GENERAL MEDICAL COUNCIL

FITNESS TO PRACTISE PANEL (PROFESSIONAL CONDUCT)

Thursday 8 November 2007

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

Chairman: Dr Jacqueline Mitton

Panel Members:

Mrs Leora LloydMr Alexander McFarlaneMr Arnold Simanowitz

Legal Assessor: Mr Robin Hay

CASE OF:

SOUTHALL, David Patrick

(DAY SEVENTEEN)

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

DISCUSSION RE DOCUMENTS 1

FRANCINE BEVERLEY SALEM, Sworn

Examined by MR COONAN 5

A

B

C

D

E

F

G

H

THE CHAIRMAN: Good morning everyone. We are here today to continue the case of Dr Southall, which in fact began a year ago now. Mr Coonan I think is in the process of conducting the defence case, Dr Southall having given his evidence. Before we go ahead I should just mention, you will notice that we are four panellists rather than five, and regrettably Dr Sarkar has not been able to be available to continue with this case for so many weeks. I understand that both sides were aware of this, and it is not a problem. We are of course quorate, with Mr McFarlane being our medical member.

MR COONAN: Madam, I think the position is that we were officially told about it about five minutes ago, but Mr Tyson and I deduced it about half an hour ago, because there was no place setting. But the GMC did not inform either party of this event, so it has come as a complete surprise to both Mr Tyson and myself – and I see Mr Tyson nodding.

I take no point about it, because legally, under the rules, of course, as you said, you are quorate; but I just make an observation, for what it is worth, that it might have been nice, if the GMC had known about this event earlier, that we might have been told.

THE CHAIRMAN: Mr Coonan, Mr Tyson, I can only apologise and say that I as Chairman was unaware of the fact that you had not been told. In fact quite the opposite: I believed when I found out myself on Monday that you had been told, so I am not quite sure where the administrative problem arose. But it is now a matter of history, and I can only apologise for it. I hope it does not present a problem.

MR TYSON: May I just endorse what my learned friend said, that we only learned about it this morning.

MR COONAN: Madam, as you rightly say it is a matter of history now, and we take no point about it; these things happen. You are quorate and the case can therefore as a matter of principle proceed.

Madam, in a few moments I am going to call before you some evidence in relation to heads of charge 3 to 6. If you would take a moment to orientate yourselves you are probably now, certainly with the re-reading you have been doing, familiar with the structure of the case. But it is really in relation to particularly head 5(b) and head 6 that the next witness, Francine Salem, who is a social worker, will be called. Before I do that could I just ask for your indulgence for some 10 or 15 minutes. Ms Salem arrived from Shropshire at around nine o'clock and we were served at two minutes past nine with a bundle of documents. I am not complaining about that, but just simply as a matter of fact we were served with a bundle of documents by my learned friend’s solicitors. I think we agree that in fairness Ms Salem should see these documents – they are not her documents – before she steps into the witness box. I think my learned friend agrees that that is the case. The reason for it will become apparent, and I do not think it is right that I should go into the reasons. As I say, they will become apparent in the course of her evidence.

I am going, if I may, to ask you for 10 to 15 minutes so that she can read through this clip of correspondence, some 44 pages. She has started reading them but I am told she had not quite finished when we came into the chamber. I would rather she read it now than interrupt her time to read it when the time arises.

T.A. REED & CO.

Day 17 - 1

A

B

C

D

E

F

G

H

THE CHAIRMAN: That seems a very reasonable request. I will just look round to the Panel – I see that everybody nods that that should be granted. I see you rising, Mr Tyson.

MR TYSON: I am perfectly content with that, Madam Chairman. The 44-page document is in response to a document that we received two days ago, a document which we had been searching for for some three years, and it is as a result of that that there has been a scurry of correspondence.

THE CHAIRMAN: Can I suggest, Mr Coonan, that the Panel will retire back to our room and we can be told when you are ready, which we will expect to be in around 15 minutes’ time.

MR COONAN: Yes, I do not think it will be any longer than that, madam. I am very grateful for the smooth running of that approach.

(The Panel adjourned for a short time)

THE CHAIRMAN: I understand that you are ready to proceed, Mr Coonan?

MR COONAN: Yes. Thank you very much for the time you have given me, madam; that is the case.

MR TYSON: Madam, my learned friend may be able to proceed, but I have difficulties, and my difficulties are these, in that in the last 36 hours a number of documents have been served on me in relation to this witness, including some in the last three minutes.

The history of this matter is that on 31 October a number of documents relating to this witness were served, including three more contact sheets and a document relating to something that happened on 16 January from a team leader. This was served on us by letter dated 31 October. By fax of yesterday, the handwritten notes of the social worker in the course of the interview with Professor Southall were served on us. They are difficult to read and incomplete. Then this morning I have had served on me a curriculum vitae of the social worker, which I take no point on, an undated document relating to something in this social worker’s handwriting to discuss with the police; an undated contact sheet relating to her contacts with the police; some unknown, undated document which I have not had a chance to look at – and these were the matters all relating to this witness.

Madam, the 44-page document – which I think I may have to trouble you with now – relates to the efforts of those instructing me to get material out of this local authority. It is in that context where I either object or certainly would want further time to consider the new material.

Can I just indicate, I am going to put this to the witness, but I would ask it to be the next C number, which may well be 19 or 20.

THE CHAIRMAN: 19.

MR TYSON: A copy of correspondence of those instructing me with ---

THE CHAIRMAN: Is this t he 44-page document you were ---

T.A. REED & CO.

Day 17 - 2

A

B

C

D

E

F

G

H

MR TYSON: Yes.

THE CHAIRMAN: This is the one that was referred to by Mr Coonan, is it?

MR TYSON: Correct.

MR COONAN: I do not know whether my learned friend is seeking to put this in now?

THE CHAIRMAN: It would appear so.

MR COONAN: I just want to enquire the purpose of this. I can understand that some of the material may in fact be deployed in cross-examination of the witness, and indeed I may take the witness to some of the material myself, but I do not understand what is the purpose of putting it in to you now. If it is to object in some way to the evidence being given, that is one thing; if it is to ask for further time to consider it, that is another. But I would like to understand what the purpose of it is.

THE CHAIRMAN: Mr Tyson?

MR TYSON: The purpose is two-fold. In relation to some of the documents I object to them going in at all; in relation to other documents it is to seek further time so that I can examine them.

THE CHAIRMAN: Mr Tyson, if you object to them going in, does that put a question-mark on whether we should receive them at this time, should that matter be resolved differently?

MR TYSON: In relation to whether they go in – and perhaps I can identify the documents which I currently object to going in – it is a typed contact sheet with page 58 at the bottom; a manuscript document written on a pro forma headed “Notes of strategy discussion” and at the bottom it has the number 43. As far as the other documents are concerned, as I say, I have not had enough time, because they have only been served on me five minutes ago, to work out whether I object to them or not.

THE CHAIRMAN: Mr Tyson, it is clear that in some sense you feel put on the spot by having just received these documents. Would it help if we simply have another short adjournment while you consider those documents and how you want to proceed, and indeed whether you can come to some agreement as to which document should go in? If the matter has to come back to the Panel, fair enough, but at least perhaps you would like the time.

MR TYSON: Madam, that would be a preferable way of dealing with it, because I do not want to add to time by forcing a determination on you, if it can be sorted out in the usual way.

THE CHAIRMAN: We will adjourn again for another short time. I hope this matter can be sorted fairly shortly, but we will retire while you resolve matters. Mr Coonan?

MR COONAN: I am sorry, madam, but just before you do that could I make one observation. The full account of the background of this will emerge in any event during the evidence, so none of this is going to ultimately, I suspect, be shut out at all; the Panel will see the full account. But I just say this: I am somewhat flabbergasted to hear my learned friend

T.A. REED & CO.

Day 17 - 3

A

B

C

D

E

F

G

H

say this, because during the conversations we have been having he has never suggested that there was any objection to these contact sheets. Equally I find it very difficult to understand how he can object to it, since these contact sheets were in the bundle served on us by the General Medical Council, by Field Fisher Waterhouse, before this hearing began – and this is it. The two documents he has referred to particularly at pages 43 and 58 are actually in this bundle, served on us by him. I am sorry to use rather theatrical language when I say I am flabbergasted, but I am. I just do not understand how he can maintain the objection.

Having said that, and in an effort to lower the temperature, I do think it might be helpful to have a few minutes to sort it out.

THE CHAIRMAN: I think that is the best way forward at the moment; you have made that point. I think Mr Tyson, given a few minutes, may be able to discuss it in private and that might help.

We will adjourn until we hear that you hare resolved the matter or that you need the Panel to resolve the matter. We hope that you can do that in a fairly short timescale.

(The Panel adjourned for a short time)

THE CHAIRMAN: Mr Tyson, are you content for us to proceed now?

MR TYSON: Madam, I am. I am grateful that you have given us extra time. A plethora of recent documentation has been served on us in relation to this witness, in the last few days, when there has been, as you know, about a year since the last hearing for them to do that, but with a bit of goodwill and a bit of commonsense, I am now agreeable that a number of this new material should come in and be received by you from this witness.

I make no objections to the material that is going to be put in front of you, and I am content that my learned friend should produce it via this witness.

THE CHAIRMAN: Mr Coonan?

MR COONAN: Madam, I make no observations about the preliminary observations my learned friend made about time. The fact is that the documents which we seek to place before you, and my learned friend has removed any objection he has to them, and therefore you will receive them in the usual way through this next witness.

THE CHAIRMAN: Mr Coonan, I think your microphone is a bit far from you, would you move it round as we are having a little difficulty hearing Mr Tyson as well. This is a big room and we do not always hear well. Please bear that in mind.

MR COONAN: Is that better?

THE CHAIRMAN: Yes, thank you.

MR COONAN: With your leave, I will call Miss Francine Salem.

T.A. REED & CO.

Day 17 - 4

A

B

C

D

E

F

G

H

FRANCINE BEVERLEY SALEM, SwornExamined by MR COONAN

(After introductions by the Chairman)

Q Miss Salem, would you begin by giving the Panel your full name and professional address?A My full name is Francine Beverley Salem, and I work at Talbot House, 3 High Street, Wem, in North Shropshire.

MR COONAN: There should be to your left a bundle, C1. Before you open that may I just mention one or two preliminary matters: first of all, I am going to be asking you some questions about a family who we have called “the M family” and we are concerned with Mrs M, her two children, the eldest M1 and the youngest M2. I am going to try my best to refer to either Mrs, M1 or M2. Occasionally I may fail to do that but could you try, please, to adopt the same approach.

Madam, at this stage you may think it appropriate to say something to the press.

THE CHAIRMAN: Indeed, I was about to stress that I should. Following what Mr Coonan has said, may I remind any members of the public or press who are present that if the name of the M family or any other information which reveals who they are is given that it must not be published. This family is being kept anonymous for the purpose of these proceedings.

MR COONAN: Thank you. (To the witness) Miss Salem, I think you are a social worker, is that right?A I was a social worker in 1998, yes.

Q Could I ask you please as the first step to produce your CV for the Panel? (Same handed and marked as D21/A). Miss Salem, I think you out there that you qualified as a social worker in 1988, is that right?A That is right, yes.

Q And if we look at the second page, you qualified and obtained a university degree in 1988 and in 1998 you obtained a Diploma in Professional Studies in Child Protection?A Yes. I did.

Q Just to remind ourselves, that was the same year as the events about which you are going to speak.A Yes.

Q If you then go back to the first page, we see under the “employment” section, taking it from the bottom to the top, that you commenced working as a social worker in the Children and Families department in May 1988 at Trafford Borough Council, until April 1994, and then you went to Telford where you were a senior social worker in the Child Protection Team between April 1994 and September 1997, so three years there, is that right?A Yes, that is right.

T.A. REED & CO.

Day 17 - 5

A

B

C

D

E

F

G

H

Q I will come back to that in a minute. Then in September 1997 you were promoted to senior social worker at Shropshire, between September 1997 and April 2001 in what is called the Initial Assessment Team, is that right?A That is right, yes.

Q So during the time with which the Panel is concerned, in the early part of 1998, you were then a senior social worker, a member of the Initial Assessment Team, is that right?A That is right.

Q Just going back to the second page and moving matters forward, in 2000 you obtained a Post Qualifying Award in Social Work, in 2003 an advanced award in Management Proficiency and then in 2006 you were then undertaking a Social Care Management qualification: what is the present position. Who are you employed by?A I am still employed by Shropshire County Council as a Team Manager with the Case Management Team. Within my team we have the children that are looked after by the local authority and the ones whose names are on the Child Protection Register, so it is the longer term cases.

Q I want to take you back to 1998 and to the general structure of what your duties were. You had been a senior social worker for three years in the child protection team at Telford. What is the job of a senior social worker in a child protection team? What does he or she do?A It is multi-faceted, but mainly it is undertaking enquiries under section 47 of the Children Act, so we would be making either joint or single agency investigations into physical, sexual abuse or neglect – anything that constituted significant harm at that time. There was also a developmental role with the other social workers in taking on more complex ones, co-working some of the cases with them, that sort of thing.

Q By the time February 1998 came around, when you were a member of the initial assessment team, were your working and your duties and approach different then than they had been at Telford?A No, not really, because what happened in 1997 was that Telford & Wrekin split up from Shropshire, so the child protection teams actually were no longer – they were then called the initial assessment teams. I chose to go into North Shropshire because it was closer to home than the one based in Telford & Wrekin at that time. So the duties were more or less the same.

Q Did you come into contact frequently with children?A Yes, on a daily ---

Q It may sound an obvious question, but ---A On a daily basis, yes.

Q On a daily basis?A Yes.

Q What was the working structure in the department? Did you have a senior above you, a line manager or a team manager?A The structure above me was that we had a team manager, then there was the senior social workers and the social workers and the social work assistants, in that sort of hierarchy.

T.A. REED & CO.

Day 17 - 6

A

B

C

D

E

F

G

H

Q Did the team manager therefore supervise you?A Yes.

Q Did you have a system of recording contacts with people as part of your duties in the child protection team?A There is an expectation that we write down on our contact sheets – or did at that time – every contact that we had, so it was normally telephone calls, home visits, meetings were minuted as well. Now it is all done on computer; we do not handwrite them any more.

Q Apart from the contact that you would have with various people, of the people that you did have contact with, would that include police officers?A Yes. A lot of our investigations were done jointly with the police, and we would have strategy meetings and discussions as per requirements.

Q Are those investigations involving the police section 47 investigations?A Yes.

Q Can you give the Panel, please, some idea of your general experience and – sparing your blushes – expertise by February 1998 in the field of child protection as a senior social worker?A I suppose by the very fact that I was a senior at that time meant that I had to have had and exhibited the experience that was required for that level, and the complexity of the cases that we were taking on. So yes, and certainly the longevity of the work that I was doing is unusual, because quite often people will tend to move on from that line of work. I think I was quite experienced, yes.

Q Were the cases complex?A Yes. The ones that came to the senior social workers were always more complex.

Q I do not want to spend an over-long time on this, but how do you measure complexity in that type of case?A Often the more complex ones involved a number of people, particular injuries – broken limbs – looking into other professionals, such as teachers, foster carers, social workers – those are the most complex ones. And certainly the ones that were subject to proceedings.

Q Had you come across by February 1998 the concept of parental-induced illness? A Theoretically, yes.

Q When you say ‘theoretically’ what do you mean?A I had not had any actual experience.

Q Had your colleagues in the department had experience of that?A Only limited. I think there was a previous case, but not that I was involved with.

Q When I use that expression ‘parental-induced illness’, had you come across the expression ‘Munchausen’s’ before then?A Yes.

Q In what context had you come across Munchausen’s?

T.A. REED & CO.

Day 17 - 7

A

B

C

D

E

F

G

H

A There was one case previously when I was at Telford & Wrekin that one of my colleagues was involved with.

Q When I use the term ‘Munchausen’s’ that can either literally refer to Munchausen’s or it could refer to Munchausen’s by proxy?A Yes.

Q Do you understand the distinction?A Yes.

Q You talked about section 47. Can I just ask you about the Children Act briefly, and the terms of the legislative framework within which you operated. First of all, were you aware as a senior social worker of the legal framework in which you operated at that time?A I believe so, yes.

Q It may be an obvious question, but I need you to tell the Panel, or not, as the case may be.A Yes.

Q In a word or two, what was the thrust of the Children Act so far as your duties were to children?A The thrust of it obviously was the paramouncy of the child, making sure that the child was safe, working with the parents, working in partnership with the parents at that time. Section 47 obviously gave us a duty to protect, really, and investigate any allegations.

Q I am just going to ask you, so the Panel can have before them the basic legislative framework that you have spoken about, to produce copies of the three relevant sections of the Act. (Handed)

THE CHAIRMAN: Mr Coonan, we have two physical pieces of paper.

MR COONAN: Yes.

THE CHAIRMAN: Two physical clips.

MR COONAN: We could call them B and C. May I suggest that section 1, with the arrangement of sections and the word “Statute” at the top left-hand corner, could be B, and the one with “47” at the top left-hand corner could be C.

THE CHAIRMAN: Yes. (Documents so marked)

MR COONAN: (To the witness) I do not want to spend over-long on this, Miss Salem, but I want literally to produce it. We see in document B section 1, the provision there that:

“When a court determines any question with respect to –

(a) the upbringing of a child;” –

which I refer to for present purposes –

T.A. REED & CO.

Day 17 - 8

A

B

C

D

E

F

G

H

“…

the child’s welfare shall be the court’s paramount consideration.”

Do you see that?A Yes.

Q Is that what you were referring to a minute ago?A The paramouncy principle, yes.

