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Heather Payne: Baby P and now the completely nameless

27 Nov, 08 | by BMJ

Heather Payne As if “Baby P” wasn’t bad enough, now we hear about 2 women and 19 pregnancies resulting in 7 surviving children. The nearest we have to a name for this case is “the British Fritzl.” This somehow sums up the dehumanisation of abuse – these victims are without even the dignity of a public name; rape is about power as much as sex.

We will now enter a media orgy of blaming professionals. I look at these cases and wonder whether I have missed one a bit like this, but not for want of trying.

There are times when we are, with the current state of knowledge, powerless to do anything. Our suspicions remain just that, and we are not able to find enough evidence to prove them to even the balance of probabilities, which would be enough for a child care legal case (not a criminal prosecution of a suspected perpetrator, which requires proof “beyond reasonable doubt”). We are left wondering, sometimes for years.

We know that the serious case review on Baby P identified times in the months (and 60 contacts with professionals) leading up to his death when things could have been different. This was a child well known to child protection services. Whether or not we call them “errors” is not the most important thing, as it distracts us from practical progress in these situations. We need open discussion about what went wrong but not professional victimisation.

We should focus on what could have been done differently. Each professional group should identify how they might have modified their practice to fill the gaps. This never really happens in a part 8 or serious case review- these are usually external to the people really involved. Yes the professionals are questioned by the reviewers- but it’s not really a constructive process in many cases, and frequently results in anodyne conclusions that the death was not preventable and that what is needed is more adherence to procedure, better interagency training and communication. These have been the simplistic (and entirely predictable) conclusions of almost all the part 8 or Serious Case reviews in the UK over the past few decades. They don’t seem to move us forward.

When bad things happen to children like this, we need a complex and effective response to a complex and difficult problem. People (including me) justifiably want to know the answers to questions like “how on earth did they miss those rib fractures?” and “what were social services doing ignoring bruises in a child on the register?” or “how did nobody notice that 2 young pregnant women had no boyfriend?”

Those of us who work in child protection know that you can get caught out very easily by taking things at face value. The answer to the above question about rib fractures is that if you don’t have X ray eyes and nobody has communicated any urgency to you about the child, you might well accept the parents story that the child is “under the weather” and not examine them thoroughly on that occasion. Without the full information we should not jump to the superficial, facile explanation.

What we do need is the direct answer to the judgement question, and some analysis of why a decision was a good or a bad judgement, This is much more complex and layered, takes more time and knowledge, but is ultimately the only way to create answers to help things improve. At the moment we just rake over the bones. Baby P and these nameless children deserve more.

Heather Payne, 26 November

Heather Payne is a consultant paediatrician in Caerphilly with a special interest in fostering, adoption and child protection. She is also an associate dean for educational support and disability in the Wales postgraduate deanery.

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  • Karen Mills

    i have to disagree with you, these so called professionals have not learned from their mistakes in the past why should we trust them with our most precious gift children. If newspaper articles are to be beleived the social worker who was sacked early this year expressed several cases that were being ignored and all of them were concerning children and physical abuse.

    I am a nursing student and from day one we have been told just because there are no obvious injuries on the outside this does not mean that everything is fine on the inside. That poor boy shouldve been x-rayed he must have been in agony, broken back and 8 fractured ribs on his left side anyone would be cranky.

  • Peter English

    A thoughtful piece from a reflective and experienced consultant, and a nursing student feels entitled to “disagree with” her.

    Good grief.

  • Tony Green

    Well, yes there are and always will be child protection blind alleys. Obviously one has to learn by sensible retrospective analysis, and I can only agree that a trial by media is most certainly to be condemned. However:

    Serious errors cannot simply be ignored.

    The GMC is investigating the examining consultant doctor now, and quite rightly so. This case actually occurred 15 months ago and only NOW have they chosen to suspend her and investigate fully. This is a direct result of the media attention/publicity.

    If her chosen actions and decisions were those compatible with good practice from a normal Child protection Paediatrician she will have nothing to worry about.

