Great Ormond Street and Baby P: was there a cover up?BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d4691 (Published 02 August 2011) Cite this as: BMJ 2011;343:d4691
Baby Peter Connelly had bruises on his face and back and a two month old lesion on his head when he was seen by Sabah Al-Zayyat, a locum consultant paediatrician, at the child development centre at St Ann’s hospital in Tottenham, north London, on 1 August 2007. The bruises were typical of abuse, according to the two leading paediatricians who later reviewed Dr Al-Zayyat’s work at St Ann’s, and should have raised suspicion—particularly in a toddler who, as the notes showed, was on the child protection register.
It was the last chance to save his life but it was missed. He was sent home, and a letter went to Great Ormond Street Hospital referring him for investigation for possible metabolic disease. Two days later, aged just 17 months, he was dead. A postmortem examination found eight fractured ribs; a broken back; an area of bleeding around the spine at neck level; numerous bruises, cuts, and abrasions, including a large gouge in his head; a tear in his frenulum that was partially healed; and missing nails. One ear lobe had been pulled away from his head, and a tooth was found in his colon. In November 2008 his mother, Tracey Connelly, her boyfriend, and his brother were convicted of causing or allowing his death, and a media storm erupted.
The case of Baby P—his full name was not released at first—became a cause célèbre. The picture of the blond, blue eyed toddler in his bright blue pullover who was so let down by health professionals and social services sparked public outrage. Government ministers looked for someone to blame. Attention focused mainly on the social workers rather than the doctors who had seen Peter, and Haringey’s director of children’s services, Sharon Shoesmith, lost her job.
How could a consultant paediatrician have missed the obvious signs that Peter was being battered? He had already been to North Middlesex Hospital three times in his short life, and hospital staff had diagnosed non-accidental injuries on one of those visits. But Dr Al- Zayyat was unaware of this—there was no record of those hospital visits in the notes. Nor did she have the training required in the job description for the post of community paediatrician which she held. There were only two consultants in a clinic which was supposed to have four, and there was no one in the crucial post of “named” doctor for child protection. In short, concluded Jonathan Sibert and Deborah Hodes, who were commissioned to review the case, the state of affairs was “clinically risky” and “the present arrangements for seeing child protection cases at St Ann’s cause grave concern.”1
The doctors at St Ann’s were employed by the world famous Great Ormond Street Hospital, a centre of excellence with an international reputation. Seen as one of the world’s great children’s hospitals, Great Ormond Street now finds itself at the centre of a murky whirlpool of allegations, accused of management cover-up, bullying and targeting of staff who raise safety concerns, and trading on its reputation.
Newspaper articles, BBC reports, an NHS whistleblowing special in the magazine Private Eye, and even an editorial in the Lancet2 charge the hospital with concealing the extent to which it failed Baby Peter by not passing on the full, highly critical, report by Professor Sibert and Dr Hodes to the first serious case review set up to learn lessons from the tragedy.3 Government minister Lynne Featherstone called on the chief executive officer, Jane Collins, to resign and demanded that health secretary, Andrew Lansley, launch an investigation into the alleged cover-up. Her call was supported by an unknown number of anonymous consultants at Great Ormond Street Hospital in a letter to the Lancet last month.4 But Mr Lansley has now vetoed an investigation. A Department of Health spokesperson said: “These matters have been extensively investigated. GOSH [Great Ormond Street Hospital] has acknowledged and apologised for its part in those events. The Secretary of State does not believe it would be beneficial to revisit these events once more.”
Children from all over the UK and indeed the world come for treatment to Great Ormond Street’s Bloomsbury site, in the heart of academic London, where it is building a shiny new medical unit with donations from, among others, the family of billionaire Lakshmi Mittal, one of Britain’s richest men. Just a few miles to the north is St Ann’s, a Victorian edifice in Tottenham serving Haringey, the 10th most deprived of England’s 354 districts. In 2007, 36.4% of its children were officially deemed to be living in poverty.
Great Ormond Street sees children with rare and complex disorders who could probably be treated nowhere else in the UK. The decision to get involved in community paediatric services in Haringey was, says Michael Burch, specialty lead for cardiology at Great Ormond Street, taken with good intentions but in retrospect was a mistake. “I don’t think the trust had previous knowledge of working in complex community matters. While I think they wanted to get teaching hospital expertise and ivory tower teaching hospital medicine out into Haringey, I think it’s just very difficult to do that. People at the time thought it was a very noble gesture to try to get involved with a very deprived borough and to try to offer help from the service, but it clearly didn’t work that way.”