Q The paramouncy principle? The rest of the section again is self-evident and I will not ask you to comment on that. Over the page there is a reference to section 98. Are you familiar with section 98?A Yes.

Q I am going to read this out.

“(1) In any proceedings in which a court is hearing an application for an order under Part IV or V,” –

pausing there, that in a word refers to care proceedings?A Yes.

Q“no person shall be excused from –

(a) giving evidence on any matter; or(b) answering any question put to him in the course of his giving evidence,

on the ground that doing so might incriminate him or his spouse of an offence.”

Right?A Yes.

Q Then:

“(2) A statement or admission made in such proceedings shall not be admissible in evidence against the person making it or his spouse in proceedings for an offence other than perjury.”

Again, in a word, looking at the nature of the proceedings which might ensue, or investigations leading to proceedings that might ensue in the Family Proceedings Court, as it is now called, the principle – and I think I can lead on this – is that full disclosure of everything should be made – is that right?A Yes.

Q By any party to the proceedings – is that correct?A Yes.

T.A. REED & CO.

Day 17 - 9

A

B

C

D

E

F

G

H

Q Finally, if we look at document C, it sets out the provisions of section 47 of the Act and sets out the duty on a local authority in sub-section (1). Again it is self-evident. If the sub-sections there are satisfied, and I do down to the last three lines:

“… the authority shall make, or cause to be made, such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare.”

Then sub-section (2) in particular deals with the situation after an emergency protection order – an EPO – has been obtained; is that right?A Yes.

Q You are familiar with this legislation, are you?A Yes.

Q Before we leave that – and I will come on to it – what is the nature of an EPO, an emergency protection order?A Do you mean the circumstances around taking out an application?

Q Yes, just briefly.A Usually we would apply for an emergency protection order when we felt that there was life and limb risk, when we felt there was immediate risk, and that would be whether it was ex parte as well.

Q That means without notice?A Sorry, yes. Otherwise we would have to put people on notice of our intention to take proceedings, and look for an interim care order.

Q That is all I am going to ask you by way of preliminary background. Would you put those documents to one side, please. I want to ask you now to have in front of you C1, and would you open it at tab A. There should be immediately in front of you a letter dated 23 January 1998, which bears your signature; is that right?A It is, yes.

Q It is addressed to “Dear David”, and we can see at the top “Professor David Southall” – yes?A Yes.

Q Miss Salem, I want to ask you a number of questions arising out of and preceding this letter. Was that the first contact that you had with, as he then was, Professor David Southall?A Do you mean this letter?

Q Yes. A No, I think we had had a telephone conversation prior to that.

Q You can see in the first line the reference to that telephone conversation, and I will take you to the contact sheet in a moment. Apart from the telephone conversation did you know Dr Southall – Professor Southall?A No.

T.A. REED & CO.

Day 17 - 10

A

B

C

D

E

F

G

H

Q It may be that we all have different ways of working, but why did you address him as “Dear David”?A I think probably, to be perfectly blunt, it was probably me trying to show that I was not going to be intimated, or – you know, when you speak to teachers as well, and teachers call themselves ‘Miss Smith’, or something – it is getting on a par with people, I suppose. That is probably me doing that there.

Q Right. If we then take that letter and move on to tab D and page 375, you will see I think a reference to that telephone call, is that right?A Yes.

Q If you look at the date on the left-hand side, the photocopying has cut it off.A Yes.

Q On the second line:

“T/C to Professor David Southall at North Staffs Hospital and gave him a brief summary of involvement & concerns.”

If necessary you can look at the original file, but can the Panel take it that that is a reference to 23 January 1998?A Yes, it is.

Q We see there- and I am going to read that part:

“Telephone call to Professor David Southall at North Staffs Hospital and gave him a brief summary of involvement & concerns.”

Pausing there, were those the concerns by that stage of social services?A They were the concerns that had been shared with us at the initial referral from Mrs M’s employers at that time ---

Q Yes, I will come to that.A --- and we had found out.

Q But they were essentially concerns feeding into social services and concerns expressed by social services by the time you telephoned Professor Southall?A Yes.

Q“David Southall shared my anxieties & felt that I was right in my suspicions that this may be P. I. Illness.”

Just pausing there, what is that a reference to?A Parental-induced.

Q“He believed that we had a ‘major’ C. protection issue here and suggested that we need him ‘on-board’.”

T.A. REED & CO.

Day 17 - 11

A

B

C

D

E

F

G

H

Pausing there, did you in fact have your own suspicions that this may be a PI illness case at that stage?A At that stage, yes.

Q The note says:

“Agreed that I would send him a copy of the ‘key documents’ and he would do a preliminary report as a matter of urgency.”

Pausing there, I should ask you formally, is that your handwriting?A Yes, it is.

Q We see in the right-hand margin the initials FBS.A Yes.

Q Those are your initials, are they?A Yes, they are.

Q I am not going to ask you this throughout this exercise, but in every column we see in these contact sheets, similar writing and your initials. Can we take it that they are in your writing?A Yes; I would have initialled them.

Q We see at the top on the contact sheets, and this follows through, the name of the social worker, Francine Salem, at the top?A Yes.

Q When you were making this telephone call to Professor Southall and writing this letter we have looked at in tab A, in what capacity were you acting?A Do you mean like as a social worker?

Q Yes. What were you doing? Were you part of the initial assessment team?A Yes.

Q Were you simply receiving queries, concerns? Did you have an active role? Can you help the Panel, please.A Yes, we were beginning to gather information at that time, and certainly the case was allocated to me almost immediately, so that was my role to do that.

Q Who allocated the case to you?A The team manager.

Q Who was that?A Clive Bartley.

Q If we look back in tab D we will see the contact sheet material which led up to the telephone call on page 375, is that correct?A Yes, I think so, yes.

T.A. REED & CO.

Day 17 - 12

A

B

C

D

E

F

G

H

MR COONAN: There is one document which I think we should add to this for completeness. I wonder if you could produce that now from the file, it is dated 16 January 1998. (Same produced and marked as D21/D)

MR TYSON: Whilst this is done, I was wondering if my learned friend could ask this witness in relation to the documents at the beginning of D, to which he was taking the witness, to help us with some dates.

MR COONAN: I am going to do that and I understand why my learned friend raises it because the dates have been cut off in the photocopying, and I think from your copies too they will be cut off, but Miss Salem has the file with her, so that can be done as a simple mechanical exercise.

(To the witness) Looking first of all at this document, this comes from the file, Miss Salem, and we can see on the second page that the author of that document is Clive Barley, is that right?A Uh-huh.

Q Certainly from our understanding of the documents, and I think it follows Mr Tyson’s understanding of the documents, this appears to be the first documentation setting out concerns in relation to the M family, is that right?A Yes, that is right.

Q I am not going to take you through this document exhaustively: it is easy to read. Since you are familiar with the document, would you distil for us what you read from this document, wearing your hat in terms of child protection at that time?A Okay. There was a new face, I suppose, at the hospital that Mrs M was working at and who had reason to look at the Part 8 review on M1, and purely by coincidence that afternoon she came across the records of Mrs M, the high sickness rate, the reason she was giving for that was that M2 was being bullied at school and was threatening to kill himself. The two things had come quite quickly and the worker from the hospital was concerned really that there was a pattern forming; that obviously there had been those tragic circumstances with M1 and here we were two years later and M2 was making the worrying threats that M1 had gone through previously. She had also had the opportunity to look at M2’s accident and emergency records and felt that the explanations were inadequate; the timing of them she felt was questionable and she felt that there was an unusual amount, and also given that she had already read in the Part 8 review that it had been reported that M1 had had an unusual amount of presentations at the GP, she felt there may be some concerns and these were obviously shared by myself once she gave me that information.

Q You mentioned the Part 8 review, and we can see a reference to that in the third paragraph of this document. First of all, what is a Part 8 review?A A Part 8 review takes place when a child dies, basically, where they get all the agencies that have had any involvement together, and make sure that there was nothing that we could possibly have done really to prevent that, and to learn lessons from it.

Q At any rate, as we go through this, this is the first significant piece of information, is that right?A Yes.

T.A. REED & CO.

Day 17 - 13

A

B

C

D

E

F

G

H

Q If you think this is wrong say so, but it is the first bit of information from the standpoint of social services which set alarm bells ringing, is that right?A Yes.

Q That document went in the file did it?A This is in the file, yes.

MR COONAN: Then we go back to tab D, and look at the top left-hand corner on page 370. It may be that you will have to help us, please, with the exact date, because I think all of us are labouring under the same problem of the photocopying

MR TYSON: Just as a matter of practicality, I wonder whether we could do this as a once and for all exercise, and if this witness could take us through tab D and then tab V.

MR COONAN: I was going to do that.

MR TYSON: I am grateful.

MR COONAN: Miss Salem, do not worry about it, it is just that they came from the social services to Field Fisher Waterhouse, solicitors for the complainants, in this form, with the dates cut off. Let us look at page 370.A That is dated 20th of the first.

Q Go please to page 373?A That is the 20th of the first still, it is continued.

MR COONAN: Page 374 at the top?

THE CHAIRMAN: It has just been pointed out, there is a date which seems to be in the punch hole on page 373.

MR COONAN: Madam, you are quite right, there is a date there, halfway down the page, as the Chair has said.A The 21st.

Q Over the page.A 374 is also the 21st, where it says “continued”.

Q Halfway down the page.A The 22nd.

Q Page 375 I think you have already confirmed that that is the 23rd but you had better double-check it.A Yes, it is, it is the 23rd.

MR COONAN: Then if you would complete the exercise and go on to tab V.

THE CHAIRMAN: Mr Coonan, forgive me, Mr Simanowitz has got a query.

T.A. REED & CO.

Day 17 - 14

A

B

C

D

E

F

G

H

MR SIMANOWITZ: On the top of page 375 in the margin there is something written, I do not know whether that is a date.

MR COONAN: (To the witness) Can you help with page 375, Mr Simanowitz points to the top left-hand ---A Just before “debrief”?

Q Yes.A “Continued”.

Q If you move on to tab V, at the top of our page 95, the same formulation, the top left-hand corner, is that a reference to “continued”?A Yes.

Q In fact this is the same page as the previous page we were looking at but with further entries on it, and the further entries begin, do they not, on 26 January 1998, is that right?A Yes.

MR COONAN: The dates there are readable, I hope, for the Panel too, and on page 96, similarly: on page 97, similarly: 98, 99, 100 and 101, I think the dates there, I hope for everybody are readable.

MR TYSON: Can I just ask what is in the punch hole on page 99?

MR COONAN: Is there a date there?A On page 99?

MR COONAN: Yes.

MR TYSON: Just before “Dr Southall returned my call …”A 25th of the second.

MR COONAN: Madam, is your readable? Mine is.

THE CHAIRMAN: On that page, but on the following day there is a punch hole on page 100, the second date from the bottom, next to “Coroner’s report arrived”.

MR COONAN: Is that the 22nd?A The 22nd, yes, “Coroner’s report arrived”.

MR COONAN: Madam, I am in your hands, I hope that completes that exercise for the Panel.

THE CHAIRMAN: I believe so, there are no more questions.

MR COONAN: (To the witness) I would like to go back to tab D and look at some of the substantive matters. This is again by way of background leading up to the telephone call you had with Professor Southall. On the 20th, at the top, there is a record of a telephone call with Steve Martin, FPU. What is the FPU?A The FPU is the Family Protection Unit.

T.A. REED & CO.

Day 17 - 15

A

B

C

D

E

F

G

H

Q Where?A At Shrewsbury police station.

Q So it is a police department is it?A Yes.

Q We can see from elsewhere that Mr Martin was indeed a police officer, and this is your writing again, is that right?A It is, yes.

Q “Informed him of the recent and historical concerns relating to the [M] family. Requested further information relating to any instances of domestic violence [at the address] and any local intelligence info. Agreed to invite him to a strategy meeting.”

Again pause there: what was your thinking at that time that led you to the idea of having a strategy meeting?A The procedure are that we would have a strategy meeting, that is standard practice.

Q Is it standard practice to invite representatives of the FPU to attend?A Yes, that is procedure.

Q On the rest of this page, and I am not going to take you into any detail in particular, so the Panel know, of matter which are acutely sensitive, but just for the record I would highlight the fact that you made a series of telephone calls to the school, is that right?A Yes.

Q And to a Mrs Pare, is that right?A The head teacher, yes.

Q And then to the C&F Service, what is that?A The Children and Family Service is the community adolescent mental health service.

Q Then there is another telephone call, and if you go to the bottom of the page, from the GP.A Yes.

Q The Panel can see the content of that telephone call: was that standard to bring the GP into the picture?A Again, that is part of the procedures.

Q At the bottom of the page, and I do not propose to read this out, the Panel can see it, an observation made by Dr Treasure, the GP, is that right, that you have recorded in inverted commas?A Yes.

Q I draw the Panel’s attention to the rest of that entry, so if we just pause a moment while the Panel read it to themselves. (Pause) Then just before halfway down, you were informed of an incident in 1992 in the context, if I can put it this way, of allegations of domestic violence, is that right?

T.A. REED & CO.

Day 17 - 16

A

B

C

D

E

F

G

H

A Yes.

Q You received information from Ann Gray: just remind us who Ann Gray was?A Ann Gray was from the orthopaedic hospital where Mrs M worked.

Q I think we have been told already, but was she the Director of Nursing?A Yes.

Q Do you record in that document, on that page, 371, that you had discussions there about the hospital’s record-keeping procedure.A Yes, yes, we did.

Q Did you record that the records suggested that the injuries had no explanation?A I think there was inadequate explanation, yes.

Q Then going down a few more lines: did you receive a telephone call from Dr Alison Solomon?A Yes.

Q The Panel have heard evidence from Dr Solomon already. You record there the information that Dr Solomon gave you, is that correct?A Yes, that is right.

Q Over the page, page 372, you received further information from the headmistress of the school there mentioned.A Yes.

Q And you record the observations of the headmistress, which are set out in some detail on that page: did you record all that?A Yes, I did.

Q Right at the bottom of the page, just taking you to the last three lines: did you record the headmistress’s observations about Mrs M and her reference to making an appearance on a television programme and an article in a magazine?A Yes, I did.

Q Again, over the page, further records of telephone calls in to you, again from the headmistress, a continuation record, is that right?A Yes, that is right.

Q Halfway down, a date you have given us because it was punched out, on 21 January, “Discussion with TM”, who is TM?A Team manager.

Q I should take you to the previous three lines:

“Telephone call to Ann Gray - agree that she would contact surrounding hospitals to see if they had any involvement with the family”.

T.A. REED & CO.

Day 17 - 17

A

B

C

D

E

F

G

H

Again, I do not need any particular detail, but what was the strategy there, the purpose of that?

A To see if there was any other information which any of the other hospitals had. Because we are on a border with Wrexham as well, quite often people will go to the Wrexham hospital, because it is just as quick.

Q On the rest of page 373, again you record a series of telephone calls to various people, some of whom we have already identified. Again, if I can deal with this compendiously, was this a part of the process of information-gathering which you embarked upon?A Yes, it was.

Q Page 374, on the second line – and we are now on 21 January – is a record of a telephone call to Ann Grey in which you inform her of the meeting on Monday. That is the proposed strategy meeting. Is that right?A Yes.

Q And she sets out some further information about M2 having been at hospital with a suspected particular injury. We see that set out on the fourth line. Do you see that?A Yes.

MR TYSON: A suspected condition.

MR COONAN: It says that nothing was found and he was discharged home on 17 January. Is that right?A He was discharged on the 17th, yes.

Q Then on 22 January, did you visit Ann Grey and the theatre manager at the hospital where Mrs M worked?A I did.

Q Again, did you record there, so the Panel can see it, the information that you were supplied with?A I did, yes.

Q Again, the material is self-evident and the Panel will understand why I do not go into the fine detail of this. Dropping down to the last three lines, you have a discussion with Julian Parker. Who is Julian Parker?A Julian was the team manager of the case management team. Presumably at that point my own team manager was not available, so you go to the next one.

Q Who agreed with you that you should contact the legal section to request a representative to attend the strategy meeting on Monday. What was the thinking behind that, Miss Salem?A I think because of the concerns that were being passed to me and because of the complexity of the issues involved, really we wanted some legal advice on the way forward.

Q Then on page 375, there is a debrief session with the team manager. Is that Mr Bartley?

T.A. REED & CO.

Day 17 - 18

A

B

C

D

E

F

G

H

A Yes, that would be.

Q To inform him of today’s events and bring him up to date. Then, “Telephone call to Detective Sergeant Hanna.” Is that right?A Yes.

Q “Who remembered the case.” Is that a note that he or she remembered the case?A Yes. He remembered the case.

Q And:

“Discussed reasons for expressing concern re M2. He felt that there had to be concern for M2 at the time in light of parental disharmony and M1 killing himself.”

A That is right, yes.

Q By the 23rd, as we see self-evidently from the next entry, a report of a strategy discussion was written. Was that written by you?A Yes.

Q We will see that if you look at tab B. The Panel have looked at this document already and I am just going to highlight a number of sections within it. On page 355 at the bottom you set out the background material and you say:

“It is these concerns …”

That is a reference to what had preceded it. Is that right?A Yes.

Q

“ … which prompted our department to make enquiries under S47 of the Children Act 1989.”

The Panel have a copy of section 47. Do we take it that all the steps which had been taken, all the inquiries and so forth which are set out in the contact sheets, were all those being carried out in pursuance of section 47?A Yes.

Q I do not know and maybe it does not matter, but is there a formal moment at which section 47 begins to operate, or do you not do it that way?A I think if it is identified that there are child protection concerns, then the team manager would make the decision that we need to go in under section 47, as against section 17, which is identification of just a child in need.