    I am disappointed to see fellow doctors such as the author of this article close ranks and try and shield her from this necessary scrutiny.
    (I speak as a doctor myself by the way Mr English, does that pass your snob test?)

  • mick parkinson

    A thoughtful piece from a reflective and experienced consultant, and a nursing student feels entitled to “disagree with” her.
    Good grief.
    Peter English

    Peter thats her right to disagree, having had three broken ribs i can asure you the pain is near on unbearable, let alone being squeezed on those same fractured ribs to be held up because your paralised from the waist down… this was grose misconduct in any way you look at it, the above articule is written by a doctor looking to safeguard thier unaccountability for lack of care and or competance! which is so rife in this country it’s now part of british culture.
    it boggles the mind how people here have grown so lazy and self centered not to mention detached,but i for one don’t see a way of saving this once (a long time ago granted)great country, like a rat escaping a sinking ship i want to go home(OZ) where if you managed to screw up this badly a doctor wouldn’t even be allowed to work near children cleaning bedpans, and would most likely face manslaughter charges along with others in this case, unfortunatly for baby p and many others this sort of thing will continue to happen and it’s easy to see why, the culture here is so geared up making excuses for the criminals and scum that victims rarely get justice compare the trail and conviction for that hells angel biker 7 people convicted but which one pulled the trigger??? who knows, all these people will proberlly be given life sentences when only one pulled the trigger. When people like the author above start defending this sort of disgrace of an example of a doctor i asure you it’s not for the good of society it’s to protect thier own skins. SHAME ON BRITISH SOCIETY FOR ALLOWING THIER COUNTRY TO BECOME THIS DEPRAVED
    (i feel more than ashamed to have to admit being of british herritage and this case alone will haunt me for the rest of my days)

  • David

    Tony Green:

    “I am disappointed to see fellow doctors such as the author of this article close ranks and try and shield her from this necessary scrutiny.”

    There is no suggestion that the author has tried to shield a colleague from proper scrutiny but a commendable concern that the doctor might already be the victim of journalists who in the past have maliciously defamed distinguished paediatricians so exposing them to the inept attention of the GMC whose action against one of them was described by the High Court as ‘bordering on the irrational’.The background fear that a complaint against you by child abusers and their supporters on the Net and in the newspapers might well generate a compassionate anxiety about how this doctor will fare after the verbal assault on her for her supposed ineptitude.

  • Johnboy

    I have mixed feelings about the value of blogs, but I do like to see reasoned comment such as that made by Heather.I don’t like slanging matches.

    Karen’s comment is just one of many like it made in the media and amongst the wider public. Within blogland there is free speech. Karen is in my humble opinion 100% wrong. I would like to hear what she has to say in a few years time if she becomes a children’s nurse.

    Tony Green is wrong about the doctor having nothing to worry about, if the GMC fail to prove any charges she may well have immense trouble resuming her career.

    It is true that the GMC has responded to media publicity, how wrong is that? They do it all the time. As we know the media is always full of “errors”.

    I am in late middle age and have been safeguarding children for many years.

  • Heather Payne

    Please also see the AvMA (Action v medical accidents) charter of understanding between health professionals and people affected by medical accidents

    http://www.avma.org.uk/data/files/pages/charter.pdf

  • Heather Payne

    http://www.lynnefeatherstone.org/2008/11/reading-baby-p-serious-case-review.htm

    It would appear that my view coincides with Lynne Featherstone,the MP for Hornsey and Wood Green. So how about it, Ed Balls?

  • Heather Payne

    Heather Payne Blog update 30 Nov 2008

    Baby P – Paediatricians closing ranks? or government ?

