• child protection
• communication skills
• patient safety

In January 2001 in London, 8 year old Victoria Climbié’s great-aunt and her partner were convicted of her murder. During the last few months of her life she had come to the attention of doctors in two hospitals and social workers in two local authorities, but she remained unprotected. In consequence, the Secretary of State for Health set up an independent inquiry under a senior judge, Lord Laming. It reported in January 2003.¹

Unusually, given the history of enquiries into similar cases in the UK, the prime criticism was directed not to those Lord Laming referred to as “ . . . the handful of hapless, if sometimes inexperienced, front line staff”, but to “ . . . the managers and senior members of the authorities whose task it was to ensure . . . services for children like Victoria . . .”.

The report calls for major national organisational changes: the Government has promised to respond this spring. It seeks further training for paediatricians and general practitioners which will be delegated to their Royal Colleges. Social service departments are given a list of tasks, as are National Health Service trusts. I shall deal only with the last of these.

NHS chief executives will have to complete an audit by the end of April on how they protect children. In May the Secretary of State will have the results, collated by the Commission for Health Improvement, on his desk.

In keeping with the thrust of Laming’s critique, it will be “managers and senior members” rather than clinicians who will be responsible for undertaking this task. Nonetheless, there is a paradox as 10 of the 16 priority recommendations directed at healthcare workers direct doctors how they should behave when dealing with individual patients. Of the other six, one involves provision of interpreters where needed, one the correct completion of the identification sheet for every new patient contact, and just four require chief executives to carry out a governance role in monitoring the compliance of clinicians with certain aspects of their work with abused children. The moral and ethical responsibility will stay where it should be—with clinicians who owe children a duty of care. The onus therefore remains on front line staff, even though Laming appears to suggest otherwise.

The report’s findings with regard to the hospital departments which dealt with Victoria make clear why this should be. Ten doctors in two paediatric units dealt with Victoria during her admissions of just over 24 hours and 14 days, respectively. Only one is accused by Laming of failing to diagnose physical abuse. Issues raised included:

• A nursing care plan did not refer to abuse even though it had been diagnosed by the admitting doctor.

• Doctors should interview such children alone (or with an interpreter) without fear of compromising social service investigations.

• If a registrar and consultant disagree on diagnosis, their discussion should be noted.

• Delegated note keeping should be checked and agreed.

• Telephone or face-to-face discussions about a child must be recorded.

• Senior house officers (SHOs, junior residents) or nurses may not discharge such children from hospital and there must be a documented follow up plan.

• A full physical examination must be performed and documented within 24 hours of admission.

• Difficult conversations with possible abusers should not be left to SHOs.

• Doctors must provide full reports to social services departments and correct misunderstandings in writing.

Paediatricians reading this list may be forgiven for assuming they represent a summary of normal practice and asking themselves why it did not happen in this case. Few of the reasons have to do with inadequate medical knowledge. Most have to do with poor note keeping skills or chaotic working patterns.

At one point a specialist registrar who made a correct and prompt diagnosis had gone off duty by the time the consultant arrived because the latter was conducting a community clinic. They never conferred.

A registrar wrote a note of a consultant’s ward round. The two doctors subsequently disputed the accuracy of the note. One question was whether “no physical abuse issues” would have been preferable to “no child protection concerns”.

A locum SHO wrote a referral slip to the duty social worker. She believed it would provoke a visit. Laming pointed out the letter did not ask for a visit. It began: “Thank you for dealing with the social issues [of this child]”.

Three separate messages were sent to a social worker but none referred unequivocally to non-accidental injury. The social worker wrote to the ward sister requesting confirmation but this memo never reached the eyes of a doctor, presumably being filed within nursing notes.

An SHO noted: “ . . . For home visit today with police. ?Discharge after that if it is safe”. He informed the enquiry that his note implied: “if we had received a report from police and social services that they had a safe place for her to go she may possibly be discharged”. The nurse who sent her home a few hours later assumed the note implied a definite discharge plan and further assumed (wrongly) that the police had conducted their visit.

“doctors [should be taught] how to write [so] that readers will understand”

This brief resumé of a complex tale leads me to suggest some potential solutions. Any colleague who has examined case notes in the course of investigating a complaint or providing an expert report to a court will know the frustration of not being able to conjure up a picture of what happened from the written account. It is not a question of length—rather of accuracy—as is apparent from the extracts above. Conflation of factual findings with speculation is commonplace. The use of shorthand (“?discharge”) may not mean what was intended to those schooled using a different jargon. I suggest it is time to resurrect problem orientated medical records^2,3 which separate objective findings from subjective interpretation, prefer an assessment (by necessity discursive) not a diagnosis (proscriptive), and demand a plan every time a note is made. Furthermore, each problem identified should be numbered and listed on each subsequent occasion. In the meantime, when writing notes, SHOs might like to recall the “pub” test (“If I read this out to someone in the pub would they know what I was talking about?”⁴). For those who prefer something fancier, how about “narrative”? Laming rightly asks for paediatricians to be further trained. I think we should start at medical school by teaching doctors how to write in such a way that readers will understand.

As to the horrors of rotas and shifts, it may be impracticable to demand face-to-face meetings but, in their place, there has to be a thorough handover note. This must be read and, if disputed, the differences of opinion detailed for all to see, then argued out in person at the next available opportunity. In any case it is surely not acceptable to be responsible for acute admissions, even if delegated to trainees, at the same time as conducting a non-acute clinic outside the hospital. Acute paediatric medicine involves being immediately available for consultation and coexists uncomfortably with the multitude of other tasks expected of NHS consultants. Chief executives should make sure that consultant work plans clearly separate acute and non-acute work.

History forbids pious hopes that there will be no other Victorias in years to come. But we can try.