Q This is much wider.A Yes.

Q On the second page, page 356, again I think you are summarising – is this right? – a lot of the material which we have just been looking at in the contact sheets. Is that fair?

T.A. REED & CO.

Day 17 - 19

A

B

C

D

E

F

G

H

A Yes. And identifying what the concerns are.

Q In the fifth paragraph, you say, “I remain concerned”, and you set out the reasons for your concern there. You deal with the Part 8 review at paragraph 2 and at paragraph 3, I will just draw your attention to this:

“Records suggest that Mrs M believed that M1 had taken his own life as a result of being bullied. The Part 8 Review did not substantiate this allegation at all.”

Did that have any significance for you at that time, that fact?A It did, because what we were hearing now was that Mrs M was raising concerns that M2 was now being bullied.

Q Just follow that through logically, would you?A Since there was no evidence in the first instance, we were concerned again that this was a smokescreen basically.

Q Then in paragraph 4, there is a reference to what was discerned from the police records.A Yes.

Q The details of what was found in the police records is then documented. They relate to 1992 and 1995. In paragraph 5, again you summarise what we have just looked at, again in a little superficial detail, from the contact sheets. Again, I am not going to read it out; the Panel can see it for themselves. Then finally on page 358, which I will draw the Panel’s attention to for the purpose of the transcript, are these your words, Ms Salem, in paragraph 8?A Yes.

Q It says:

“Ultimately, there appear to be a lot of similarities between M1’s life and now M2’s. I do not believe that the questions around the circumstances of M1’s death have been answered which only heighten my own concerns for M2’s safety and welfare.

I believe, also, that we cannot rule out the possibility of M2 being the victim of parent induced illnesses, which would in turn place large question marks over M1’s experiences and ultimately his death.”

Was that your own view, or was that view by that stage shared by anybody else in the social services department?A With my team manager. We always discuss our recommendations with our team manager first.

Q Again, we touched on this earlier, but to what extent are you, as it were, constantly feeding back information and getting feedback from your team manager as an investigation unfolds?A On a regular basis and certainly the more complex the issue, the more regularly you do it, both from a supervisory point of view, but accountability as well.

T.A. REED & CO.

Day 17 - 20

A

B

C

D

E

F

G

H

Q Attached to that document at page 359 is a summary of the background information from Mrs M’s police statement. Is that right?A Yes.

Q Again, at page 361, a summary of medical complaints by M2. Was that culled from hospital or GP notes, or both?A I think that was from the hospital.

Q At page 362, again a series of hospital or GP interventions in respect of M1. Is that right?A Yes.

Q Again, were those culled from GP or hospital records, or can you not remember?A I cannot remember, but I suspect it was the Part 8 review.

Q Then there is a computerised printout on page 363, tab C. Let us look at this briefly, if only to identify it. What is the nature of that document?A This has come from the Part 8 review.

Q Was this available to you when you were compiling the preliminary initial report?A I cannot remember, to be honest.

Q It has the date of the 23rd at the top. Can you remember one way or the other?A I cannot remember.

Q It is clearly potentially relevant information. Is that right?A Absolutely, yes.

MR TYSON: In order to assist, if one looks at paragraph (a) on page 354, you will see a reference to that.

MR COONAN: Yes. My learned friend refers to that and we are going to look at this letter in a moment. Do you think that is the chronology there referred to on page 353?A It must be, yes.

Q Let us look at that letter. Go back to tab (a), please. There is the telephone call which we have looked at on page 375, tab (d). You are now writing to Dr Southall and you enclose the report – is that right – of the strategy meeting we have just looked at at C1?A The interim, initial assessment report, yes.

Q As you have just said, the chronology is at tab (c). Then did you include the Part 8 review and witness statements?A Yes.

Q I will come back to those in a moment. Then there is a magazine interview with Mrs M, which you will find at tab (e), pages 376 and 377. Is that what you sent Dr Southall?A I must have done, yes.

Q We have seen a reference to the magazine interview in the contact sheets which I took you to.

T.A. REED & CO.

Day 17 - 21

A

B

C

D

E

F

G

H

A Yes.

Q You also included contact sheets. That by definition could only include pages 370 to 375 or any part thereof, could it not?A Yes.

Q That is the chronology of matters up to that date. Do you think you sent Dr Southall pages 373 to 375?A Yes. That could only be what it refers to really.

Q I said I will come back to it and I do. At paragraph (c) on page 354, the Part 8 review and the witness statements. By this stage, you had received, had you, a number of document, not only the Part 8 review, but various witness statements? We can see that running from tab G through to tab M. Just to formally take the Panel through this, Miss Salem, do you have at tab G a witness statement from Mrs M provided to the police in 1996? That was four days after the death of M1. Is that the document you sent to Dr Southall?A I believe it is, yes.

Q Then, running through the next tab, a witness statement from M1’s father. A Yes. Q Then at tab (i), from the headmaster; at (j), from a teacher, whose name was mentioned in the previous hearing.A Yes.

Q At tab (j), from a supervisor at the school.A Yes.

Q Then from somebody who was a special support assistant at tab (l).A Yes.

Q At tab (m), is this the Part 8 review?A That is the report which came from it, yes.

Q As we can see, not written by you, but a solicitor in the legal division, we see on page 5. So just to complete the picture, if we now go back to the letter which you sent to Dr Southall – we had reached 23 January – what was the purpose of sending him this documentation?A I believe it was what I felt was relevant documentation for him to give us some advice on the way forward.

Q Why did you approach Dr Southall, as opposed to Dr X or Y and so on? Do you follow?A It was obviously because of Professor Southall’s knowledge in the area of parental-induced illnesses, which was one of the hypotheses at the time.

Q We have seen your suspicions about that in the initial assessment. Can we then move on, please, to the strategy meeting itself on 26 January? If you now turn to tab (v) you will see a long reference to that. At page 95, we see the date of 26 January in the left-hand margin and it says:

T.A. REED & CO.

Day 17 - 22

A

B

C

D

E

F

G

H

“Strategy meeting held – Agreed that more information was needed and key tasks were distributed. To reconvene on Thursday 29th January 1998.”

The actual documentation for that meeting we can find at tab (o). I am going to spend a little time on this, Miss Salem. Do you have the minutes of that meeting at tab (o)?A Yes.

Q We can see the people who attended. I just pick out a number of people – Ann Gray, Director of Nursing; yourself.A Yes.

Q Two representatives from the legal division, Miranda Garrard and Tim Collard; and Clive Bartley, team manager, Dr Solomon, Child and Family Service; and Steve Martin from the FPU in Shrewsbury. Of course, as we know, Dr Southall did not attend that meeting, is that right?A Yes, that is right.

Q If we look at the reason for the conference as set out:

“The meeting was convened to discuss concerns surrounding [M2] … The meeting wished to pool information on [M2’s] situation and establish the nature and degree of concerns raised and to plan the way forward and discuss any immediate action required.

[M2’s] brother died by hanging on 3rd June 1996. A Part 8 Review took place on [M1’s] death and because of the recent concerns raised about the similarities surrounding this family the meeting was convened to discuss further information.”

Then there is a distillation of what Ann Gray reported to the meeting, and again I am not going to read all that out; the Panel can read that. Again in this first part of the document is the structure that people’s concerns are recorded before any recommendation for action is taken?A Yes; it is a logical sequence, really.

Q We go through it on page 2 and page 3, various people whose names we have seen in the contact sheets are now, as it were, speaking directly in the group and their views being recorded – is that right?A Yes, and also hearing each other’s views, because that is part of the information sharing process.

Q On page 4, the second paragraph down, one of the contributors was Dr Solomon.A Yes.

Q Was [Mrs M] present at that meeting?A No. Parents are not invited to the strategy meeting.

MR COONAN: I apologise for that.

T.A. REED & CO.

Day 17 - 23

A

B

C

D

E

F

G

H

THE CHAIRMAN: I trust that the warning that I gave earlier about non-disclosure of names has been taken to heart.

MR COONAN: On page 5 ---

THE CHAIRMAN: Mr Coonan, I am sorry, because of that I think one of the Panel members missed the last answer that the witness gave. Perhaps you could wind back a question. We were perhaps distracted.

MR COONAN: The question was whether Mrs M was present?A No, parents are not invited to strategy meetings.

Q They are not permitted to attend?A No.

Q On the page about half-way down there was a reference to the part 8 review being discussed and an observation made there that we have seen already, and again I do not wish to repeat it in public. There were contributions from the police officer, Detective-Sergeant Martin, who:

“… informed the meeting that as yet no more detailed information is available other than what appears in the Coroner’s report. He outlined the similarities in [M1’s] life to what was currently happening to [M2]. He … read an extract from [Mrs M’s] statement …”.

That is presumably a reference to the witness statement, which we have seen?A Yes.

Q On the circumstances surrounding M1’s death. Then Detective Inspector Warwick, who was also present:

“… stated that the verdict on [M1] was an Open Verdict. He explained that there was only certain verdicts that the Coroner could bring. A suicide verdict would have needed evidence to support it, but there was no evidence for this, the only verdict left to bring was Open.”

On page 6, as part of the summary of the part 8 review, there is recorded a number of events there, in particular in relation to M1. I take you to the last three lines of the first paragraph, detailing the circumstances in which it was reported that the mother had found M1 hanging from the curtain rail by her belt. Is that right?A Yes.

Q Then I take you to half-way down the page, the fifth paragraph:

“A document was circulated prepared by Annette Clarke, Senior Social Worker (Assessment) based in Wem. She had prepared a number of hypotheses on Munchausen’s Syndrome by Proxy.”

Pausing there, did you know Annette Clarke?A Yes, she was our assessment worker.

T.A. REED & CO.

Day 17 - 24

A

B

C

D

E

F

G

H

Q She is described there as a senior social worker. Was she an experienced social worker?A She was a very experienced social worker, but she would undertake assessments rather than going out and doing the investigations, so she would undertake core assessments, as they were called.

Q Can you keep your finger on page 6, and move in the same tab, just to identify this. Would you look at pages 17 through to 20. Is that document referred to there on page 6 a number of hypotheses on Munchausen’s syndrome by proxy?A Yes.

Q Let us first of all identify the content of this document beginning at page 17, and then I shall go back to page 6. On page 17 she writes “Hypothesis 1 – MDBP”. That is clearly a typing error? That should be MSBP? A Yes.

Q That is hypothesis 1. She summarises a number of factors which, as it were, raise that hypothesis in her opinion, and highlights questions of the mother reporting M2 – looking at item 4 – M2 talking of suicide. There is a reference to violence at paragraph 5, and there is a question too about the mother being a nurse, in paragraph 7, and Ms Clarke flags up that she was a nurse in A&E with access to emergency services, MSBP linked to this fact, and various questions raised throughout. Again it is self-evident on the face of the document. Did you see this document before it was produced to the meeting?A I really cannot remember.

Q Still in hypothesis 1, if you go to page 18, this is continuing the paragraphs’ sequencing, and we are now in paragraph 8, and she raises this question:

“If [M2] is talking of committing suicide, then he may be experiencing increased emotional turmoil due to” –

and then a series of factors:

“a) Mother’s exaggeration of School problems,b) presentation at A and E,c) referral to C and F S,” –

that is the Child and Family services, is that right?A Yes.

Q“d) mother taking lots of time off work,e) keeping [M2] off School (his attendance has been very poor).8.2 His emotional health may be impaired by his mother’s actions, …8.3 [M2] also has a family history of dealing with stress by attempting suicide,” –

and again details are set out. Then finally at 8.4:

T.A. REED & CO.

Day 17 - 25

A

B

C

D

E

F

G

H

“If [M2’s] talk of suicide is fabricated by Mother to seek attention for herself, would she provide him with the medication or opportunity or increase the suggestion to him that he should kill himself?”

Just pause there for a minute. Were these matters which emerged through Annette Clarke?A No; certainly these were obviously concerns that I shared.

Q Were they the same concerns that were shared by your team manager?A Yes.

Q If we go back to page 6 for the moment, we see in bold print “Item 1”. Is that a reference to hypothesis 1?A I do not know.

Q Or some other agenda or minutes? I am just trying to see where we ---A I do not know, because it goes on to Items 4, 5, 6 and 7, and I do not understand ---

Q Fair enough; we will deal with it on a free-standing basis in a minute. Hypothesis 2:

“[M2] is being emotionally abused by his mother through commission and omission”.

Under the sub-heading of “Child Indicators” again there are a number of factors which are collated together and set out. Under “Likelihood of Significant harm” again a number of factors collated and set out and a number of questions again implicit in those issues; is that right?A Yes.

Q Over the page at 19 under that heading, a number of questions which are at least potentially relevant to the question or significant harm or the likelihood of significant harm, which again are clearly set out and I do not need to take you through them.

Finally hypothesis 3, “Best Case Scenario”:

“1. Mother has used A and E frequently because she knows all the staff well and knows [M2] will get efficient and effective treatment.2. Mother has reacted sensibly to [M2’s] talk of depression and suicide by ensuring School are aware of her concerns and arranging a C and F referral via her GP.3. In taking time off work, and keeping [M2] off School she believes that she is dealing appropriately with her concerns about [M2] and making sure that she is picking up on them earlier than she did with [M1].4. She is under a great deal of stress her husband having just left, and requires support in dealing with [M2’s] problems.5. School are oblivious to the fact that there are in fact bullying issues at School for [M2], which is contributing to his feelings of depression and helplessness.”

Miss Salem, at that meeting – and again I am going to take you to the rest of the meeting at pages 6 through to 8 in a minute – can you help the Panel: was the view of social services at that stage an open-ended view or opinion about what was going on here, or had any final conclusion been made as to what was going on?

T.A. REED & CO.

Day 17 - 26

A

B

C

D

E

F

G

H

A No, no final conclusion had been made, and we were sharing information and gathering information and trying to agree a multi-agency way forward. But certainly, no, those were three hypotheses that were discussed, and obviously the questions that were raised, we needed to look further into all three of them.

Q Can we go back to page 6 now, please. Again, just to introduce it, although we do not know what specific items were, but item 1:

“Ms Salem informed the meeting that she has grave concerns about the similarities in the boys live[s]. The threats should be taken seriously. The hospital presentations are another concern, are they parentally induced? The presentations themselves are very unusual.”

Again, did that represent your view at the time?A Yes, it did.

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

Again, was that a reference to the telephone call that you had had with him?A It was, yes.

Q On 23 January?A Yes.

Q“Item 2 – no analysis of patterns of behaviour has emerged yet.”

Then under that in the second sub-paragraph:

“The meeting decided that all presentations to hospital need to be reviewed. Information has been vague about all visits to A&E. There is an added problem in that [Mrs M] works in the A&E area.”

At page 7, just above “Item 3” in bold:

“Suggestions were made that bullying is used as a smoke screen.”

Can you remember where that came from, that suggestion?A I cannot remember.

Q “There is no evidence to suggest either of the boys were bullied.

Item 3 – Dr Solomon said that all the referrals to the Child and Family Service had been valid in helping the family overcome the bereavement process. [Mrs M] could be over anxious about [M2].”

T.A. REED & CO.

Day 17 - 27

A

B

C

D

E

F

G

H

The head teacher, whose name is mentioned:

“… felt that [M2] is in need of help and [Mrs M] is not doing anything about it. He needs to talk about the death of his brother.”

Then Dr Solomon commented again about how M2 seemed to improve and then went down hill again.

“She thought he seemed to have worked through the emotions around bereavement.”

Then dealing with the series of items flagged up:

“Interview needed with GP[M2] is under considerable emotional strain”.

Then at item 7:

“[Mrs M] is a Health Care Assistant in Theatre. She is very good at her job and appears to cope with the stresses.”

Then there now appears to be a direct reference to the hypotheses – is that right, at 8.1? If we look again to 18 at the top, do you see a reference to 8.1?A Yes.

Q Is that right?A Yes.

Q Does that seem to be the position?A It does seem to be, yes.

Q 8.1 “recognised” and then this recorded:

“There was not sufficient evidence to suggest [M1] killed himself”.

Q Was that a consensus view?A I think they were referring to the verdict from the inquest.

Q The underneath that:

“Accurate correlation between school and health is needed to tie up the absences of [Mrs M] and [M2]. Full records are also needed of [M1’s] absences … and [Mrs M’s] absences.”

And then a reference to 8.4 on page 18:

“Difficult to answer. Overdoses and suicide are part of family life”.

Hypothesis No. 2 at page 18, “accepted” and then “Hypothesis No. 3”:

T.A. REED & CO.

Day 17 - 28

A

B

C

D

E

F

G

H

“Most admissions to A&E have been to Oswestry. [The Headmistress] had suggested to [Mrs M] that [M2] is depressed, not the other way around”.

And then there was a summary on page 8:

“Grave concerns re [M2’s] emotional well-being exist. All hypotheses are potential. Dr Southall has suggested that there is concern for [M2] but if [M2] is removed from the home will his situation improve or worsen? What to do for the best is the problem.

Dr Solomon offered to speak to Professor Southall about the case.

Was [M1’s] death suspicious and are circumstances repeating or [is it] just a tragic situation due to repeat itself again?”

Then:

“Mrs Edwards” [one of the attendees] “felt that there was no doubt that further and thorough enquires are needed. There is the scope for further enquiries before [Mrs M] is informed.

A That was the chair of the meeting.

Q We can look at page 1, Mrs Edwards is the Service Manager at Child Protection, is that right?A Yes.

Q Is she a social worker?A She would be social worker trained, yes.

Q Then under “Recommendations”.

“1. More information from the Coroner’s Report is required.”

Again, in a word, Miss Salem, why was that recommendation highlighted?A I believe it was to find out more information about the circumstances about M1’s death.