Barbara Buckley, one of the two medical directors at Great Ormond Street Children’s Hospital NHS Trust, who arrived at the trust in April 2008, acknowledges that it was “naive” of Great Ormond Street management to think there could be effective governance in a situation where it employed the doctors but they worked on another site in a service run and managed by another trust, Haringey Teaching Primary Care Trust. Great Ormond Street took over the full running of the service in April 2008 but transferred it to Whittington Health in north London in May this year.
The partnership began in 2003 when Haringey, which was having recruitment problems, approached Great Ormond Street, thinking the “brand” might help. Four consultants were appointed, but a financial crisis at Haringey in early 2006 led to cuts in the child health service’s funding and back-up staffing. In 2006, the four consultants at St Ann’s wrote a letter highlighting concerns about a “lack of unified records,” “missing records,” and “no child protection follow-up.” Two of the consultants left and a third, Kim Holt, who complained about the workload, became embroiled in what turned into a long running dispute with Great Ormond Street management. She was signed off with work related stress in 2007, and it was announced last week that she will return this summer to work in the local paediatric community services, now under Whittington Health.
Dr Holt says she was offered £120 000 to sign a compromise agreement and leave, but it contained a gagging clause and she refused. She regards herself as a whistleblower who was targeted by management for raising concerns. An investigation in 2009 by the law firm Bevan Brittan, commissioned by NHS London, the strategic health authority, concluded that it was fair to describe her as a whistleblower, that she was a conscientious doctor, and that the workload of the consultant team was excessive between 2006 and 2008—but that she had not been targeted or bullied.5
It was against that background that Dr Al-Zayyat was hired as a locum in January 2007 to fill a consultant post whose requirements—two years’ higher professional training in community child health or neurodisability, broad in-depth experience in community child health, and a knowledge and understanding of national guidance and legislation on child protection—she lacked. She had never been on a specialist training programme, although the job description mentioned this as a core requirement. There were only two consultants in a clinic where there should have been four, and Professor Sibert and Dr Hodes noted that the lead consultant, Sukanta Banerjee, believed the unit was in a “clinically risky” situation, with too few staff, no nurse, and difficulties in linking with the local hospital, the North Middlesex.
When Peter arrived with his mother and her friend, the referral was to assess his behaviour, which included head butting family members, head banging, and throwing his body around—behaviour which, the Sibert review noted, could itself point to abuse. Dr Al -Zayyat failed to examine him properly because he was “miserable and cranky.”
Peter’s death was swiftly followed by the launch of a Metropolitan Police murder investigation and a serious case review by the local safeguarding children board. In the course of the serious case review, Great Ormond Street commissioned its own review of Dr Al-Zayyat’s practice at St Ann’s. Professor Sibert, emeritus professor of child health at Cardiff University, and Dr Hodes, a consultant community paediatrician in Camden, north London, both experts in child protection, were put forward by the Royal College of Paediatrics and Child Health. What they found was damning, but the hospital sent the serious case review only a truncated version, with an action plan but with about half the overall content of the report left out.1 Among the missing findings were the facts that Dr Al-Zayyat was not qualified for the job and had little training in child protection and that Peter had waited around four months to be seen from the original referral. The recommendation that a “named” child protection doctor was needed urgently was omitted. Instead, the action plan called for one to be appointed.
A crucial section that was left out said: “Dr Banerjee is clinical director of the service. She says that it is a ‘clinically risky situation.’ Dr Banerjee feels that she is fire-fighting all the time. We agree with her and we believe the present arrangements for seeing child protection cases at St Ann’s cause grave concern. In particular the lack of consultant staff and the problems linking with the North Middlesex and Great Ormond Street make things very difficult.”
This was important information for the serious case review, whose role is to learn lessons for the future, say the authors of the review, Edi Carmi and Fergus Smith. “We were shocked and disappointed not to be given all relevant information by Great Ormond Street,” said Mr Smith, a veteran of more than 30 reviews. “No serious case review can fulfil its purpose if people withhold relevant information. We are used to having to overcome gaps. What we didn’t anticipate, because it had never happened before to our knowledge, was information deliberately being held back.”
So why wasn’t the full report sent to the serious case review? Lynne Featherstone, in allegations set out on her website (www.lynnefeatherstone.org), has accused the hospital chief executive, Jane Collins, of a cover-up. The trust board, which says it has reviewed the legal advice given at the time and is standing by Dr Collins, has delivered a point by point response calling on Ms Featherstone to retract her accusations. The MP, in a detailed rebuttal, has refused and called again on the health secretary to investigate.