    It’s inevitable that the ghastly details of the Baby P case make people angry. The details make me angry too. My work (and much of my home life) is focused on the wellbeing of children, and I’m just as much of an obsessive neurotic as most other Doctors- my personal and professional pride is hurt if I make a mistake. But I am at my most dangerous if I think I cannot get it wrong, and this is why I say we must work in a milieu that supports professionals in the open sharing of work dilemmas and difficult problems. In medicine we may not know we’ve got it wrong until much later- for example late diagnoses of meningitis or cancer, failure to spot an abnormal CTG – this list could go on and on but you get my drift.

    We could apply a standard type of root cause analysis to child protection disasters like baby P. The key thing to me would be to answer the question ‘ if a child protection plan is in place and the child presents with bruising, is the plan working?’ This question would generally only be answered by a full Section 47 (S47) investigation and medical examination – but this requires a clear multidisciplinary process, and careful interprofessional communication about concerns and risk assessment.

    So even though an individual might make an error of judgement there should be checks and balances in the system (to avoid errors travelling down the ‘Swiss cheese’ holes described in the James Reason model http://www.bmj.com/cgi/content/full/320/7237/768 ).
    The Laming report recommended that Police Officers learn how to challenge Doctors – not just for the hell of it, but to ensure that they established a clear collective understanding of what was happening for the child and the potential risks.

    So to put this in context – when I see a 17 month old child with bruises, the parent or carer may have no explanation (I’m worried – kids do have accidents but in a child of this age the parents should have them under close supervision- or there’s an explanation I’m deliberately not being told) or some explanation. If the parents can give me a clear and consistent account of bruises, which is detailed as to time, antecedents, the child’s reaction and so on, I may feel this is an adequate accidental explanation, especially if social services and police have gathered supporting information .
    But if I hear that darned coffee table has been up to its tricks again, giving them multiple bruises in lots of places (what, did they bounce?) then I’m not going to be very convinced, and my conclusion would be that the explanation is not a reasonable account of the injuries seen, so this is likely to be non accidental injury (NAI). The protection of the child is firmly the responsibility of Social Services, through supervision or removal. BUT these judgements and risk assessments are made under S 47 child protection working – usually the same day.

    If you introduce a gap of weeks or months, you are into a completely different mindset – no apparent urgency or social services concern, maybe even an intimation that the child protection plan is about to be discontinued. This is a much more difficult situation to deal with, and if there is no social worker present to explain what question they want answered, the Paediatrician may have limited information to make a risk assessment.

    The recent Government announcement that the full report of the investigation into Baby P will not be made public is a great concern http://news.bbc.co.uk/1/hi/uk/7742733.stm
    – surely it could be adequately anonymised so that we could all understand the reason why Baby P died. This may require Paediatricians, Social Workers, Police or other agencies to admit they made a mistake. In an environment of hysteria and moral panic it’s no surprise that there is confusion and obfuscation. Have we seen Paediatricians closing ranks? Or an undignified and unfunny game of musical chairs initiated by the people with the greatest accountability declining to shoulder it and show proper leadership for children’s services?

    I’ve always been a fan of Charles Kingsley’s ‘Water Babies’, and it’s time for Mrs Doasyouwouldbedoneby to make an appearance to help children once again. http://ecoflourish.com/Inspiration/asyouwould.html
    It’s essential that we as professionals are accountable for our work, but unless we have a supportive response to possible errors, we will not be able to learn and improve. Systems (appraisal and critical incident reporting) are in place to detect the irresponsible, lazy or ignorant Doctor, and there are clear routes for action if a Doctor’s performance is persistently inadequate. However, the best way to get people to change (thus showing they have learned) is to support them in reflection and self knowledge. This is hard edged, evidence based risk management and will make children safer.

  • Ivor Rowlands

    In the Guardian on the 27th of November there was an article by a social worker describing her day and her work load. I have no evidence that this is typical but anecdotal evidence suggests it is common. I suggest those interested should read it at http://www.guardian.co.uk/society/2008/nov/26/baby-p-child-protection-social-workers
    If it even approximately reflects the national situation then there is no need for any enquiries other than to establish it as true. If it is, then we are all to blame for Baby P and the other cases that occur about once a week – the system is hopelessly under resourced. That is the fault of politicians who are so ready to blame everyone else but also of all of us.
    Ivor Rowlands, retired engineer.
    I support child protection workers in the most disinterested manner I can.