Q “2. Interview with GP to take place.3. Interview with A&E staff to take place and records investigated further.4. Professor Southall’s view to be sought.5. Mr [S] to be interviewed again.6. Police and social services to undertake a joint Section 47 investigation”.

There is a reference to further information about absences from school, and then finally:

“The group to reconvene on Thursday 29 January …”

At the end of that meeting, and allowing for the fact that further inquiries were going to be made, can you summarise for the Panel, from memory, if you have a memory of this, what

T.A. REED & CO.

Day 17 - 29

A

B

C

D

E

F

G

H

the overall assessment and consensus was about what social services thought they might be dealing with?A I certainly feel that we were keeping an open mind at that point. However, the concerns in relation to the parentally induced illness could not be ignored, and we needed to rule that out because obviously that was a very pressing immediate concern. The emotional welfare, certainly, of M2 was of concern, and we needed more information on which to base an informed decision about the way forward.

Q One of those elements in the way forward was to receive an opinion from Dr Southall?A It certainly was, yes.

Q Let us see what happened next as things rolled forward. If you look at the log entry in tab v, we see at page 95, for 27 January, the bottom left-hand corner, again is this you doing the writing and the telephoning to Miss Gray?A On 27th of the first?

Q Yes.A There is a telephone call to Ann Gray and one from her, yes.

Q “… to ask her to contact the doctor at A&E who had dealt with the incident when [M2] had been assaulted.”

Then:

“Telephone call from Ann Gray who had spoken to David Southall – he has not yet received the [information] which we sent on Friday but will attend Thursday’s meeting. Expressed his opinion to Ann Gray that we should be removing [M2] from home. Agreed to fax more [information] to him. [Telephone call] to David Southall’s secretary, she informed me that my documents had arrived with him. Agreed to fax minutes of strategy meeting to him today”.

What is the next word?A “Info faxed”.

Q Pausing there: does that therefore mean that you faxed across to Dr Southall the minutes of that meeting we have just been looking at?A Yes.

Q Then halfway down the page, you see the entry: “Telephone call from Professor Southall …”A Yes.

Q “… who reiterated his concern for [M2’s] welfare. Arranged for myself and Clive Bartley to visit him [Dr Southall] tomorrow to discuss the case further”.

A Yes.

Q That was 28th, and, of course, Ann Gray, whose telephone call with Professor Southall you were reporting, had been in attendance at the strategy meeting?

T.A. REED & CO.

Day 17 - 30

A

B

C

D

E

F

G

H

A Yes, she had.

Q On 28 January, page 96, just over halfway down, on the fourth line:

“Clive Bartley and myself visited Professor Southall at North Staffs Hospital to discuss this case now that he has the full information.”

Pausing there: that is the documentary information, is that is right?A Can you just clarify where we are?

Q Yes, the fourth line down, on 28 January, page 96.A Yes, sorry, I am with you, thank you.

Q “Clive Bartley and myself visited Professor Southall at North Staffs Hospital to discuss this case now that he has the full information”.

A Yes.

Q That is a reference, is it, to the material that had been sent with the letter and the …A Strategy meeting minutes.

Q … strategy meeting minutes?A Yes.

Q “Having considered all the information available he is still of the opinion that mother has a Munchausen syndrome and that this will lead to [M2] being at serious risk of harm from her. Advised us that we should remove [M2] at once, have him medically examined at once and also memorandum interviewed immediately.”

Pausing there for a moment: what is that phraseology, “memorandum interviewed”, what does that mean?A I am sorry about that sort of ---

Q No apologies, but would you just deconstruct that for us?A When we are interviewing children that have either been subject to or have witnessed abuse then we interview them under conditions which – they are now called DVD interviews but at the time they were video interviews, so that the child did not have to go through the incident several times: they could take their time. It was a better way of interviewing the children, on video, at that point.

Q The note goes on, do you see where I am?A Yes.

Q It is the third line up:

“He spoke with Arnold Bentovim – child psychiatrist, who was of the same opinion and agreed to see M2 once we had got him. Professor Southall wanted to see the medical records of the whole family so we rang the office in Wem and asked them to contact the GP and make arrangements for us to view the files. See notes by R Williams.”

T.A. REED & CO.

Day 17 - 31

A

B

C

D

E

F

G

H

Who is R Williams?A R Williams is the social worker.

Q Is that Ruth Williams?A Yes, from the office.

Q “From North Staff Hospital Clive Bartley and myself went to the Shirehall at Shrewsbury to meet with Kim Stanley …”

I think Kim Stanley is actually the head teacher at school, is that right?A Yes.

Q “… and Steve Martin” (the police officer). “Kim feels very strongly that there were no indications that [M1] was being bullied within school prior to his death. Kim pointed out several discrepancies within [Mrs M’s] statement that she made to the police at the time of [M1’s] death.”

Pausing there a moment, how important was that opinion to you in analysing and investigating this matter?A Well certainly from an investigative point of view any times that somebody – if there are any inaccuracies or there is anything that is inconsistent would obvious lead to concerns, and that is something that we look for when we are doing investigatory work.

Q Still on page 97, the last three lines of the first block of text, do you see: “An EPO today …” do you see that?A Yes.

Q “An EPO today was considered but not appropriate placement was available and it would appear that [Mrs M] is not aware of our concerns relating to MSBP”.

Was that your belief and understanding at that time?A Yes.

Q Was it considered to be – and forgive me if I use this phrase – a good thing that a parent in these circumstances does not know at the time about these concerns?A That was our understanding at that time, yes, that the risk that she posed would be somewhat lessened if she did not know.

Q If we look at the next day, 29 January, at page 97:

“Attended at Market Drayton Magistrates with Clive Bartley – an EPO was granted following our application.”

There is then set out a passage where – and I think the Panel have heard about this before – a friend or neighbour of the Ms heard a police message on CB radio and warned her what was going to happen and so forth, all right?A Yes.

T.A. REED & CO.

Day 17 - 32

A

B

C

D

E

F

G

H

Q But I think just for formality’s sake, if you would keep your finger in that and move to tab P: is this the formal application for the emergency protection order that I have just taken you to on page 97?A It is but this is not my handwriting.

Q You can see, it is obviously a court document and your name is on the front of the document. You are noted to be the applicant for the order, is that correct?A Yes.

Q At the bottom on page 2, although the body of the writing in the document itself may not be yours, is that your signature at the bottom left-hand corner?A It is, yes.

Q Dated 29 January. The reason for the application on page 2:

“There is professional concern that the child [M2] is at risk of significant harm at the hands of his mother”.

On page 3 there are the usual background details to alert the court to; similarly on page 4, and then on page 5 you repeat (I say “you” because you are the applicant, it goes out in your name) exactly the same wording as appears on page 2.

When you sought this order from the magistrates court, which we can see at tab q was granted. You see towards the bottom:

“An Emergency Protection Order is granted to the applicant [yourself] …”

which under the law gave you parental responsibility for the children, is that right?A Yes.

Q The court authorised you to remove the children to accommodation provided by or on behalf of yourself, is that right?A Yes.

Q And then the court directed that a medical or psychiatric examination or other assessment be granted, and that was the order. What were you yourself seeking as the applicant to emerge from the application itself?A Well to secure his safety at that time, and to make further inquiries whilst he was safe.

Q Just so the Panel understand, it may be self evident, the application for an EPO is made without notice?A This one was, yes.

Q If you now move to tab R, we can see here the minutes of a child protection meeting, or strategy meeting, on Thursday 29 January 1998, at 3.30 p.m. Do you see that on page 1?A Yes.

Q This was the same day, of course, that you were at the magistrates court seeking the EPO, is that right?A Yes, that is right.

T.A. REED & CO.

Day 17 - 33

A

B

C

D

E

F

G

H

Q This was the meeting which had been flagged up on the 26th as being adjourned to be reconvened on Thursday the 29th.A Yes.

Q If we look again at the people who attended: Kathryn Edwards, again, Ann Gray, again, Tim Collard, again, Steve Martin, again, Dr Solomon, again: did you in fact end up being able to attend any part of this meeting?A No, I arrived back at the office just as it finished.

Q But it is a document which is in the files. Did you come to see this document in the course of your continuing involvement with the M family?A Yes.

Q Can we look by way of background to what is yet to come: on page 2 it is noted in the third line down that Clive Bartley and Francine Salem would be joining the meeting later in the afternoon. In the second paragraph:

“It had been agreed that police and social services would make some individual enquiries and also some joint enquiries … The police were to obtain more details from the coroner and there was to be further liaison with Professor Southall and, in fact, a meeting had taken place yesterday.”

Pausing there, is that the reference you have taken the Panel to already?A Yes.

Q In the third paragraph ---

MR TYSON: I just rise to my feet. My learned friend will know why. This is a report of a meeting where this witness was not present, so we are hearing hearsay upon hearsay. I agree that it is a meeting of which she got the records.

MR COONAN: I do not know whether my learned friend is taking objection about admissibility or not. It is part of the social services files which the witness has said informed her future approach to the case. Either my learned friend has a point on it or he has not.

MR TYSON: I am putting a warning shot across my learned friend’s bows.

MR COONAN: I simply do not understand why there is a need for a warning shot at all. It is a document which is there. I am taking the witness through it as being a document she saw. It is in the file and was there for the future management of the case. I simply do not understand my learned friend’s point.

THE CHAIRMAN: Mr Coonan, would you like to continue? I am sure if Mr Tyson has a formal objection, he will make that known.

MR COONAN: I am sure he will. (To the witness) So that there is no doubt about it, Miss Salem, let us go back to the beginning. This document went in the file.A Yes.

T.A. REED & CO.

Day 17 - 34

A

B

C

D

E

F

G

H

Q Did you see the document after it went in the file?A Oh, yes.

Q Was it one of the working papers for the future management of this case?A Yes.

Q In the file.A Yes.

Q Any decisions and so forth which you had to make or assessments and so forth, were those informed by this document in whole or in part, together with other documents?A Yes, and certainly the recommendations were something that would inform them.

Q Is that how social workers work? They look at the file as a whole.A Yes. They should do, yes.

Q They should do. Let us get back on track and look at page 2. We have just been looking at the text in paragraph 2 and I will just pick it up again:

“The police were to obtain more details from the coroner and there was to be further liaison with Professor Southall and, in fact, a meeting had taken place yesterday.”

Then in paragraph 3, there is a reference to the GP, Dr Willows, and it indicates:

“Dr Willows had been spoken to about medical information and the number of attendances at surgery for M2 and his mother. It became clear that these had increased since M1’s death. The talks with Professor Southall had indicated that there were very serious concerns and he felt that action should be taken to protect M1.”

Just pausing there, again, this is, is it not, a summary of that which had occurred up to that point?A Yes.

Q I do not think I need trouble you about the next couple of paragraphs, save just to draw attention to the final paragraph, which is again I suspect a reference back to what we have been looking at, but can I just draw your attention to it?

“Nigel Breeze told the meeting that he had spoken with Clive Bartley on the telephone and was able to give some information about the meeting with Professor Southall. During the interview with Professor Southall contact had been made with Dr Arnon Bentovim and he had felt that action should be taken and also that he would wish to see M2 himself. They both confirmed that they would be prepared to put their advice in writing.”

Is that a reference back to the contact sheet note which we have seen?A It is, yes.

Q Then at the top of the page:

T.A. REED & CO.

Day 17 - 35

A

B

C

D

E

F

G

H

“Dr Willows confirmed that she had spoken to Professor Southall to run through information concerning Mrs M. He felt this supported his feelings.”

Then in the third block of text:

“Ann Grey spoke to Professor Southall on Tuesday morning when he said he had limited information, but felt that M2 was at risk and should be removed immediately. He asked to have as much information as possible. She then contacted Clive Bartley and Francine Salem and suggested that they have a direct link with Professor Southall, which they did. He did not say directly why he thought the child was at risk. He had asked how M1 had died. He had not received a report. He also inquired about a referral on M2 and was told of a number of attendances at A&E etc. There was concern because M2 had been talking about suicide. He also asked about Mrs M in terms of working at the hospital.”

Again, much of this is background to the taking of the EPO that very day. Is that right?A Yes.

Q Then I am going to take you, please, to page 4, which brings the matter, as it were, up to date as of the 29th. Looking at the third block of text:

“Steve Martin …”

That is, the police officer –

“ … said that yesterday the decision was made that M2 should be taken today and not last night, as it was felt that if he was suicidal it would be important to find the right placement and this was not available at such short notice. This morning Social Services got an EPO out from Market Drayton Court. Mrs M was taken to the police station and some time later she told them where M2 was. M2 was found, his father arrived and together with Social services they went to the placement. Father said he would like to look after M2. Steve Martin pointed out that now there was an investigation under way by the police, all the information that came to his attention would be open to disclosure. He is hoping that the information flow towards Mrs M would now stop. The police are yet to make a decision about how to look at all the information they have and whether they will prosecute Mrs M or not. There is a medical arranged for 11am tomorrow ….at the Royal Shrewsbury Hospital … There is a possibility that M2 is a victim and he may be threatened. A background enquiry is to be undertaken and the investigating team need to have an information sharing meeting and decide how to go forward. Mrs M knows that we are looking at the possibility of Munchausen’s Syndrome by Proxy. The police made arrangements for her to go to a solicitor. Father has been told that Mrs M may be responsible for the death of M1 – at this stage Steve Martin does not know who told him this but he was not happy that this information had been passed on.”

Again, just pausing there, did you, when you reviewed the file and saw this report or these minutes, note the police’s view that they were unhappy that that information had come to the attention of the mother?A Yes. The police made it quite clear.

T.A. REED & CO.

Day 17 - 36

A

B

C

D

E

F

G

H

Q Quite clear that what?A That they were not happy that that information had been given to mum.

Q Then at the bottom of the page:

“Steve Martin said that the police need to speak to Professor Southall and Dr Bentovim as soon as possible which will ensure that the Defence cannot use these experts themselves.”

Then two short passages on page 5. At the top of the page:

“Steve Martin stated that the history of domestic violence in the marriage will be investigated.”

In the third paragraph:

“Kath Edwards commented that we must remember that there may be concerns that the child suffered harm for other reasons than his mother having Munchausens. There is a very serious background of domestic violence and we must not overlook other possibilities.”

Pausing there, did that continue for a time to be the view of social services?A Sorry, did what continue to be the view?

Q That there may be an alternative view.A Yes, most definitely.

Q Then on page 6, in the fourth block of text, beginning “Tim Collard” – he was the solicitor from the legal department, as we have seen – it says:

“ … raised the issue of the EPO – on Monday we will need to get an ICO … ”

What is that?A An interim care order.

Q

“ … or is the plan to extend the EPO? Kath Edwards felt that the plan should be to ask for an extension of the EPO in order to have a case conference.

Dr Solomon asked whether the investigation was a joint one with Social Services under Child Protection or was it criminal to which Steve Martin replied that it was a criminal investigation. The approach was a joint one but investigation of an offender is done by the police. Dr Solomon felt that the Child Protection investigation has not progressed far enough for that. Kath Edwards pointed out that at this stage we are talking about things being done in the correct way in the event of a criminal investigation taking place. Steve Martin added that people should now be aware of what they are saying and to whom. The first priority is to protect M2.

T.A. REED & CO.

Day 17 - 37

A

B

C

D

E

F

G

H

Kath Edwards said that a meeting would need to be held between police and Social services to progress the issues – Steve Martin will link with both Professor Southall and Dr Bentovim after the medical and then the team would decide a way forward.”

Then the penultimate section of that block:

“Kath Edwards confirmed that there would now be a multi agency Case Conference and that will take place early next week. Clearly as part of that there is normally parental involvement but this will be worked out by those arranging it plus the independent Chair. The police have major decisions to make regarding the previous enquiry.”

Then the recommendations, which I want you, please, to comment on in a moment. Recommendation 1 is self-evident. Recommendation 2:

“Following that Police and Social services will jointly plan further Child Protection enquiries.”

What did that mean, Miss Salem?A I understood that to mean continue with what we were already doing, because we had already decided that we were having a joint section 47 investigation and I felt that was just a continuation.

Q Then recommendations 3 and 4:

“Police will be making further plans regarding possible criminal investigation depending on what information is forthcoming.

As part of the enquiries the Police will be linking with Professor Southall and Dr Bentovim.”

I think the next one is self-evident. At 7:

“Given the importance of holding multi-disciplinary Case Conference early next week the meeting would recommend that a direction is made for an extension of the EPO.”

Just to help the Panel, please, Miss Salem about this, we have the section 47 investigation – I am speaking now in general terms, as opposed to the specific facts here – one has the section 47 investigation involving police and social services and other agencies, and you may a the same time have a potential criminal investigation. Is that something that you have come across before, that you have these two investigations in parallel or in tandem?A Yes. Very often.

Q Is that something which applied here? We will see how it developed in a moment, but is that something which was going to apply here or was applying in this case?A It could potentially have applied, yes.

THE CHAIRMAN: Mr Coonan, I observe the time and the fact that Miss Salem has now been giving evidence for a little over two hours. Is this an appropriate time to break for lunch, or is there something you wish to wind up?

T.A. REED & CO.

Day 17 - 38

A

B

C

D

E

F

G

H

MR COONAN: Madam, that has brought me to the end of that document, so it would be convenient.

THE CHAIRMAN: In that case, we will take a lunch break until two o’clock. (To the witness) I need to warn you, Miss Salem, that you must not discuss your evidence or the case with anyone while you remain on oath.A That is fine.

(Luncheon adjournment)

THE CHAIRMAN: Mr Coonan?

