and Dawn Reed thereafter brought libel proceedings against Newcastle City Council and that Review Team. In a judgment delivered on 30 July 2002 the Honourable Mr Justice Eady found that the claimants were entitled to judgment against the Council and members of the Review Team. You gave evidence on oath in the libel proceedings during which you acknowledged that, as most of the children allegedly abused were pre-verbal or poorly verbal, the medical assessments of them were of a potentially critical nature. In the course of your evidence you further agreed that
- there were deficiencies and/or inaccuracies in your recording in the Child Protection Medical Records;
- there were inconsistencies as between your medical records and your medical reports;
- there were inconsistencies as between your medical reports and police witness statements; and
there were on occasions confusing uses of terminology.
In relation to the eight children cited during this hearing, your actions have been found to be inappropriate in relation to seven, irresponsible in relation to six, and unprofessional in relation to five.
You accepted that the Generic Report referred to above was written to support the claims of parents for criminal injuries compensation on the basis that their children had been sexually abused by Christopher Lillie and/or Dawn Reed. You accepted responsibility for the content of that report and indicated that you wrote it without reference to records and notes, and that there were inaccuracies within it. You further accepted that, in one instance, your claim that an identical bacterium was isolated in boys was inaccurate and did not have forensic probative value. You expressed regret that you had included in the report “any event which potentially could have arisen from this crisis”. You have accepted that the report was overstated, exaggerated and emotive. In relation to this report your admitted conduct has been found to be inappropriate, irresponsible and unprofessional.
The Panel has been provided with three sets of specific guidance on child sexual abuse available to you in 1993 and 1994, namely:
- the report of the Royal College of Physicians “Physical signs of sexual abuse in children”, dated 1991, (the RCP report);
- the Report of the Inquiry into Child Abuse in Cleveland 1987 (the Cleveland Inquiry report); and
- the Department of Health document “Working Together under the Children Act 1989”, dated 1991, (Working Together).
You have confirmed that you were aware of each of the above documents. The Panel has noted Mr Coonan’s comment that Working Together states at paragraph 1.14 “This document is not intended to be a practice guide for any particular agency or worker”. However, the Panel also notes that this paragraph goes on to say that “it provides a brief account of some of the legal and ethical considerations which underpin work in child protection”. The Panel is therefore of the view that the principles outlined in the document are applicable to your practice.
It is clear from all of the guidance, and indeed you have admitted in evidence, that accurate, precise and comprehensive record keeping is of paramount importance in cases of alleged child sexual abuse. In particular, the RCP report states at page 5, paragraph 2.3, that doctors undertaking examinations “… will need to keep meticulous records”, particularly as the doctor should be aware that they may need to “… present reports, and give evidence in courts”. Indeed, the Cleveland Inquiry report states in paragraph 6(d)(iii) “The doctor concerned should recognise the importance of taking a full medical history and making a thorough examination … of completing full and accurate medical records [and that] those records should be made at the time of the examination”. Working Together states that “Well kept records are essential to good child protection practice”. It further states at paragraph 5.14.9 that “Recording of … interviews should be accurate and should differentiate between fact, hearsay and opinion”.
The Panel has seen several instances throughout your records where you have failed to record exactly what the child had said to you during examinations, and where potential confusion might arise as a result. The RCP report states at paragraph 10 “The single most important feature is a statement by the child” and at paragraph 2.1 “… it is good practice to record verbatim what both the child and the interviewer say”.
A further feature in several of the documents presented to the Panel is that you failed to be consistent in the terminology used to describe the physical findings you saw, and that your descriptions of physical findings in subsequent documents were different from those in the medical records. The RCP report states that “It is very important, as was stressed in the Report of the Inquiry into Child Abuse in Cleveland 1987, that a consistent vocabulary is used to describe the appearances of the ano-genital region in order that doctors and others may understand each others’ descriptions”. The Panel considered that it is particularly important in police statements that the same wording is used to describe physical findings as was used in the medical records because of the weight which may be placed on factual medical evidence in judicial proceedings.
The General Medical Counsel’s document Professional Conduct and Discipline: Fitness to Practise (January 1993), which was applicable at the time, states at paragraph 36 that “The public are entitled to expect that a registered medical practitioner will afford and maintain a good standard of medical care. This includes a conscientious assessment of the history, symptoms and signs of the patient’s conditions [and] sufficiently thorough professional attention, examination and, where necessary, diagnostic investigation”. At paragraph 45 it is stated that “Doctors are … expected to exercise care in issuing certificates and similar documents, and should not certify statements which they have not taken appropriate steps to verify. Any doctor who in a professional capacity signs any certificate or similar document containing statements which are untrue, misleading or otherwise improper may be liable to disciplinary proceedings.”