  • Al Read E Resign’d

    I see that there have been a raft of resignations and jobs lost from the Haringey council and childrens services, as well as possibly one of the doctors involved.
    None from the Govt cabinet however, not even the Minister for children.
    Our political masters will be happy with this rather irrelevant musical chairs performed if it distracts from reality. This is that these situations cannot be wholly prevented without a system where children can be removed in their thousands. There may be many thousands of children living in similar conditions around the country. At the moment the workers who help with children with Child protection plans and who make decisions about how to help families are already on a razor edge. there are children and families in severe difficulty with broken families on one side (and no adequate replacement- ‘children looked after’ are not generally a happy bunch)and the risks of significant emotional and physical abuse on the other. The newspapers/media want it both ways and the Government responds with hasty sacrifices of other peoples jobs.
    Risk assessments are only that and will not be 100% all the time. Mistakes will continue to be made.
    I dont think we should be complacent but should focus on how to decrease the likelihood of errors.
    What will happen in a blame game?
    doctors and Social workers will avoid child protection if they have any sense.
    Experienced staff will leave to do other things
    Inexperienced staff will find themselves having to make decisions that maybe they are not fully qualified to.
    There will be a rapid turnover of staff so there may be no continuity in care for many families.
    The so called improvements will increase the bureucracatic workload without an increase in the number of workers.
    This is likely to increase defensive working instead of children focused care.

  • Catherine Bonnet

    I agree with Heather.
    The solution to protect better our children from being re-abused is political rather to increase targets against our colleagues: to change the child protection law and to find funds for doing more studies and trainings. Why?

    The first step to prevent new child abuse is to be able to recognize it. Sometimes it may be very difficult if the professionals have not received an appropriate/regular training. In particular, the detection of abuse in babies and children under 6 years old may be very difficult as they have no or not enough words to explain to their doctors.
    Pregnancy as the results of father’s rape may be quite difficult to detect. The symptoms are hidden. Until I carried out a study in 1987-1989, I have not been able to detect abuse at the prenatal time. I discovered then how some pregnant teenagers are not able to recognize they are pregnant and why they cannot seek for help. We have to admit it is very difficult to become a new mother after being raped or sexually abused in childhood.
    http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6V7N-464247Y-1X&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=baeb42175043cb0253cf2f79c626aac7

    The second step is to get strong and clear child protection law like it is in Canada and USA (obligation to report with full disciplinary and law immunity).
    Similar disciplinary attacks of physicians who had reported suspicion of abuse in France showed that there were failings in our law.

    http://books.google.fr/books?id=h9hsMSZllE4C&dq=L%27enfance+musel%C3%A9e&printsec=frontcover&source=bl&ots=9FFcJYRat9&sig=0UySC6NS6xpWNxMLJCXi8IIwuwI&hl=fr&sa=X&oi=book_result&resnum=6&ct=result

    Thanks to the support of Juan Miguel Petit, the Un Special Rapporteur on the child pornography and sexual exploitation who came to visit France in November 2002, the French parliament forbad disciplinary sanctions in the penal code on 2nd January 2004.

    http://daccessdds.un.org/doc/UNDOC/GEN/G05/129/65/PDF/G0512965.pdf?OpenElement

    However the climate of doubts and fear which have arisen after these disciplinary sanctions may have deterred doctors to be trained in detecting child abuse and reporting. How is it possible to work if you may be damned to detect/to report and damned not to detect/to report. The first victims of such failings in the law are the children.

    http://www.thenational.ae/article/20081114/FOREIGN/904375828/1135

    We would hope that members of parliament follow the recommendation of Hina Jilani, the Special Representative on Human Rights Defenders on 16th March 2005, page 92 alinea 267:
    ‘The Special Representative remains, however, preoccupied that this legislation (January 2004) and the way it is implemented may not go far enough in effectively shielding physicians against abusive complaints. In particular, the Special Representative remains concerned about the fairness of proceedings before the disciplinary bodies of the Ordre des Médecins. She believes that physicians play a vital role in the protection of children against the most serious violations of their rights and that they have to in turn effectively protected in this role as human rights defenders.’