MR COONAN: Miss Salem, we had been looking at tab (r). Could you just open it again, please? We had reached the end of page 7. Just for completeness, I want you to look at page 8, please. You remember the minutes of that meeting we looked at which took place on 29 January and the last recommendation signed by Kath Edwards was a direction for an extension of the EPO. Here on page 8, we have a document which is headed “Child Protection Case Conference Invitation” for a meeting on 9 February, we see in paragraph 1. At paragraph 8, under “Reason for Case Conference”:

“M2 removed from the care of his parents under an EPO due to concern he may be experiencing MSBP.”

Do you see that?A Yes, I see it.

Q Then at the bottom of the page, paragraph 10:

“M2 is currently accommodated and placed with Foster Carers in Market Drayton. Supervised contact is being arranged for the parents. The Local Authority is applying for an Interim Care Order.”

That appears to be the end of that document. Implicit in that of course is clearly a change of approach from an extension of the EPO to an application for an interim care order. Do you see?A I see what you mean, yes.

Q Can you help the Panel as to the thinking behind that now?A From memory, I cannot, but imagine an extension of an EPO would only be for a short period of time and an interim care order is more significant, usually up to six weeks. An ICO is up to six weeks.

Q We can then leave that and we can move on, please, to the next tabs (s) and (t), but first (s). It had been foreshadowed that Dr Southall would be preparing a report and in tab (s) we see a letter from him addressed to you dated 30 January 1998:

“Following a telephone conversation with your team manager today I enclose a very preliminary report on my involvement with this family. We discussed the additional

T.A. REED & CO.

Day 17 - 39

A

B

C

D

E

F

G

H

information that I would require in order to make a more complete assessment and hopefully this will be available in due course.

In the meantime I would be very pleased to hear that M2 has been taken to a foster family and that you have an emergency protection order. I am sure that this was the safest response to a very difficult situation.”

Did he enclose that report, which is set out at tab (t)?A Yes.

Q Miss Salem, I am not going to take you through the whole of the detail, for two reasons. First of all, because many of the paragraphs are summaries of the documents which we have already looked at. Is that correct?A Yes, it is.

Q I just draw your attention to a couple of matters. First of all, on the first line of page 177 of tab (t), he says:

“I have examined the following documents in order to make this very preliminary report.”

The same phrase used in the letter. Then the summaries and the Panel can see the sources of the summaries. On page 181, in the second main bit of text, beginning “Reading this history”. Do you see that? In fact it is the third.A Yes.

Q It is a comment, if we just turn back the page briefly to 180, on the statement of Mrs M which you had earlier supplied to Dr Southall.A Yes.

Q Then he makes this comment?

“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] hanging 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.”

That was an observation he made, and I want you to bear that in mind when we come to later events, all right?A Yes.

Q When you received this report did you find anything odd or concerning about the observation that Dr Southall was making there?A Odd in what way?

Q In any way. Did you find it odd that the doctor should be making an observation like that – a paediatrician?A At the time I do not recall finding it odd, no.

T.A. REED & CO.

Day 17 - 40

A

B

C

D

E

F

G

H

Q Then we look at page 182, and again a reference to the strategy meeting on 26 January – do you see at the bottom of the page?A Yes.

Q We have looked at that. Then we come to his initial and very preliminary opinion on page 183 at paragraph 17. I want to read this because I want to know, please, what the opinion of social services through you was at this stage; do you understand?A Yes.

Q“In the light of all the above information I contacted Dr Arnon Bentovim, a Child and Adolescent Psychiatrist who has a particular expertise in life threatening child abuse. He informed me that suicidal hanging of a child of only 10 years is a very rare phenomenon. He felt that the history now surrounding [M2] and the very sinister similarities between what is actually happening to him in terms of alleged threats of suicide, alleged bullying that cannot be substantiated, injuries and attendances at the accident and emergency department all create further concern.

Like myself he felt that it would be very important for [M2] urgently to be seen by an expert child psychiatrist. He volunteered to provide this as a consultant to the social services department. He also considered like myself that it would be safer to remove the child from the family at this time …”.

Then dropping down to the next paragraph:

“I then discussed the situation with the family’s GP.”

I will not read the rest of that paragraph; the Panel can read it for themselves. Over the page. The third paragraph is an observation made by the GP about the mother and again for obvious reasons I will not read that except to draw the Panel’s attention to it.

Then finally at 18:

“I was very much concerned for the safety of [M2] given all the above circumstances and felt that the best approach would be to try and obtain an [EPO] and place [him] as soon as possible in a high quality foster home. I felt that at the same time he should be seen by a child and adolescent psychiatrist, ideally Dr Bentovim. I also felt that the mother should be offered psychiatric support. I feel that all medical records relating to the children in his family, including [M1], should be examined. …

Information about [M1’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.”

Miss Salem, when you received that what was your view as a senior social worker, given the circumstances in the section 47 investigation that had begun?A Certainly that concerns that Professor Southall was raising were very much along the same lines that we had already gathered, and the information that we had gathered as well.

T.A. REED & CO.

Day 17 - 41

A

B

C

D

E

F

G

H

Certainly the information regarding it being a rare phenomenon that M1 should take his own life in that way was of concern, and managing the risk, this had to be take into consideration.

Q Having received that, the next step is that I think there was an application made for an interim care order, which we can find at tab (w). This is a court document, is that right?A Yes.

Q Again the Panel will be able to read so much of it as is directly relevant, but it is formally, as we can see, an application for an interim care order, page 1. On page 3 you rehearse the current position, towards the bottom of the page:

“The child is currently in the care of Shropshire County Council under an Emergency Protection Order …”.

On page 4 your name is mentioned as the social worker in question, and then again looking through the pages, basic family background details. Then we come on to page 7, “The grounds for the application”, mid-way down the page of a document which is dated 3 February 1998, you see at the top right-hand corner. The grounds are:

“… that the child is likely to suffer significant harm and the harm, or likelihood of harm, is attributable to

the care given to the child, or likely to be given to the child if the order were not made, …”

et cetera, and you have ticked that box.A Yes.

Q Those were the grounds.A Yes.

Q You set out the material supporting that, at the bottom of page 7. Page 8 at the top, the plan for child M:

“The child to remain in Local Authority Foster Care whilst assessments are carried out. This placement needs to be secured by the making of an Interim Care Order.

There will be reasonable contact for the child and his parents, initially twice a week, but subject to review, it will be supervised and take place at a neutral venue”.

As applications go was it a fairly standard form of interim care order appointed actuary?A This?

Q Yes.A Yes, it was.

Q Did you provide a witness statement in support of that, which you will see at tab (u), and is that also dated 3 February 1998 and signed by you?A Yes.

T.A. REED & CO.

Day 17 - 42

A

B

C

D

E

F

G

H

Q Much of this – is this right – repeats in summary form the material which you and I have covered during the course of this morning in a very distilled form?A Yes.

Q In those circumstances again I do not propose to repeat it; it is there for the Panel to read. But I do take you to page 3. I think it is perhaps worthwhile setting the scene as of 3 February 1998, immediately before the hearing. I take you to the second paragraph on page 3:

“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 North Stafford Hospital to request his opinion. He suggested to me that on the basis of the information I had given him, that he believed [Mrs M] had Munchausen Syndrome and that this would have serious implications for [M2's] welfare.”

Then you deal with the strategy meeting on the 26th, and then you say again, almost repeating what you have told the Panel, but I will read it anyway:

“On 28th January, myself and my Team Manager visited Professor Southall who had opportunity to read all the relevant documentation. He confirmed his belief” –

pausing there, whose belief?A Professor Southall’s belief.

Q Your team manager visited Professor Southall. Do you see the nature of the sentence: “He confirmed his belief”. Who are we talking about?A Professor Southall.

Q Right.

“… 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.”

Again you say, repeating other matters, ending up on the bottom line:

“I believe a full assessment is needed to look into alternative causes.”

In that context you were referring specifically to bullying – at the bottom paragraph – is that right?A Yes.

Q I want to turn, please, to the next tab, (v), where you pick up a visit you made to see Mrs M. If you turn to page 98 – Miss Salem, I am taking this strictly chronologically, you understand? On 12 February 1998, right at the bottom:

“Home visit to see [Mrs M] with Ruth Williams. Went through the LAC paperwork” –

what is that?A Looked-after child’s paperwork.

T.A. REED & CO.

Day 17 - 43

A

B

C

D

E

F

G

H

Q“and [Mrs M] signed the contact sheets sent to Marilyn Inwood.”

She was the guardian ad litem?A She was.

Q“Letters sent to Dr Southall and Dr Bentovim re my intentions vis-à-vis assessment process.”

Before I ask you a question about this can I also take you to 23 February, which is the next entry on the same page, 99:

“Home visit made by prior arrangement to see [Mrs M] as part of the assessment process – discussed childhood & progressed to first divorce.LATER – conference with our counsel at Shirehall …”

and so on. You made two home visits, on 12 and 23 February, to see Mrs M. Was 12 February the first time you had met her? I do not think there is another reference in the documents to seeing her.A I do not think that was the first time I had seen Mrs M, no.

Q Just take the 12th and the 23rd, the two documented ones anyway. How did she come across to you in terms of her approach to you as a social worker?A I had been present, which is why – I had seen Mrs M before, because I had been present a the point of the EPO and the removal of M2, which had been a very traumatic incident, to say the least.

Q For whom?A For all of us, but obviously particularly for Mrs M. So even at that point she did see me as the person that had removed M2, and obviously not a good way to start any relationship with someone.

Q Was there anything that sticks in your mind which allows you to give the Panel that description?A At the point of the EPO?

Q Yes; or indeed on the 12 or 23 February.A The point of the EPO obviously Mrs M was refusing to tell us where M2 was, and was extremely upset and was very clear in her thoughts at that time about what she wanted to happen. She was very cross. On the second occasion that I did see her, and subsequently, Mrs M did begin to calm down and was cooperative with the core assessment process.

Q As matters stood in late February, how would you say your relationship with her was?A It certainly improved during the core assessment, because it was at a time when Mrs M could talk about her own experiences, and it did improve. But that is not uncommon.

Q Again, still on page 99 you will see on 25 February there is a telephone call between yourself and Dr Southall; is that right?

T.A. REED & CO.

Day 17 - 44

A

B

C

D

E

F

G

H

A Yes.

Q I am going to read this:

“Dr Southall returned my call – Discussed the way forward. Dr Southall felt that Dr Bentovim should be seeing [M2] as soon as possible and then see [Mrs M] herself. He believed that the sooner this is done the better.

Dr Southall felt that we should be trying to establish a good rapport with [M2] to try to facilitate him ‘opening up’. When I told Dr Southall that I felt [M2] was rather defensive, he indicated that this was worrying in itself, as if there was nothing to hide then h e wouldn’t be defensive.

Dr Southall wanted us to get the SOCO” –

That is the scenes of crimes officer, is that right?A Yes.

Q –

“report and to interview the doctors that actually saw [M2] at hospital A&E to discuss the precise nature of the injuries. Also” –

and this is a reference to getting hold of the original letter, to, I think, the magazine editor of the magazine article that we have looked at. A Yes.

Q Then there is a reference to M1’s appendix, and we have seen that in an earlier document which I did not read out fully, being OK when removed.

“Dr Southall did not feel that this was hard evidence as this does happen on occasions.”

In the light of that conversation did you agree or disagree with the approach which Dr Southall was suggesting?A With regarding to the beginning of rapport with [M2]?

Q Yes, or indeed any element of this telephone conversation, suggesting that you get hold of the SOCO report and interview the doctors, all the elements in that. Did you agree or disagree with the proposals?A I agreed that that would be the best way forward.

THE CHAIRMAN: I understand, Miss Salem, it is very easy to slip up; that is why we gave the global warning at the beginning. There are one or two people in the public gallery. If anybody is reporting, then the same warning which was given this morning applies, and that is that no names should be reported in connection with this case.

MR COONAN: (To the witness) Miss Salem, I want to produce a document which has been missing from this sequence that we have, which is dated 4 March. Perhaps that could be produced, please.

T.A. REED & CO.

Day 17 - 45

A

B

C

D

E

F

G

H

THE CHAIRMAN: This will be D21E. (Handed)

MR COONAN: Can you confirm that this comes from the social services file?A Yes.

Q We see at the top of the page the date 4 March. Your name is on it as being one of the parties to the discussion: is that your writing?A It is, yes.

Q Parties to the discussion: Sergeant Martin, DC Edwards, your team manager Clive Bartley and yourself.A That is right.

Q I want to go through this with you because of a further document which will emerge later on:

“Summary of discussion:

Police confirmed that they are not ‘re-investigating’ [M1’s] death but wish to speak to [Mrs M] regarding an ‘ambiguity’ in her statement about how the belt was wrapped around [M1’s] neck as well as the pole. Police believed that this did not constitute a re-opening of the investigation. Concern was expressed by [social services department] that there appeared to be a lot of ‘ambiguities’ with the statements taken in 1996. However police did not feel that these constituted ‘hard facts’ or new evidence.

Agreed = Police to visit [Mrs M] today to discuss how belt was attached to the pole and will liaise further with us.”

We have had some evidence about this, but I want your view: did you come to know what the result of the police visit to Mrs M was?A I cannot recall at this moment.

MR COONAN: All right, if you cannot remember that is fair enough. That was 4 March, and then we come to an important event, which is the hearing before His Honour Judge Tonking in the County Court on 10 March 1998, and in so far as we need to look at it you will find this in C4 which is in a separate file, and you will be helped if necessary.

MR TYSON: I do not know if it assists my learned friend but the judgment was given on the date mentioned but it was a four day hearing up to that date.

MR COONAN: Yes, I appreciate that, yes. I have not come to the detail yet. (To the witness) Miss Salem, you will be relieved to know I am not taking you through the whole of this document. The Panel have read it once already, if not more than once, but I am just producing it, as it were, to set the scene so that we know what we are talking about. The first question I want to ask you, which is a matter which is self-evident from the judgment, is, at that stage the basis of the application involving an allegation of MSBP, if I can use the acronym, was not then being pursued, do you remember that?A Yes.

T.A. REED & CO.

Day 17 - 46

A

B

C

D

E

F

G

H

Q Can you help the Panel why at that stage for the purposes of the application it was not being pursued?A As part of the process that we were undertaking anyway we were doing a core assessment and from that core assessment other concerns were being raised. It was not complete at the time, in March, but it was certainly well under way. We also did not have an expert witness to the hearing, which did affect the way the process went, the court hearing.

Q When you say you did not have an expert witness, you will have to spell that out for us, what do you mean?A Professor Southall was not able to be present.

Q And therefore not available to give oral evidence or be cross-examined?A Absolutely, yes.

Q Did that fact of itself, the fact that you could not pursue as a basis for seeking the interim care order on an argument based on MSBP, did that mean to say that your concerns about MSBP disappeared?A Not altogether, but certainly they were being overtaken at that point by concerns regarding the emotional welfare of M2.

Q For the purposes of my questions, was the issue of MSBP still a live issue so far as the social services were concerned?A Yes.

Q Can you recall now what the view of the Guardian ad litem was about the potential role of MSBP?A Certainly the Guardian was supporting the local authority.

Q Which was? You will have to spell it out for us. Was she still concerned about MSBP?A Yes, certainly she was, yes.

Q Again, I am not going to take you to it but we can see the exchanges between the judge and counsel at the end of the judgment as to what those concerns were and how they were to be managed. I am going to take you therefore to what your understanding was at the end of the court proceedings. Were social services still intending to pursue an investigation in relation to MSBP?A I would have to look at the documents to be …

Q That is a fair point. If you look at C4 you will see that at the end of the judgment, which finishes at page 26 but if we look at page 27, Mr Anthony, who appeared for the local authority (the applicant) was addressing the judge and he is saying:

“What the local authority would seek to do, clearly, is to have a further report from Professor David Southall …

The details of that are set out, and then on page 35 at letter D, Mr Hillman, who then appeared for the father, said:

T.A. REED & CO.

Day 17 - 47

A

B

C

D

E

F

G

H

“ … in view of the prospective involvement, if need be, of Dr Blueglass …”

Dr Blueglass is a psychiatrist, is she not?A I believe so.

Q “… clicking into play if triggered by a positive Munchausen’s diagnosis by one of the other experts, because that is the only context in which Dr Blueglass would then come into play, if there is a positive Munchausen’s diagnosis.”

Then we take it up at the bottom of page 40 at letter G, here the judge observes the following:

“And I think that what Mr Anthony” – counsel for the local authority – “is saying so far as the local authority are concerned is that they really cannot simply go to Dr Southall, who is really looking primarily at the adult element of the case, and not go to Dr Bentovim.”

The argument there, cutting it short, was the involvement of both these doctors.A Yes.

Q Over the page at A, the judge says:

“ … but when I say the adult side, he is looking at …”

Intervention: … “query Munchausen’s” and then Mr Khan who appeared for the mother agreed: “Indeed, your Honour, yes.

Finally, so far as the post-judgment exchanges are concerned, at page 42, between B and C, this is counsel for the local authority speaking:

“… my understanding is from reading Dr Southall’s report that he is talking in terms of him principally looking at it as an expert of a child where there has been life-threatening – he puts it life threatening – child abuse. That is perhaps not the best way to put it but, as I understand it, that is what Dr Black will also be looking at.”

Towards the end of that judgment, at page 25, at G, Judge Tonking analysed the evidence that was available to him and comments at the bottom:

“I am troubled by the fact that the investigation still has a very long way to go:”

That, of course, preceded the exchanges that I have just taken you to.A Yes.

Q This is really by way of background but as of the end of that hearing what therefore was the way forward in terms of involving Dr Southall, from your standpoint?A We certainly wanted Professor Southall to see the parents, but there were other expert witnesses to be instructed as well.