Great Ormond Street has maintained that it received advice from lawyers and the police that it should not send the full report to the serious case review because disclosure might prejudice the outcome of the forthcoming criminal trial of Peter’s mother, her boyfriend, and his brother. A hospital spokesman told the BMJ that staff had initially intended to hand over the full report. But at a meeting in May 2008 the trust’s external legal adviser, David Mason, a partner in the law firm Capsticks, advised that they should seek police advice first. After a discussion with Mr Mason to clarify what was said at the meeting, the spokesman explained: “It was only after David had pointed out the legal risks associated with this approach that GOSH staff decided to take his advice and instead to discuss the matter with the police first. If GOSH had not discussed this matter with the police, but had simply circulated the full Sibert report and circulation had then led to the collapse of the Baby Peter trial GOSH would, quite rightly, have been seriously criticised by the police, the judiciary, the media, and the public, and potentially those held responsible could even have faced contempt proceedings.”
But after several press reports in which the hospital was quoted as saying it had acted on police advice, the Metropolitan Police issued a statement denying it had given such advice. It said police would never advise on what should be given to a serious case review, which was not within their jurisdiction. A Met spokeswoman speculated that a misunderstanding may have arisen from a discussion between police and hospital about disclosure issues.
Nor is it obvious how giving a document to an inquiry that would have a duty to keep it confidential would be likely to prejudice a forthcoming trial. Serious case reviews often run alongside a police investigation, in anticipation that the alleged perpetrators will face trial. But even in the highly unlikely event that the Sibert report somehow became public after being sent to a confidential review, nothing in it would appear to be potentially prejudicial to a jury deciding on the guilt or innocence of the three perpetrators. The elements that had been removed point to failings in employing, training, and managing Dr Al-Zayyat and shortcomings in the service.
Dr Collins and the board chairman, the Labour peer and academic Tessa Blackstone, declined the BMJ’s invitation for an interview. But the trust’s two medical directors, Dr Buckley and Martin Elliott, agreed to speak to us. “There was never any intent to withhold information to manipulate the outcome of the serious case review,” said Dr Buckley. “I’ve read and seen the information that was shared with the police and the correspondence with the police and I’m confident that Great Ormond Street Hospital and the people who were working for Great Ormond Street Hospital did what they believed was police advice. That’s exactly the sort of thing that’s being shared with the secretary of state [Andrew Lansley] so he can see there is very clear information available.”
Professor Elliott, who became a director only last September and still works as a cardiothoracic surgeon, said: “I had the opportunity to look at those papers with a cold and relatively unemotional eye. I could not convince myself, and I approached it cynically, that there had been any intent at all to withhold information. The whole narrative looks like one where people were trying to give out information but not wanting to share stuff which wasn’t about Baby P.”
The Sibert report did not become public until May 2011 when BBC London political editor Tim Donovan obtained it under a freedom of information request and Great Ormond Street put it on its website. No one would have expected that there would be more than one serious case review. But Ofsted, the inspection body, declared the first review “inadequate” and a second was ordered.6 Great Ormond Street says it gave the Sibert report to the second serious case review and it is listed in the documents seen by the authors of the part of the review dealing with health agencies’ involvement in Peter’s case. But the chairman of the panel overseeing the second review, Graham Badman, says that he has no recollection of seeing it and he later asked the hospital for a copy. The hospital says: “We don’t know whether Mr Badman saw the Sibert report. The internal sharing of relevant documents within the SCR is a matter for them.”
The trust says it published the Sibert report at last because the reasons for not doing so no longer applied. The two serious case reviews had been published, the General Medical Council proceedings against Dr Al-Zayyat had finished—said to be “suicidal,” she was allowed to remove herself voluntarily from the medical register without facing a hearing—and the authors of the report had changed their views on publication.
The controversy over the trust’s handling of the Baby P case has also brought into the media spotlight a wider dissatisfaction on the part of some consultants with hospital management, which had been rumbling away for some time. Emails exposing concerns in the radiology department have found their way into the press. Consultant radiologists have been investigated for allegedly wrongly claiming back the congestion charge London imposes on drivers who take their cars into the centre of town. Musculoskeletal radiology, crucial to diagnosing the causes of broken bones in suspected child abuse cases, has suffered after the departure of two expert radiologists.
Christine Hall, who retired from Great Ormond Street in 2006 as professor of paediatric radiology but is still in contact with her former colleagues, said a big concern was the decision of management after her retirement not to take any more child abuse referrals from other hospitals, although Great Ormond Street is a tertiary referral centre. The trust said the decision was taken before Baby P’s death “due to the impact on the rest of our services.”
Professor Hall said radiologists would get referrals asking whether a child had a bone disorder or non-accidental injuries and would have to refuse the referral. As a result, “the radiologists were extensively verbally abused down the telephone by paediatricians who didn’t know what the hell to do with these patients. I don’t think it was serving the community in the best way, and it wasn’t serving the courts in the best way and it wasn’t serving the families in the best way.”