    As child doctors, we would like so much that members of parliament understand the meaning of the children/teenagers silence: how it is difficult to disclose child abuse while you are under 6 years or a pregnant teenager? We would very much appreciate the parliament introduce in the law the obligation to report as well a full immunity against any disciplinary, civil and law actions for protecting the youngest members of our society.

    Doctor Catherine Bonnet
    Consultant in child and adolescent psychiatry
    Chevalier dans l’Ordre de la Légion d’honneur

  • Michaael Innis

    Referring to Baby P Heather Payne asks , “how on earth did they miss those rib fractures?” and “what were social services doing ignoring bruises in a child on the register?”

    It was not the social services that are answerable for “ignoring bruises on the child” the mother took the child to the hospital and it was for the hospital to investigate the problem.

    Bruises on an infant are known to be ‘herald’ lesions which portend intracranial bleeding, rib skull and limb fractures, bleeding from any site (including the nose,intestine and lungs), lesions which look like “bite marks” and “cigarette burns” , loose teeth which fall out easily, and sores all over the body.

    Some doctors mistakenly attribute these lesions to ‘Non-accidental Injury’ but they are in fact exactly what one might expect from severe deficiencies of Vitamins C and K (1,2,3,4,5)especially when associated with Systemic Vasculitis as in Kawasaki Disease.

    In the case of Baby P much attention was paid to the anatomical lesions but there was no mention of the Laboratory Findings which if disclosed will almost certainly show Protein Induced by Vitamin K Deficiency raised, Serum Vitamin C low, Neutrophilia, Lymphopenia, CRP, AST, ALT elevated.

    All the lesions on Baby P could be accounted for by malabsorption of essential nutrients and Systemic Vasculitis.

    The court heard that Baby P’s back had been broken by slamming him down over a bent knee or a banister and he had received the blow that probably caused his death when his face was struck with such force it knocked out a tooth, which he swallowed.

    But as the late Alan Clemetson remarked:

    “One earnestly hopes that a sickly, whining, growth-retarded child with bruises and spontaneous fractures due to Barlow’s disease today would be correctly diagnosed and treated and not be labeled as an “abused child” by misguided opinion. It is interesting to note that the diagnosis of Barlow’s disease has become a rarity, while the diagnosis of “child-abuse’’ has risen enormously. Malnutrition is thought of as a thing of the past, but unfortunately, poverty, unemployment, and malnutrition are still very much a part of the modern world.”(6)

    Having seen and treated several cases of Scurvy abroad I agree with the Professor.

    David Cameron said he was “sickened to the core” by the crime and the council’s refusal to apologize, insisting that the “buck had to stop somewhere”

    I suggest the “buck” stops with Parliament. The diagnosis “Non-accidental Injury” without first excluding Nutritional Disorders Genetic Disorders and Systemic Vasculitis, should be outlawed.

    The Council was blameless –attribute the blame to a failure to recognize a Nutritional Disorder and Systemic Vasculitis.

    It is not too late to disclose Baby P’s Laboratory results and show how accurate or inaccurate was the diagnosis of Non-accidental Injury.