Q Absolutely and we will look at that, but so far as Dr Southall’s role was concerned, what did you at that stage, as the social services, expect or anticipate he would be doing?

T.A. REED & CO.

Day 17 - 48

A

B

C

D

E

F

G

H

A Sorry, I am with you. certainly looking into the MSBP side of it.

Q Just for formality’s sake and looking at the chronology, there is one further contact sheet which was just put in our file, which is 11 March 1998, although I do not think anything turns on it, certainly from my standpoint. (Same handed and marked as D21/F). This was not in the original documents supplied to the parties, and so it is being put in so the Panel have as complete a bundle of this as possible, and we can see that it begins on 10 March, and I think we have got the same problem here because some of the dates in the left-hand margin have been cut off. Can you do your job with the file do you think?A I cannot seem to find it.

Q I do not want to waste time.A I am sure that it will say …

Q There maybe other dates down the left-hand margin, but I do not want to waste time now but maybe in due course you can look at it again particularly because I do not think there is anything specific that I need you to specifically draw attention to so perhaps we can leave that for the moment. I want to come to an important document in tab x. This is a letter of instruction to Dr Southall, from Mr McLaughlin, a solicitor in the Legal Department. Have you seen this document before?A Yes.

Q Did you have a hand in its drafting?A I cannot recall at the moment. We do sometimes; other times it is the Legal Department.

Q On the first page there are just four elements to it identifying personnel, and on the second page, in the first paragraph there is again a summary of what had happened up to the granting of the EPO: in the second paragraph there is a summary of the result of the court proceedings that we have just looked at. Again in summary, if we pick it up halfway into the paragraph:

“At this hearing no Interim Care Order was granted to the Local Authority after four days of hearing evidence although the judge indicated that the threshold criteria in Section 31(2)” – that is of the Children Act.

A Yes.

Q “… were met in respect of the volatile relationship between the parents, at this time the original application for the [EPO] was made. The judge had heard evidence from Mrs Inwood during the course of the proceedings, who supported the local Authority’s application and plan that [M2] remain in foster care with contact planned. He had verbal evidence also from Dr Solomon … whose view was that [M2] could be safely returned home”.

In the next paragraph:

“Directions were given on 10 Mach 1998” – the day of the judgment – “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.”

T.A. REED & CO.

Day 17 - 49

A

B

C

D

E

F

G

H

There is then a reference to Professor Stevenson’s role, and then in the last paragraph, a formal introduction was given to experts about the general accepted principles in relation to acting as an expert:

“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 … This does not prevent you from having direct discussions with Mrs Inwood as she is in effect the Court’s independent reporter …”

Her report is enclosed.

Mr McLaughlin on the next page sets out a schedule of a document which had been filed with the court and then he specifically asked Dr Southall in items 1 to 7 to particularly address the following issues: 1 and 2 are self-evident: 4, 5, 6 and 7 are self-evident. Could I just ask you about item 3? The letter ---

MR TYSON: I must interrupt, as my learned friend will realise, this witness is not the drafter of this document. She says she cannot recall if she had a hand in the drafting, so to get her view about what a particular paragraph meant in it is of no value to you at all in my view.

MR COONAN: I do not accept that. Perhaps I could lay the ground if my learned friend has a concern about it to see whether or not the view of the witness is of any assistance, or maybe, to you. If you bear with me I shall attempt to lay further ground.

(To the witness) This document we know was sent to Professor Southall. Did you know the basis upon which he was instructed to see Mrs M?A Yes.

Q How did you come to know the basis on which he was instructed?A Following the various discussions, from being present at court and discussions directly with Alan.

Q With Alan McLoughlin?A Yes.

Q We have touched on it to a certain extent, and I am going to ask you to stay off the terminology of this document for the moment and ask you to just deal with it at large. The question is this. Did you think that Dr Southall was going to be or had been – whichever – instructed to consider the question of MSBP?A Most – yes.

Q You were about to say “most”.A Definitely.

Q Is that your answer: most definitely?A Yes.

Q Did you come to see this letter of instruction?A Yes.

T.A. REED & CO.

Day 17 - 50

A

B

C

D

E

F

G

H

Q It does not specifically mention MSBP.A No, it does not.

Q Is that a problem for you?A It is not, because I would have said that it had been captured within this.

Q Is there any particular section of the document which would capture it?A Certainly number three would say that to me.

Q At any rate, whatever the precise wording of the document, is it your evidence that you anticipated that Dr Southall would be carrying out or seeing Mrs M – at least seeing Mrs M – for the purposes of investigating the question of MSBP?A Yes.

Q Before we come to the interview, there is one final document I want to formally produce to complete the flow of contact sheets. There is one dated 16 April 1998. Can you formally produce that, please? (Same handed) Madam, I think this might be G. Miss Salem, again, to forestall any of Mr Tyson’s sensitivities about documents, can we deal with it in this way? It has your name at the top.A Yes.

Q It is typed. Does this document come from one of the social services files in front of you?A Yes.

Q You can confirm that, can you?A Yes, I can.

Q We see in the bottom right-hand corner a sort of squiggle which might or might not be a signature. Can you help us about that?A It is the signature of the team manager.

Q Who is?A Clive Bartley at that time. Just to help, this was a contact sheet he would have had typed up because he was renowned for bad handwriting, so as it would have had my name at the top, it is just like all the other contact sheets in there and that is why my name is there.

Q I should ask you this, again, bearing in mind Mr Tyson’s previous interventions. Did you come to see this document?A Yes.

Q It is dated 16 April. It is now approximately four weeks after the letter of instruction which we have seen in tab (x), which is dated 17 March. In this note, Mr Bartley notes a discussion with Ruth Williams, going to see Dr Black. Dr Black was a psychiatrist and she had been instructed as well. Is that right?A Yes.

Q Following the judgment of the court. The papers had been released to her by order of the judge.A Yes.

T.A. REED & CO.

Day 17 - 51

A

B

C

D

E

F

G

H

Q It says:

“Dr Black would like sight of Post Mortem report and Coroner’s report … ”

Then the comment, “Wouldn’t we all”. Was it the case that you had not seen it at that stage?A Yes. We had not seen it at that point.

Q Then there is a reference to Dr Bentovim and then a meeting with Detective Chief Inspector Warwick and Sergeant Martin of the Family Protection Unit.

“The police now confirm that they will be re-opening an investigation into M1’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 M1’s death and that it would be in everyone’s …

And that has been underlined –

“ … best interests if 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 and

b) to impart/share any information which may have a bearing on each agencies own enquiries.”

Then:

“WEST MERCIA POLICE – will now pursue their own enquiries in the knowledge that Social Services Department will over the next few weeks be discussing in more detail with Mr and Mrs M the circumstances and history to M1’s death and how this may impact upon M2 presently.

DCI WARWICK – would like a copy of [the] judgment and in return he will make every effort to have all police material made available to Social Services Department and Professor Southall so that he offer a more considered opinion.”

As of 16 April, there appears to have been a change compared with the contact sheet we looked at in relation to 4 March, where the police indicated that they were not re-opening the investigation. I am not of course asking you whether it was correct or incorrect for the police to do that, but the fact that the police were re-opening an investigation as of this date, does that in any way prevent social services from carrying out its own investigation pursuant to two things: one, the Children Act and secondly, the direction of the court?A No, it did not.

T.A. REED & CO.

Day 17 - 52

A

B

C

D

E

F

G

H

Q Can I take you, please, back to C1, tab (v) and can you turn to page 100? Just by way of preliminary, Miss Salem, between pages 99 and 100 there is the whole of the month of March and most of the month of April, save for the documents I have taken you to which we do not have. I just want you to know that. Social Services have not provided those documents either, as I understand it, to Field Fisher Waterhouse or to us.A Yes.

Q So I do not know. There may be other entries in the files in relation to that period of time which we have not seen. Whether that point may become relevant or not, we will have to wait and see. At the moment I am just putting that marker down. Do you understand?A Yes.

Q On 20 April, if you look at page 100, at the top of the page, we see:

“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 30 kgrammes for a 10 year old boy. He felt that the police should be looking closer into this.

Professor Southall reiterated his belief that Dr Bentovim should be doing a full assessment.”

Again, did you find anything odd about Dr Southall raising that as an issue at this stage?A No.

Q The next entry on 21 April – again, all these are in your writing:

“Telephone call to Detective Sergeant Martin to ascertain what the police position is at this time, prior to making contact with Mrs M to continue the assessment.”

I leave out the next few lines and go to the end of that block of text:

“Telephone call from David Steel Martin. Agreed that I would continue with our assessment process.”

Miss Salem, pausing there, when you use the phraseology “assessment process”, is that a reference to either a section 47 or the post judgment process? Is that a term of art, or just a descriptive terminology? Just help us.A It is undertaking a core assessment, where you look at different aspects of somebody’s life. You do individual profiles of parents, we look at their background, we look at how the pregnancy went. You have to take a very holistic view and it takes a long period of time. That is the assessment process.

Q Briefly, on 23 April, turning on to tab (y) and taking this chronologically, there is a letter from Mr McLaughlin to Professor Southall. The date is in the top right-hand corner. It says:

“I refer you to my letter of instruction dated 17 March 1998 …”

And we have looked at that –

T.A. REED & CO.

Day 17 - 53

A

B

C

D

E

F

G

H

“ … and now enclose a copy of the transcript of the Coroner’s Inquest, together with the post-mortem report …”

He talks about questions of deadlines and filing a report, which I need not trouble you with. Again, it looks as if, does it not – and we can see from the following documents; I am not going to take you to them – the transcript of the evidence given by the witnesses at the inquest and other documents. Just flip through them. It is self-evident.A Yes.

Q Did you see these documents yourself?A Yes. On 23 April, I have written that the coroner’s report arrived.

Q You are looking at page 100, just above the hole punch.A Yes.

Q Then on 24 April, again on page 100, about ten lines from the bottom:

“Telephone call from the legal department – Professor Southall wants to see the M family … ”

I say that deliberately, because there is a little asterisk there –

“ … next week. Agreed that we would provide a rail warrant to get them over to Newcastle.”

Is that a reference to the family?A Yes.

Q To include Mr M?A Yes.

Q Then there are some observations about other matters. I do not think I need trouble you with that. Over the page, still on the 24th, halfway down, we see “RW t/c”. What is that?A That is “Ruth Williams, telephone call”.

Q Then:

“ … arranged transport to be provided on Monday morning to and from Professor Southall’s appointment. Telephone call from Mrs M – informed her of travel arrangements made for Monday to get her to Stafford/Professor Southall. Mrs M informed me that M2 was away for 3 days at an outdoor activity centre. Mr M is unable to attend the appointment on Monday because he has already taken the following day off for an appointment with Dr Solomon.”

We will see in due course there was a letter sent indicating that he had employment difficulties. Off the top of my head, I cannot remember the reference, but it will come to me in a moment. I think the final document I would like you to look at before we come to the interview is tab (dd) in C1. First of all, there are a number of preliminaries. You will see

T.A. REED & CO.

Day 17 - 54

A

B

C

D

E

F

G

H

first of all that it is a note for the file. On the second page it is dated 27 April 1998 and it signed MGG. I think we heard evidence last time that was Ms Garrard.A Yes.

Q I think her name appears on the list of attendees at the strategy meeting. Although it is dated the 27th, it actually relates to events prior to the 26th; we can see that from the bottom of the first page. Do you see it is a document written prospectively, prior to the 26th?A Yes.

Q Have you seen this document, or did you see it before the interview on the 27th?A No.

Q Have you seen it since?A Only in regard to these proceedings.

Q It is in the file.A No.

Q It is not. Then I will not ask you about it. I will tell you why; there is no secret about it. When social services supplied material to Field Fisher Waterhouse, they included matters from the legal file as well as the social services file.A This will be from the legal file.

Q Therefore, can we come, please, to some of the immediate matters before the interview itself? Can I take you to the log on page 101, please, for 27 April? This is tab (v). This is the same day apparently as the interview itself. Towards the bottom of the page, five lines up, we see:

“Professor Southall contacted the initial assessment team this morning and requested that I be present during the discussion with Mrs M today. This was agreed – see report. Telephone call from Legal requesting copy of Kilroy video for Dr Southall – advised that the barrister had it.”

Then over the page at 102:

“The reasons that Professor Southall suggested I be present during the discussion with [Mrs M] was because he would be addressing the following issues:-(1) Who the belt belonged to.(2) How was it wrapped round the pole.(3) Was toxology (sic)done.(4) Question needle mark in [M1’s] arm.He felt it would be useful if a social worker was present.”

And that is an entry signed by yourself. A (The witness nodded)

Q You took the telephone call and you obviously spoke to Dr Southall. A number of questions for you, please, arising out of that. Was that first of all, in terms of the request that you be present, something that you personally had experienced before, that you be asked to be present by a consultant paediatrician?

T.A. REED & CO.

Day 17 - 55

A

B

C

D

E

F

G

H

A I think these circumstances are particular, so in these circumstances where we are looking at the MSBP, then no, because I had not had that experience before. However, if you liken it to – I do not know – a physical injury, then we are on occasion present when a physical injury would come in, and a doctor may talk to a parent about how that had happened.

Q In a social worker’s presence?A Yes, when we get particular injuries to children.

Q Allowing for the fact that you yourself, as you told the Panel, had had no direct experience of a Munchausen situation, did you nevertheless find the request by Dr Southall that you be present for this forthcoming discussion in any way odd or strange or inappropriate or unprofessional?A Not at all.

Q Did you approve of it?A I felt it would be helpful to myself as part of my core assessment.

Q Just spell out for the Panel’s benefit, please, why did you think it would be helpful?A Because it would mean that Mrs M would not have to be spoken to twice about how M1 – the circumstances of that happening.

Q How did you think this interview was going to be for Mrs M? Did you think it was going to be easy or difficult for her?A I thought it would be difficult for her.

Q Why?A The nature of what was being discussed, really.

Q Did you think at that time of any other reasons why it was an appropriate thing to do, for you to be present while Professor Southall was conducting this interview?A No.

Q Did you think there was anything unusual or odd about the topics that he was proposing he would cover, on page 102?A No, because they were questions that needed to be asked or needed to be resolved in order that we could clarify some of the points that had come up over the previous months, some of the concerns, some of the ambiguities and anomalies that we have referred to previously.

Q You have told the Panel that by this stage the police had intended to reopen the investigation. Did you think it was nonetheless appropriate that these matters should be covered in this proposed interview, even though the police were going to reopen the investigation?A I think by this time there was some debate as to whether the police were going to reinvestigate or – a term that they began to use subsequently was review their evidence, to see if there were grounds to reinvestigate. There was a subtle difference.

Q Whatever subtle difference there may be, I am just asking for your reaction to this proposal that we saw here, at the time. Did you think there was anything odd or –

T.A. REED & CO.

Day 17 - 56

A

B

C

D

E

F

G

H

inappropriate, I think is probably the best word to use – inappropriate about these matters being raised by Dr Southall?A Not at this time, no.

THE CHAIRMAN: Mr Coonan, I want to take a break at some time this afternoon, and I anticipate that shortly you will be getting into the substance of the very important matter of the interview itself, during which I would not wish to make an interruption.

MR COONAN: Yes.

THE CHAIRMAN: Even though it is slightly early, would it be appropriate before you get into that for us to take a short break?

MR COONAN: I can see the sense of that, and in fact with one or two other questions I am nearly complete before we get into the interview proper. So if I could be permitted to deal with those, I would be very content.(To the witness) At this stage – and this of course is the same day as the interview itself – what was your understanding about Mrs M’s understanding as to who would be present? In other words, putting it in a rather less convoluted way, did you personally tell Mrs M or tell her solicitors that you would be present at this interview?A I do not recall telling Mrs M, because it was not my interview to do that, and I had made assumptions that that would be done. So, no, I did not.

Q I think to complete matters I promised I would turn up a letter about Mr M. It is D4. I do not know whether you have the D bundle there?A Yes.

Q We see that D4 is dated 24 April and it is from a firm of solicitors acting for Mr M, because – again just pausing for a minute – we know that both parents were separately represented in the proceedings.A Yes.

Q The solicitors are writing to the local authority legal department:

“… we have contacted our client regarding the proposed appointment. Our client has spoken with his employers but unfortunately, in view of the short notice given, they will not allow him the appropriate time off work …

Our client apologises and emphasises that he is not being difficult … but you must appreciate that this was extremely short notice and he must abide by his employers decision.”

There is a suggestion about seeking a further appointment with Professor Southall. At any rate, that sets the background for why he did not attend.A Yes.

MR COONAN: That brings me to a convenient moment, madam, if that is convenient to you.

T.A. REED & CO.

Day 17 - 57

A

B

C

D

E

F

G

H

THE CHAIRMAN: We will take a break for about 15 or 20 minutes. We will return between half past and twenty-five to.

MR COONAN: Thank you.

THE CHAIRMAN: (To the witness) Miss Salem, I have to remind you not to talk about your evidence in the case during the break.

(The Panel adjourned for a short time)

THE CHAIRMAN: Mr Coonan?

MR COONAN: Miss Salem, just before we come on to the interview I think you are in a position to help the Panel with the missing dates on the document?A Yes.

MR COONAN: Madam, can we deal with this. It is D21F, which was put in this afternoon, and I think certainly on my copy I have no dates at all.(To the witness) Can you help?A It should read ---

Q Which line?A Top line. “5/3/98”, “10/3/98”.

Q Any others on that page?A On that page?

Q About eight lines down. “T/C to Mrs P”. Was there an entry there?A Yes, but I cannot read that – my own handwriting. When it says “Later”, the next paragraph down, it is 10/3/98.

Q And the next one, where it says “T/C to Mrs P”?A 11/3/98.

Q Any more?A No.