The Panel considers that you did not adhere to the principles of good practice outlined in the documents above in your production of medical records, medical reports and police statements with regard to seven children.
With regard to the generic CICB report, the Panel considers that the purpose of such a report is to inform the CICB’s decision making process when considering claims for compensation. This compensation is awarded from the public purse and therefore, as the author of such a report, you had a responsibility to ensure that the contents were accurate, precise and capable of being proved, so that any expenditure of public money would be fully accountable. The Panel notes your defence that a similar report had been provided in relation to the Bolam Street crisis, and, as it was not criticised, you adopted the same style and format with the Shieldfield Nursery report. The Panel does not accept this defence, as the report which you provided in relation to Bolam Street had been written following the conviction of the care worker involved and therefore the facts were no longer in dispute.
You have stated that you saw your role in providing the report as acting as an advocate for the children involved. Whilst the Panel agrees that this was entirely appropriate, this did not absolve you from your responsibility to ensure that the information you provided was accurate. In such a professional report there was a need for measured language, and your failure to use such language may have undermined the content. Further, this had the potential to affect the claimants adversely.
During the period in question, you were practising as a Consultant Paediatrician specialising in forensic paediatrics. Throughout its consideration of your case, the Panel has been careful to judge you against the standards expected of Consultant Paediatrician undertaking this work. You have told the Panel that you were looked upon as the person with most expertise in this specialty in the Region, and you accepted tertiary referrals from across the north of England. Indeed you had been a senior lecturer in Paediatric Forensic Medicine for four years, had been responsible for training paediatric colleagues, organised conferences on child abuse both nationally and internationally and were an acknowledged author in the field. The Panel accepts that in the early 1990s this was still an emerging field of practice. However, clear guidance was available and the Panel considers that you had a responsibility, not only in relation to your own individual practice, but also as a supervisor of more junior colleagues and an expert in the field, to set an example by complying with the standards set out in the guidance.
The Legal Assessor has advised the Panel that its duty is to act in the public interest, ie to ensure public safety, to ensure public confidence in the profession, to uphold the standards in the profession and to maintain the reputation of the profession. In deciding whether to take action in relation to your registration, the Panel has considered the issue of proportionality. With regard to this latter point, the Panel notes that it has found your record keeping to be unprofessional in relation to only five sets of records. Three of the sets of records presented to the Panel were found not to be unprofessional and the Panel has received no evidence that any other documents which you produced during that period, before, or since, were less than satisfactory.
In considering whether you have been guilty of serious professional misconduct the Panel has been advised that it should bear in mind the Court of Appeal case of Campbell v the General Medical Council [2005] EWCA Civ 250. In that case, a distinction was drawn between contextual mitigation, ie the circumstances in which the doctor found himself at the time of the incidents in question, and personal mitigation, ie testimonials and other character evidence. In particular, the Panel’s attention has been drawn to the words of Lord Justice Judge in that judgment:
“… the error under consideration may need to be examined in the context of a dedicated practitioner working in isolation and under huge pressure of, say, an epidemic. Such circumstances may be relevant to the question whether he should be found guilty of serious professional misconduct. In short, the same facts may on occasion impact both on the question of whether the practitioner’s conduct amounted to serious professional misconduct, and on the appropriate consequential sanction.”
The Panel has received considerable evidence of the difficulties you were experiencing at the time of the Shieldfield crisis. It has heard that you were a sole practitioner with insufficient resources struggling to cope with an excessive caseload. The Panel has noted the testimonial provided by Professor Hobbs, Consultant Paediatrician at the St James’s University Hospital, Leeds, which states
“Her caseload was excessive. I have no doubt that she would have been at risk of confusing children in her mind, that she would have had insufficient time to have performed routine quality checks on her reports and may very easily have made the kind of errors which she has acknowledged. Errors of [this kind] in my experience occur not uncommonly in this work.”
The Panel has heard a great deal of praise of your pioneering work in establishing the service at the Lindisfarne Centre, but it appears that this had been done with little nursing or administrative support. The Panel is also concerned that, despite the support you derived from other colleagues in the field nationally, you were at risk of being professionally isolated as the sole permanent Consultant responsible for the service. Whilst the Panel cannot condone the errors identified in your practice, it has viewed these in the context of the situation in which you found yourself at the time.
At this point in its deliberations, the Panel was especially aware of the advice given by the Legal Assessor that they had to be sure of a finding of serious professional misconduct. Therefore, the Panel has found that your conduct, although falling short of that expected of a registered medical practitioner, did not reach the threshold of serious professional misconduct. Accordingly, the Panel has found you not guilty of serious professional misconduct.
That concludes this case.