    Michael Innis MBBS; DTM&H; FRCPA; FRCPath

    References:

    1. Kalokerinos A. Every Second Child Sydney Australia. Thomas Nelson 1974

    2 Clemetson CA (2004) “Was it “shaken baby” or a variant of Barlow’s disease?” J Am Phys Surg 9: 78-80 (PDF)

    3. Innis MD. Vitamin K Deficiency Disease. Jour Orthomol Med. 2008;23:15- 20

    5. Rutty GN, Smith CM, Malia RG. Late Form Hemorrhagic Disease of the Newborn. A Fatal Case Report with illustrations of Investigations That May Assist in Avoiding the Mistaken Diagnosis of Child Abuse. Amer J Forensic med Pathol. 1999;20(1):48-51

    6 Clemetson CAB Vitamin C: Vol 3 p 169 Boca Raton,Fla CRC Press 1989.

  • Heather Payne

    Dear Michael Innis
    Your comment concerns me greatly. If you were working with me as my registrar and you told me that you thought that in the case of a child like Baby P Kawasaki Disease or vitamin deficiency was the likely diagnosis, I would feel I had not trained you properly.

    I would ask you to consider the expert witness rules that would require you to state whether your views are mainstream or not, stated in the Oldham case.

    Let me make it clear to all that your views are not shared by mainstream child protection paediatricians and that your views as expressed here are seen as out of touch with accepted medical opinion.

    Please give me any evidence to consider that you feel I have missed. Also please let me know what paediatric experience you have.

    Please give me any evidence to consider that you feel I have missed. Also please let me know what paediatric experience you have.

  • http://www.law.qut.edu.au/staff/lsstaff/bmathews.jsp Dr Ben Mathews, Senior Lecturer in Law, Queensland University of Technology

    Dr Payne correctly suggests that instead of focusing on professional victimisation, there should be genuine, informed, open discussion about what went wrong and a focus on what could (and should) have been done differently by each professional group.

    Preventing, and responding to, child abuse and neglect is a complex problem that is not eradicable and our responses to it are not perfectible. Ed Balls states that he cannot be confident that all children are safe; I can assure him that there is no doubt that all children are not safe; they never have been and never will be (I hope it’s not ignorance but political savvy that produced this statement). Child abuse and neglect has always existed and always will.

    However, there is good evidence that recent efforts in Western countries (particularly the USA) to prevent abuse have succeeded in reducing its incidence, especially for sexual abuse (49% decline 1992-2004), physical abuse (43% decline 1992-2004), and neglect (6% decline 1990-2004) (Finkelhor & Jones, 2006). Early intervention, often facilitated by mandatory reporting of abuse and neglect by designated persons of severe maltreatment, has played a role in this decline.

    So, while it cannot be eradicated, child abuse and neglect can be reduced, and its effects addressed more effectively. My own view is that some of the problems apparently present in the UK (which also exist elsewhere, if it’s any consolation) are related to not just the finegrained detail of individuals’ professional practice, but the overarching parameters of the social systems involved, and of how they work (or don’t).

    Here are some personal suggestions about tactics that may assist in this endeavour, related to these dimensions of ideology and systems:

    Ideological level
    1. Children’s rights to safety must be taken seriously. While many children are loved and cherished and treated with dignity and respect, many others are not. Many children are subject to abuse and neglect that would not be tolerated were they adults. The general promotion of children’s rights to safety must occur at a societal level, led by those in positions of power eg Ministers. This can be assisted by the media. It should not be saccharine or patronising – children simply should have rights to be free from violence and to have protection from it once it has happened, just as adults do. Promoting children’s rights to safety does not deprive parents of their ‘rights’.

    2. While most would agree that it is preferable in child protection practice that children remain with their parents where possible, this principle should not yield to the overriding principle that the child’s wellbeing and safety is paramount. However, this is a thorny problem of judgment in individual cases, which is also unfortunately affected by factors such as resources, placement positions etc. There may be ways of securing the child’s safety without removing them from the home – but these may be costly. Removal is also costly.

    3. Too many of our efforts occur after the event. Prevention is far cheaper (and sounder in principle) than responses after the event. Society should invest far more in the early years, especially for disadvantaged children – in the USA the dollar return on this is 8:1 (Heckman 2006 – see note 1). As well as development of key cognitive skills (literacy, numeracy etc), children need skill development in the crucial psychosocial domains of temperance (impulse control, delay of gratification, avoid extreme behaviour), responsibility (ability to resist peer pressure, ability to seek beneficial advice) and perspective (ability to see things from others’ perspectives, to consider short-term and long-term consequences, to assess impact of behaviour on others). These skills will help reduce violence, teen pregnancy, unemployment, and substance misuse – all of which heighten the risk of child maltreatment.