Q Thank you very much; you can put that away. Now I want to come to the interview, and before we look at any of the content of it I want to deal with the documentation. Can I introduce this, please, by turning up, to remind you, in C1 at tab (gg), page 23. Just so that you know, the Panel have seen this document before, but I want first of all to identify it and then work backwards. You see at the beginning of page 23, and then turn on to page 26, that this is a typed document signed by you and dated 28 April, which is the day after the interview – right?A Yes.

Q First of all – and I want you to formally produce this – is that a typed note that you had relating to the interview that you had with Mrs M and Professor Southall on the 27th?A It is, yes.

T.A. REED & CO.

Day 17 - 58

A

B

C

D

E

F

G

H

Q It is dated 28th. Was that typed account typed personally by you?A No.

Q Who was it typed by?A We have a team of secretaries that do the typing.

Q Obviously a typist must have something in order to be able to type of the typed version, so what did the secretary in question, whoever it was, have?A She would have had this in handwriting.

Q So a handwritten version of this document?A Yes.

Q When did you write that handwritten version?A The same day, so that would have been the 27th.

Q We will now put that to one side, and I want to ask you to look at another document, which is in fact a handwritten document. You are going to be handed it, and just before we distribute it I want you to formally deal with its production. Let us take it out of its plastic folder. First of all the construct of it. Are there six pages – unless my maths are wrong?A Yes, there are.

Q At the back there are wholly separate pieces of paper on two sides, and some more writing?A Yes.

Q Let us take each separately to identify them. The first six pages, is that a photocopied document?A Yes.

Q As opposed to the document on which writing was originally written?A Yes, yes.

Q Do you understand?A Yes. I am with you, yes; this is a photocopy of the original.

Q Thank you. Is the writing on pages 1 to 6 your writing?A Yes.

Q Any doubt about that?A No.

Q The second document, the two-pager, on a much smaller piece of paper, is that your writing?A Yes.

Q On both sides?A Yes.

T.A. REED & CO.

Day 17 - 59

A

B

C

D

E

F

G

H

Q Right. I want to take each of these two sets of documentation separately, please, and we will take it as slow as you want. Is there a signature at the bottom?A No.

Q Having identified it as your writing, the Panel can now have it, or have both, in fact.

THE CHAIRMAN: Is this in fact one document?

MR COONAN: May I respectfully suggest that we might give it a separate number, because they are in fact two separate documents.

THE CHAIRMAN: So the six-page document will be D21H and the other will be D21I. (Documents handed and so marked)

MR COONAN: (To the witness) These questions are about documents.. Leave the typed document mentally to one side. You have told the Panel that the six-pager was written – and tell us again, because we have had a bit of to-ing and fro-ing – when did you write the six-pager?A These were written at the time of the interview on the 27th.

Q When you use the phrase “at the time of” that could mean – could mean – during or after.A These are the ones that were done during.

Q During? Have you any doubt about that?A No.

Q As to the two-pager, when was that written?A I could not be specific about that, whether that was at the time or afterwards.

Q Leave that to one side for a minute. The six-page document was written during the course of the interview. You told the Panel that it was used as a basis for the typed document that we have just been looking at, is that right?A Yes.

Q Which is dated 28th. When did you come across the six-pager?A Tuesday of this week.

Q When you came across it what did you do?A I rang Hempsons solicitors to inform them.

Q Since 1998 – and it may be a matter of reconstruction or not, I do not know – where has that document been?A These six pages along with other notes made for the core assessment in handwritten form were at the bottom of a box that was archived along with these and other documentation.

Q Archived where?A At Shirehall, which is our headquarters in Shrewsbury.

T.A. REED & CO.

Day 17 - 60

A

B

C

D

E

F

G

H

Q We see that in front of you you have two buff social services files. A Mmmm.

Q Did this six-page document go into those files?A No.

Q You may be asked further questions about it, and obviously there is no reason why you should not be, but is it the case that you have been asked previously whether there was any note made during the course of the interview, is that right?A Yes.

Q What was your response at those earlier times when you were asked that question?A That there was not – I did it straight afterwards.

Q Why did you at that stage think there was not such a note?A Because they were not on the file.

THE CHAIRMAN: Excuse me one moment, Mrs Lloyd is having problems hearing, so could you speak up and speak closer to the microphone.

MR COONAN: I cannot remember now precisely the question I put so I am going to retrace my steps a bit if you do not mind because it is very important.

(To the witness) You have told the Panel that the six page document that was located together with other handwritten documents, relating to the core assessment which were archived in a box in Shirehall, and the two files that are in front of you were also archived.A Along with other files, yes.

Q And that in-between times you had been asked about the existence or otherwise of a note taken during the course of the interview.A Yes.

Q What was your response to those questions? I am not going to lead you, you tell us again, please, your response at those times was what?A That there were not any; there was just the type-written notes.

Q Why did you at that stage think there was no handwritten note which you had taken during the course of the interview?A They were not on the file, there was just the typed one.

Q When you say they were not on the file, for the purposes of answering those questions that were put to you, did you have recourse to the files? Did you look at the files?A Oh yes, looked at just the files, yes.

Q Did you look in the box?A No.

Q If you had looked in the box at these earlier times what would you have found?A I would have found these.

T.A. REED & CO.

Day 17 - 61

A

B

C

D

E

F

G

H

Q This is nearly 10 years ago: are you in any doubt now, having looked at the box and found the document, are you in any doubt that it was your document written during the course of the interview?A No, this – I am quite clear that they are.

Q What caused you to look in the box?A I was preparing for today, obviously, and was reading the bundle that had been given to me, and towards the end there were letters between solicitors and our solicitor had written saying that the notes that I had taken – obviously there were notes, and I think it is at the end here – and that they had been sent off, so I thought, “Oh perhaps I did write some notes then” and was looking through … Because I’d got three boxes in my office and there it was, so by the time I had got all those out. There are boxes of medical notes. There are boxes of statements, of all the legal proceedings, and they were in there.

Q It may be when you were referred to correspondence between solicitors, I do not know, would you turn up in the same tab gg, at page 20. This is dated 13 May 1998, from Mr McLaughlin, and this is a Legal Department document, sent to Longueville Gittins, who at that stage were acting for Mrs M, yes?A Yes.

Q Apart from other matters contained in the letter, which I am not concerned with at the moment, look at the last paragraph:

“With regard to the disclosure of the written notes, I can confirm that the social worker did not some notes and she informed your client that she was doing so. I should be grateful if you could let me know as to why disclosure of these notes are deemed relevant as it is not the practice of Social Services to disclose notes or materials from the Social Work file.”

Is that what you were thinking about?A That is what prompted me to look.

Q That is what prompted you to go and look?A Yes.

Q It is a fact that Social Services did disclose the typed notes to Longueville Gittins, and we have heard evidence to that effect.A Yes.

MR COONAN: But not your handwritten notes. We do not have a typescript of the handwritten note that you have produced, which is 21/H, some of the writing is quite clear and some not so clear, and there are many people’s names mentioned in this document and for that reason if for no other reason I am not going to read it all out.

Madam, I am in your hands, if there are difficulties about particular words or sentences I am sure the witness can help, and I hope you approve of this course, that I do not propose to read it all out for the purpose of the transcript.

T.A. REED & CO.

Day 17 - 62

A

B

C

D

E

F

G

H

THE CHAIRMAN: No, but a possibility might be to briefly go into private session if it were felt necessary to go through and have the witness make clear what all the words were so we were not in danger of revealing anything that we should not in public.

MR COONAN: May I suggest that that would be a sensible course to adopt. One alternative is to prepare a typescript but we have not had time to do it because of the timescale you have just heard about, but I for one would be very content to do that.

THE CHAIRMAN: To uphold the principle that we should do everything possible in public we could perhaps restrict what is done in private to having the witness help you go through and clarify what is actually written here, and then, having done that, the questions could be asked in public.

MR COONAN: Certainly, I am more than happy to do that.

THE CHAIRMAN: I will just check that the Panel and Mr Tyson feel that that is a reasonable course to take.

MR TYSON: Mrs M went through the note that we have at 1(gg) 23 onwards, the original note that we had, quite extensively, as did I, or aspects of it, when aspects were discussed both in chief and in cross-examination of Dr Southall, so a lot of this, not including the names, is out in the open anyway, that is what I am saying. This interview, because it is central to one of the heads of charge, has been discussed in open and I think everybody who have been asked and answered questions has been appropriately sensitive about any of the names that are there mentioned, but the facts are out and have to be out.

THE CHAIRMAN: The suggestion was only to protect the named people as it is sometimes difficult when you go through. There was no intention of keeping the facts or the questions back. Are you suggesting it is not an appropriate thing to do?

MR TYSON: I am suggesting that if we can just carry on being sensitive about the names we should be able to manage to continue doing this in open session.

THE CHAIRMAN: Mr Coonan?

MR COONAN: Madam, I only raised it to be responsive to the sensitivities that is all. It is obviously the Panel’s supreme right to deal with it in the way the Panel wish.

THE CHAIRMAN: I will ask the Legal Assessor if he has a view on this matter.

THE LEGAL ASSESSOR: Madam, the fundamental principle, as has already been indicated, is that matters should be heard in public so far as is reasonable. The course that has been proposed by Mr Coonan is with an abundance of caution, but, as Mr Tyson has observed, these matters have already been canvassed in public, and by exercising the usual degree of caution no doubt the same approach can be taken. So, my advice to you is it would be appropriate to hear this matter in public, with that caveat.

THE CHAIRMAN: In which case, perhaps we can go through it and exercise such caution, and ask anyone in the public gallery, if something does slip out which should not that it is not reported further than this room; with that caveat.

T.A. REED & CO.

Day 17 - 63

A

B

C

D

E

F

G

H

MR COONAN: Madam, if you are content then fair enough. (To the witness) We will look at the content of this, and you have heard what the Chair of the Panel has said.

MR TYSON: May I say, not on a related matter, the copy I have been given – and my learned friend and I have had various discussions – it appears that on the top page, the last word I have is “children”, I do not know if that is the same as the Panel’s copies, but my understanding is that there are further words that go underneath the word “children.” Perhaps I could step over and show my learned friend the problem. (Pause)

MR COONAN: Madam, the problem is solved; misunderstanding solved. My learned friend is content. (To the witness) Let us just deal with the document before we get into the interview and other matters. Was this note a note made essentially – and you can say yes or no to this but I am just introducing it in this way, it is not a loaded question in any way – of what Mrs M was saying, as it were, wrapping up the question in what you have recorded? Was it a note of what Professor Southall was saying or a mixture of both? You tell us?A I think it was a mixture of both really. It was just my record of the event.

Q Is it intended to be a verbatim note?A No, it was intended as an aide memoir to give prompts to me to write up the full report.

Q If we look at the first page, there is a reference to M1, a reference to bullying by students and a teacher; nobody going to agree that there is bullying: that is what you have recorded. Who was speaking there do you think?A I believe it was Mrs M.

Q Then there is a note about key issues, kicking, pulling clothes, kicking books across the play room. There is then a girl’s name, and some complaints about that. There is a reference to the teacher, and in particular her name, not listening to M1, reducing him to tears. There is a reference to the appendix taken out at the time Mrs M was at a nursing home. There is then a reference to some specific behaviour, not witnessed by the children, on the last two lines, as happened to Mrs M. There is a reference at the top of page 2 to curtains being drawn. Is that “nets”?A Yes.

Q Reference to a “brown leather belt – his own – jean belt”. Where was that information from?A From Mrs M.

Q Then there is a reference to phoning the ambulance. Woman at the other end put the phone down. Ambulance men ambled down the garden path. Are all these matters that Mrs M was talking about?A Yes, they were.

Q Again the comment attributed to the ambulance man, and then towards the bottom of the page there is a reference to an accidental overdose – bad back – involving painkillers. Is that a reference to Mr SM?A Yes.

T.A. REED & CO.

Day 17 - 64

A

B

C

D

E

F

G

H

Q The same incident as the event there referred to, a serious matter.A Yes.

Q Then on page 3, there is a reference at the top to magazine articles; a reference to her declining £200: sent to the editor of Take a Break, and we have seen a reference to that already. Reference to the Kilroy Show; did not want to go on it: telephone call out of the blue; being pestered by everyone – programme on bullying. Then halfway down the page M1 told, is that “two”?A Two.

Q “M1 told two boys that he was going to kill himself”, one of the boys had a nervous breakdown and tried to kill himself. Shortly afterwards moved away. Tried to cut his wrists, and then somebody’s name. The next line: “M1 was hanging - not far from the floor”.A Yes.

Q Is that what you obtained from Mrs M?A Yes.

Q “Tall for his age”. Planning to go to Disneyland, and then a reference to a tyre blow out, and a bus beginning to pull away, caught the pavement and exploded, this incident was reported. On page 4 there is reference to the pole, “SM” [Mr M] took the pole down and put it in the bin with curtains, hammer. M1 got up before anyone else and rang him”.A That relates to a separate incident.

Q Then there is a reference to an eye incident, which I do not think is material. Then there is a reference to M2 falling over and going to the GP, and then this:

“M2 only once said that he wanted to kill himself: ‘I feel as if I want to hurt myself’. Not mentioned kill himself”.

Again, where did you get that from?A From Mrs M.

Q On the next line you have inserted “mm” is that right, in small letters?A Yes.

Q “mm doesn’t feel that M2 is being bullied – nipped in the bud by school”, then there is a reference at the top of the page to time off work – before M1 died. There is a reference to how many days off. Is this a reference to Mrs M having 38 days off and being “? Fed up with job”?A Yes.

Q Then there is a reference to Dr Solomon: “Dr Solomon – didn’t attend together – appointments for just M2 not them as a family”. Is that a reference, as the Panel have already heard, to the attendance of Dr Solomon?A Yes.

Q Then there is a woman’s name and Mrs MM, as you have recorded:

“ …suggests that R is lying. Given …”

T.A. REED & CO.

Day 17 - 65

A

B

C

D

E

F

G

H

What is the next word?A “Care leave”.

Q

“ … care leave to sort it out. MM never said kill. MM interpreted it as killing self.”

Did she say that?A Yes.

Q Then this: “DS … ” Is that a reference to Dr Southall?A Yes.

Q“DS goes through 3 scenarios:

1. Accidental/experiment

2. He decided to kill himself.

3. Murder.”

Is that you recording Dr Southall going through those three scenarios?A Yes.

Q Then the next block:

“MM – doesn’t know how to inject someone – never seen it done. Mum weighs 13/14 stone and couldn’t pull it down. Pole – MM said that it had never come down before.”

Are those various matters which you obtained from Mrs M?A Yes.

Q Then on the last page: “Took own life” and is that the “because” sign?A Yes, it is.

Q

“Took own life because being bullied at school. Not because of things going on at home. Life at home was good for M1. MM believes that no-one will admit that bullying is and was going on – witness ? … ”

Then a person’s name, L. Can you read the next bit?A “Her son has said”

Q

T.A. REED & CO.

Day 17 - 66

A

B

C

D

E

F

G

H

“Her son has said now I know how [a person’s name] felt – has threatened to kill himself.”

Again, I am not going to read those names. There are references to the teacher’s class and tranquillizers.

“Quite a few other parents ‘approx 40’ willing to make similar complaints about …”

Then a person’s name is mentioned.

“They have written to Shropshire Star to complain about [that person].”

Then this: “[That person] led M1 to kill himself.” Who made that assertion?A Mrs M.

Q “MM thinks there is a cover up.” Did she say that during the course of the interview?A Yes.

Q You have described that as an aide memoire to yourself and, as you have told the Panel, subsequently you had the document typed up. There are two questions. First of all, you have said that it was not verbatim. Are you content with its accuracy as a note which you took during the course of the interview?A I am, yes.

Q To what extent do you have an independent recollection of the events at the interview over and above that which is written in either of the two documents we have been looking at?A I have to rely very heavily on the information that I wrote at the time. Obviously it is a long time ago. I can remember the layout of the room, I can remember part of the discussions, that sort of thing. I cannot remember the ins and outs of it.

Q There are some specific aspects of that I am going to nonetheless ask you about. First of all, we should just deal with the second document. We have copies of that, which will be I. Again it is self-evident. In a word or two, how would you describe this document?A This is a list of work that was outstanding, needed to be done really.

Q I will leave that to one side for the moment. With that caveat which you have entered into about these matters – of course they are a long time ago – you have told us that you can remember the layout of the room. Where was Dr Southall sitting?A He was sitting in the middle really, the middle of the room. Can I demonstrate?

Q Yes.A If this was the room, I was sat in this corner, which is the right-hand corner, Professor Southall was sitting there with Mrs M down here. (Indicated)

Q Was there a desk? Was Dr Southall behind a desk?A He was not behind a desk, no. There was a desk in the room, but he was not behind it.

Q Do you actually have a memory of that? You can see it now, can you?A Yes, I can. I remember it because I was surprised. It was like a Portakabin type office and I remember feeling quite surprised that it was just a Portakabin.

T.A. REED & CO.

Day 17 - 67

A

B

C

D

E

F

G

H

Q We have heard about that already. Can you just hold up the paper again? Where was Mrs M?A She was down here. (Indicated)

Q Dr Southall was - ?A Was there and I was there. (Indicated)

Q Could all three of you see each other?A I do not think Professor Southall – because I was at the side of him, on his right-hand side, so he would have had to turn round.

Q He could not see you unless he turned round?A No.

Q Could you see Mrs M?A Oh, yes. It is only a small office.

Q How many feet apart were you and her?A I do not know. Probably about from there to that side, to your microphone.

Q That is the distance between you and her?A Yes. It is not a big room at all.

Q Were you sitting on chairs?A Yes.