In May 2010 around 20 consultants met at BMA House to draw up a letter expressing a lack of confidence in senior management. BMA representatives then facilitated a meeting between management and four dissatisfied consultants, Dr Buckley says, and steps were taken to try to address their concerns. The hospital spokesman said: “We understand that there were lists of names, some of whom were critical of management but not calling on the chief executive to resign.” The trust was “surprised and disappointed” at the editorial written by Lancet editor, Richard Horton, which concluded: “If GOSH’s management team had been in Wigan they would almost certainly have departed by now. Perhaps GOSH is too important to be seen to fail. Even when a child dies.” The editorial was followed by an anonymous letter from some Great Ormond Street consultants calling for “strong ministerial intervention” in ordering an investigation into the Baby P saga and the treatment of whistleblowers by the hospital. They added that they were “alarmed about the way in which senior management has treated individuals who have voiced concerns, not just in the case of Baby P, but also in relation to other clinical risks within the trust.”
A meeting of senior staff on 23 June ended with a standing ovation for Dr Collins in the face of her media vilification, although one consultant wrote to colleagues in an email which was leaked: “Unfortunately, an unwelcome note of triumphalism crept into the final moments of the meeting . . . . We would indeed have done well to mark the end of the meeting by standing in dignified silence to respect the memory of Baby Peter and in quiet contemplation of the fact that in his moment of greatest need we failed him utterly.”
The Lancet has since published a letter from 107 consultants and 52 other senior staff members supporting the chief executive and senior management and adding: “We have seen no evidence of bullying of staff who have raised concerns about clinical risk with management.”7 Several of the consultants who signed, from specialties including cardiology, cardiac surgery, intensive care, neurosurgery, general paediatrics, and psychiatry, assured the BMJ that they were happy working at the hospital and had no problems with management.
Professor Elliott said: “As soon as I was appointed I wrote to every consultant in the place and said that I expected them to tell me about problems with patient safety and I’ve reiterated that on several occasions when I’ve had the opportunity. We have a culture which is completely devoted to patient safety and quality and have invested heavily in it. The complete culture of the organisation is to put patient safety and quality at the front. Zero harm is one of the primary core goals of the organisation.” Leaked emails from the radiology risk register spoke of a “dire situation,” but Professor Elliott suggested that this showed management was actively seeking to have risks identified. “We have a very aggressive approach to finding out about patient safety, actively looking for what the harm incidence is. By asking for it, people have the potential to use it not as a piece of information but as a weapon.”
Although management has still not received the “no confidence” letter, he said, a mechanism was set up to allow those with concerns to relay them anonymously to an independent person, the medical director of another trust, who fed them back to management through the chairman of the general medical staff committee. The concerns had been dealt with, and no specific instance of targeting had come up during that process.
One consultant who signed the letter supporting management said: “There are a minority of clinicians who have concerns. I think it’s important that they’re dealt with constructively.” Another said the case of Baby P was “a defining moment for the hospital,” but added: “Every hospital is going to have its safety issues and we also have our safety issues.”
Was there a cover-up or was Great Ormond Street acting prudently on legal advice? Is it an institution with a culture of zero harm or does it silence staff who raise safety concerns? Without an independent investigation, the questions are unlikely to go away.
Baby P timeline
May 2003: Great Ormond Street enters partnership to supply doctors for community paediatric services in Haringey
March 2006: Peter Connelly is born
March-June 2006: Four consultant paediatricians raise concerns about administrative systems at St Ann’s child development centre
February 2007: Paediatrician Kim Holt is signed off with work related stress
1 August 2007: Peter is seen at St Ann’s by consultant paediatrician Sabah Al-Zayyat and sent home
3 August 2007: Peter is found dead
May 2008: Sibert report into Dr Al-Zayyat’s practice at St Ann’s is completed. Gt Ormond Street sends summary, not the full report, to the first serious case review
November 2008: First serious case review completed but deemed “inadequate” by Ofsted
March 2009: Second serious case review completed
October 2010: Both serious case reviews published
May 2011: Full Sibert report with some names and details redacted out is released after freedom of information request
June 2011: Lynne Featherstone MP, Home Office junior minister, accuses Great Ormond Street chief executive officer Jane Collins of cover-up. Lancet publishes editorial accusing hospital of cover-up
July 2011: Health secretary, Andrew Lansley, refuses Ms Featherstone’s demand for an inquiry
Cite this as: BMJ 2011;343:d4691
Competing interests: The author has completed the ICJME unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from her) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.