Q That distance is about nine feet. Is that right?A Yes.

Q That is my estimate. People’s estimates vary. Do you agree with nine feet?A Yes.

Q Again, in relation to the next series of questions, if you do not remember at all, please say so. I do not want to lead you into speculation. Do you remember the beginning of the interview and as to whether or not anybody introduced anybody else to one of the gathered three people? Do you follow what I mean?A I remember Mrs M coming in and I remember saying, “Hello” to her, because I stood up when she came in. I do not remember the discussion that took place.

Q But you have a memory, is it a clear memory, of standing up?A Oh, yes.

Q Do you remember anything she said?A No.

Q Was there any objection made to your presence?A No.

Q Do you remember how the interview began?

T.A. REED & CO.

Day 17 - 68

A

B

C

D

E

F

G

H

A No, other than what I have written in my – obviously my recollection is – no, I do not.

Q Did you make a note, as you have described, during the course of the interview? Did you write it on a pad on your knee? How did you do that?A It was on a pad. It was on a pad and – no, I do not know exactly how I was leaning, but it was one of those flip pads that we have.

Q You wrote it. Could Mrs M see that you were making a note from where she was sitting?A Oh, yes.

Q What was your role during the course of the interview?A Obviously Professor Southall was leading and did most of the talking. I was there as an observer, but also I clarified a few points.

Q When he made an observation or when she made an observation, or both?A I would imagine both, but I could not be specific.

Q Factual clarification?A Yes.

Q At the beginning of the interview, do you remember what Mrs M’s demeanour was?A I do. I remember that I was quite surprised at her attitude and some of her responses. I felt she was quite aggressive really.

Q Aggressive to whom?A To Professor Southall.

Q Do you have a clear recollection now of that?A I have a clear recollection of my own thoughts at that time, because I remember being surprised and taken aback by her attitude towards him.

Q How did that aggressiveness manifest itself?A In Mrs M?

Q Yes.A She was – I am trying to think – she was quite – the word I want to use is “bolshy”, but that is not really a proper word. She talked back to him and I thought she was quite rude on occasion really.

Q When you say she talked back to him, could you just help the Panel a little more about that, please?A She was quite assertive in some of the responses that she gave.

Q By assertive, again, can I press you just to help the Panel? Does that convey a meaning of emphasis, or does it convey repetition or the strength of the reply? I am trying to help you to choose a number of possible options. There may be many others, but just try and help the Panel.A I think it was the strength of the reply. She certainly was not intimidated and was able to give some clear responses.

T.A. REED & CO.

Day 17 - 69

A

B

C

D

E

F

G

H

Q I am going to take you directly, please, Miss Salem, to a matter which is dealt with in both the typed document and the longhand document in particular. It is on page 5 of the handwritten document, so let us take that first. You have recorded that Dr Southall went through three scenarios and you set them out. The first matter I want to ask you about is this. Did you know in advance that Dr Southall was going to deal with the three scenarios?A Not that I am aware of, no.

Q When Dr Southall dealt with those three scenarios, how did he deal with them? First of all, I should ask, do you have a recollection now of how he dealt with them?A I do have a recollection of how he dealt with them. He approached it in the way that he did throughout the meeting really, which was quite clearly, “Can you help me understand? These are the things that I’m thinking about. These are the three scenarios” basically, and was quite open and honest with Mrs M.

Q As you say in this handwritten note, DS goes through three scenarios. Just help the Panel, please – you were the one who was there – what does that mean, as he went through them?A He explained that there were three ways that M1 could have died and could she help him understand that. Obviously he either died through experimenting and it was an accident, that there was no intention, that he decided to kill himself or that he was murdered.

Q In going through those three scenarios, what was the manner in which he did it?A The same manner that he did the whole meeting. It was very calm, it was very open and very clear.

Q I will come back to that in a moment. We see at the top of page 4 there is a reference to the pole and the curtains. Do you see that?A Yes.

Q There is also a reference on page 2 to the curtains and the brown leather belt.A Yes.

Q Quite apart from the note itself, do you have a recollection of any conversation in your mind of Dr Southall talking about the belt?A Not independent of my notes.

Q Do you remember any demonstration?A Yes, I remember the demonstration.

Q You do?A Yes.

Q Can you help us as to how that came about?A I remember Professor Southall asking Mrs M how the belt had been tied, how it had actually been around the pole, and I recall Mrs M saying that she did not want to disclose – she had been advised not to discuss that particular matter. Professor Southall said that it was a crucial piece of information and would help us to move on with this. She did demonstrate then, because she was trying to physically tell us and describe it and it was very difficult.

T.A. REED & CO.

Day 17 - 70

A

B

C

D

E

F

G

H

You could not really understand how that happened, so she showed us. I think it was with a pencil as the rail.

Q During that part of the conversation, talking about the belt and so forth, did Dr Southall say to Mrs M that unless she answered, she must be guilty?A No.

Q Did Dr Southall say to her that her solicitors’ advice was wrong?A I do not recall that being said.

Q After the demonstration, do you remember Dr Southall saying sarcastically “Very clever”?A No.

Q If any one of those matters had been mentioned, do you think you would have remembered?A Yes.

Q Why?A Because those sorts of things would stand out in one’s memory, really.

Q Why?A Because they were highly – it would be unusual for somebody to say that, and unusual things tend to stick in your mind, and I would have been quite shocked if that had been said.

Q You would have been shocked?A Yes.

Q I want to return, please, to the three scenarios, and in particular the third one, which is a reference to murder. I want you to listen very carefully to this. Did Dr Southall say to Mrs M in your presence and hearing words almost precisely to this effect: “I put it to you” – “I put it to you that you killed your son. That you injected him and hung him up and left him to die and then rang for an ambulance”. Did he say that?A No.

Q Are you sure?A I am sure. I would remember something like that.

Q If that had been said by this doctor, what effect would that have had on you?A I would have been surprised, would have been shocked, I would have been very cross, and I would have spoken to my manager about that.

Q Would that have struck you as being unprofessional?A Very.

Q So therefore I come back to the question of the third element of the scenario: did Dr Southall – leaving aside the specific proposition that I put to you and those precise words I used – did Dr Southall in any way – in any way – accuse Mrs M of murdering her son?A No.

T.A. REED & CO.

Day 17 - 71

A

B

C

D

E

F

G

H

Q Again, if he had done, what effect would that have had on you?A I would certainly remember that and I would certainly have had to take that further.

Q Why would you have had to take it further?A Because that would have been wholly inappropriate.

Q During the interview as a whole I just want to ask you, and it is for you to say – I am just going to put these up for your comment. Was Dr Southall rude to Mrs M?A Not in my opinion, no.

Q Was he polite?A I thought he was very polite and very open.

Q Was he courteous?A Yes.

Q Was he aggressive?A No.

Q Was he threatening?A Not in my opinion, no.

Q Was he accusatorial?A No

Q Did he interrupt what Mrs M was saying?A No, not to my recollection, no.

Q Was Mrs M given enough time to answer the questions that were put to her?A I believe she was, yes.

Q Did Dr Southall ever say, irrespective of the belt context, that she had to answer the questions?A No.

Q If he had said that would you have noted it?A I would have noted it; I would also have remembered it.

Q Why?A Because it would have struck me as unprofessional and it would have been something I would have had to follow up.

Q The next question is asked with one of the entries in the documents in mind that I took you to earlier today. I am not going to ask you to turn it up now; you will probably remember it. Did Dr Southall express to Mrs M disbelief as to what she was saying?A No.

Q Are you sure about that?A I believe not. Again it would have stuck in my mind, I think.

T.A. REED & CO.

Day 17 - 72

A

B

C

D

E

F

G

H

Q You appreciate that he has expressed disbelief in a written context elsewhere?A Yes.

Q You are aware of that?A Yes.

Q Did he express disbelief in this context?A To Mrs M?

Q Yes. A No.

Q Was he dismissive of her?A I did not think so, no.

Q Did he challenge her answers?A He did ask for clarification.

Q Can you think of an example?A When we were discussing the belt, because we could not understand her explanation as she was trying to describe it, until we had a visual aid. So, yes, he did ask for clarification at that point.

Q Did he get annoyed with her?A No.

Q I think you mentioned that he was clear, and again it is for you to say, and help the Panel: in your opinion was he or was he not straightforward in his dealings with Mrs M?A I think he was extremely straightforward and honest with her, and more so than some of the other professionals that had been involved with Mrs M.

Q Really?A Yes.

Q He was open and honest?A And more than other professionals had been with Mrs M.

Q Can you give us an example. You do not need to mention names, but just by way of comparison can you bring it to life, that sort of comparison.A Certainly some of the health professionals, you know, were not willing to challenge, but they would say things in conferences, but not when Mrs M was present, so it was that sort of thing. But I think Professor Southall was extremely open with Mrs M.

Q Was Mrs M, during the course of the interview, visibly upset?A Not that I recall, and I think I would have noted that, because quite often we will note when people get upset or distressed, because it is pertinent to the point that they do get distressed; so we do tend to write it down.

Q Again, more specifically, towards the end or at the end of the interview, was she physically upset?

T.A. REED & CO.

Day 17 - 73

A

B

C

D

E

F

G

H

A I do not recall her being physically upset, no.

Q Perhaps I can deal with it in this way. First of all, was she hysterical?A No.

Q Was she crying?A Not that I recall, no.

Q Did the discussion have to stop at any stage to deal with any distress?A No; and again I would have written that down.

Q If Mrs M had been visibly upset would you have stopped the interview? Assuming for the minute that Professor Southall was bent on ploughing on, what would you have done?A I would have asked for a break; I would have suggested that we had a cup of coffee or we had a drink of water, or something like that, because obviously I sit in with a lot of young people being interviewed as their appropriate adult, and quite often if they get upset with police, or whatever the situation, then I will intervene and just ask for a break.

Q Did Mrs M in your judgement by the end of the interview appear to be very angry?A She did not appear to be angry as I recall, no.

Q At the end of it, did she leave the room on her own?A I do not recall.

Q Putting it all together and reminding yourself from the note and from your recollection of events, was this an easy interview for Mrs M to handle?A I would not imagine that it would be an easy interview for anybody to handle, given the subject matter. However, I think it was dealt with in an appropriate way, to make it as easy as possible.

Q Was there any element of what Professor Southall did which in your judgement was unprofessional?A No. I would have addressed that at the time.

Q How long do you think the interview lasted?A I honestly could not say; it would be a guess.

Q I am not going to ask you to guess, save this: was it as short as 15 or 20 minutes, or do you think it was longer?A It was certainly longer than that, yes.

Q How far are you prepared to go before guessing kicks in?A I honestly do not know.

Q All right; I am not going to press you. At the end of it, do you remember what your thoughts were after she had left the room?A In relation, do you mean, to Professor Southall’s conduct or Mrs M’s ---

T.A. REED & CO.

Day 17 - 74

A

B

C

D

E

F

G

H

Q You are quite right to bring me up there. There are two aspects to this; let us take them in turn and let us deal first of all with Professor Southall’s handling of it. What were your thoughts at the time? Not what they are now, but what they were at the time?A I did or I do remember the overall feelings that he had handled it very well. He had handled some very sensitive information in relation to M1’s death in as sensitive a way as possible. I thought he had handled it well.

Q And as to the second issue?A The overall, again, the things that I remember are Mrs M’s attitude to Professor Southall in the beginning. She did settle down and was not quite as rude as time went on, but again it was not one that she had been hysterical or upset or distressed; there was no recollection of that.

Q From the standpoint of social services’ next move, as it were, if I can put it that way, did you find that the interview had had value?A Yes, most definitely.

Q I am now going to move on. If you look at C1 again, please, at tab (dd), and go to page 77, you will see a typed list; and immediately if I can take you to the handwritten second document, which is document I, again would you like to comment on the apparent juxtaposition of the handwritten document I and this typewritten document at page 77?A Certainly this is a typed-up version of the other, is it not, with my handwriting at the side?

Q You tell us.A It is.

Q And it would appear on the top of the typescript a plan of action suggested by Professor Southall.A Yes.

Q As you have told the Panel, that second document, 21/I, together with 21/H, went into the box somewhere in Shirehall?A I am afraid it did, yes.

Q Just the sake of completeness, and I am going to limit my questions on this topic for obvious reasons, can you now receive a further log entry for 29 April 1998. (Same handed and marked as D21/J). This is not your note, is that right?A Yes, it is not mine.

Q We see at the top the name of the social worker, Ruth Williams.A Yes.

Q Did you on or after 29 April see this note?A Yes, it was part of the file.

Q I am just going to take you to the photocopy, which is quite poor, but it is the second part of this entry beginning “Discussed …” do you see that on the sixth line down?A Yes.

T.A. REED & CO.

Day 17 - 75

A

B

C

D

E

F

G

H

Q “Discussed M2’s visit to see Professor Southall, and she stated it was not nice …”

A That is Mrs M as against M2.

Q “She stated it was not nice, and she had a good cry afterwards, she felt like saying ‘you bastard’ and that she was made to feel like a criminal. [Mrs M] went on to say it was obvious Professor Southall didn’t give a shit what [Mrs M] said, and that he would write what he wanted anyway. He’d already made up his mind. Whereas [Mrs M] felt comfortable with Dora not Professor Southall.”

That was written and recorded by Ruth Williams on the 29th, which was two days later.A Yes.

Q When you say that entry at that time, or whenever it was you saw it, did you have any particular reaction or response to it?A I do not recall.

Q You do not?A No, I do not recall.

Q As far as you are concerned, as a witness to what happened, whatever Mrs M may have felt herself – do you follow, I am not going to ask about that – did Dr Southall appear to you to make her feel like a criminal?A No.

Q Was it obvious to you at the time of the interview that Professor Southall “didn’t give a shit” what she said?A Not at all, no.

Q Was it obvious to you that Professor Southall had already made up his mind?A It certainly did not strike me as that, no.

Q In the same vein, I want you please to receive the last document, which is dated 6 May. (Same handed and marked as D21/K) Does this come from, first of all, the Social Services file or the legal file?A The legal file.

Q Be that as it may, we can see that this is a note of a telephone call in from you, apparently, so it is on that basis that I ask you the following questions.A Yes.

Q First of all we can see the body of the note:

“She wanted to know if either Alan or myself …”

Pausing there, is that a reference to Alan McLaughlin?A Yes.

Q “ … were going to the case conference with is at … 2.00 p.m. this Thursday. I explained that I was unaware of it but I wasn’t sure about Alan. I am available at that

T.A. REED & CO.

Day 17 - 76

A

B

C

D

E

F

G

H

time although I felt that if he is available it would probably be better if Alan could go. Francine explained what had been going on recently. Professor Southall is clearly anxious for the police to really get on and open up their inquiries. Francine confirmed that [Mrs M] wasn’t terribly happy with the things that Professor Southall had been saying to her.”

That is what you were saying to Miss Garrard.A Yes.

Q Would you help the Panel about the basis of your comment to Miss Garrard that Mrs M “wasn’t terribly happy with the things that Professor Southall had been saying to her”?A I think that is a reference to the discussion that Ruth Williams had had with Mrs M on the 29th.

Q And the one we have just looked at in the previous document?A Yes.

Q We know, and I am not going to take you to the documents, that eventually Dr Southall provided a report, which is at tab z, and, again, I will ask you this globally: in it, as the Panel are already aware, Dr Southall accepts there were a number of expressions of disbelief about aspects of the account given by Mrs M or generally, all right? That is just a global observation.A Uh-huh.

Q Did Dr Southall utter any of those expressions of disbelief to Mrs M during the course of the interview?A No.

Q I have been asking you about a number of matters which concerned Mrs M’s reaction, demeanour, Professor Southall’s demeanour and the way Professor Southall asked questions, and in one particular respect the content of the questions: in other words an accusation of murder. How sure are you about those aspects, Miss Salem?A I am sure enough to be sat here today.

Q Tell the Panel, “sure enough to be sat here today”, you have been asked to come here today.A I would not have come if I did not believe that that was the case, and certainly I am confident in my own ability to challenge if anything inappropriate had been said.

Q That you would have challenged it?A Yes.

MR COONAN: Thank you very much, those are all the questions I have for Miss Salem.

THE CHAIRMAN: Mr Tyson, I have no doubt you do not wish to beginning your cross-examination at this time, am I correct?

MR TYSON: You would be correct, and I am also thinking about the witness, who has been giving evidence for a long time.

T.A. REED & CO.

Day 17 - 77

A

B

C

D

E

F

G

H

THE CHAIRMAN: Indeed. You will be content to begin your cross-examination in the morning?

MR TYSON: I will.

THE CHAIRMAN: I am assuming Miss Salem is available tomorrow?

MR COONAN: Yes, she is.

THE CHAIRMAN: Is it acceptable that we adjourn now until tomorrow?

MR TYSON: Entirely acceptable, madam.

THE CHAIRMAN: We will adjourn now until 9.30 tomorrow morning. Miss Salem, overnight, I am afraid you must not discuss the case or your evidence with anyone. That end the proceedings for today.

MR COONAN: Could I raise one housekeeping matter, I know Miss Salem might be concerned about the original files because she asked earlier today whether the room would be locked during the luncheon adjournment. I am wondering what she would wish to happen to them.

THE WITNESS: I will take them with me.

MR COONAN: It is a question for you, madam, are you content she takes the original files? They are the property of the Social Services.

THE CHAIRMAN: Presumably they are in Miss Salem’s custody at the moment, they have been brought into the custody of the Panel?

MR COONAN: That is right, nor of us.

THE CHAIRMAN: That is a matter for Miss Salem.

(The Panel adjourned until 9.30 a.m. on Friday 9 November 2007)

T.A. REED & CO.

Day 17 - 78