    4. Intensive and sustained assistance (including financial, health, education, respite) is essential for children and families found to be most at need – largely for the same reasons as in point 3. Piecemeal attempts will not succeed.

    5. Families identified as in need should not be universally demonised, or criticised. Many of these parents have, for want of a better term, been dealt a less than ideal hand of cards. Many abusive and neglectful parents are repeating their own childhood experiences. Where appropriate, the attitude should be one of assistance, not punishment. This is still compatible with removal of the child for his or her safety, where necessary. These judgments are not easy to make, but this is the task. Of course, in appropriate cases, parents may not be willing or able to look after their children, and in some cases criminal prosecution is necessary.

    Systems level
    6. There needs to be a massive increase in funding and personnel. At present it is not humanly possible for child protection workers to do their job properly. This creates further problems of burnout, resignations, further staff shortages, recruitment of inexperienced workers, who are more susceptible to making unsound decisions – who then get burnt out, resign, and continue the cycle.

    7. Leaders (those who lead) and managers (those who manage or administer) should be knowledgeable about the field (ie the children, families, and workers involved), and should genuinely care about it.

    8. The performance of leaders and managers should not be measured by key performance indicators or performance targets (in most areas of their work), but by qualitative measures.

    9. Workers need sound training and supervision, and need to be working to the same script. It is not acceptable for some workers to be predisposed to removing children according to a low risk threshold, while others fail to remove a child despite compelling grounds.

    10. Workers also need adequate protection, especially in cases where the parents are hostile, intimidating or violent.

    11. Worker training efforts should begin in high-quality qualification courses, whether tertiary or otherwise.

    12. Key people in child protection roles need support and protection in carrying out those roles. The key example is that those who report suspected child maltreatment in good faith should not be subject to disciplinary or other legal proceedings for such prosocial and responsible actions. This has happened in the UK but not in other countries. The effect of exposing these people to adverse consequences is that fewer will be willing to disclose their suspicions and this will lead to more child abuse, including deaths.

    13. In one sense it is understandable that social workers do not want more reports of child maltreatment, as they already cannot cope with the numbers of cases they have to deal with. However, without a good system of uncovering cases of abuse and neglect, more children will be abused and neglected, and more will die. Evidence proves that professional reporters (eg doctors, nurses, teachers, police) are responsible for uncovering the majority of cases of child abuse and neglect. At the same, time, systems need to be protected from unjustifiable numbers of “clearly unnecessary” reports. The question of what type of reporting system a society should have is currently raging in Western countries, and this should be on the agenda in the UK (see sources in note 2).

    Note 1.
    A body of research in economics, neuroscience and developmental psychology shows the developing child’s experience from the prenatal period through early childhood is a powerful factor shaping interdependent cognitive, linguistic, social and emotional competencies, which influence future success, and that key abilities are best able to be formed during an identifiable series of developmental periods during which the brain and behaviour are most amenable (Knudsen, Heckman, Cameron & Shonkoff, 2006; Shonkoff & Phillips, 2000). The family environment is a critical predictor of early cognitive and noncognitive ability, and the emergence and persistence of gaps in these skills occurs by age 4-6 (Carneiro & Heckman, 2003). Environments that do not develop these skills at early ages place children at a disadvantage which may never be restored. James Heckman, who in 2000 was jointly awarded the Nobel Prize for Economics, has contrasted the effect of early intervention with attempts in adolescence and later and concluded that (2006, p. 1901) “The dynamics of human skill formation reveal that later compensation for deficient early family environments is very costly – it is economically inefficient to invest too late in the skills of the disadvantaged – economic return from early intervention is high”. A 2005 RAND monograph (Karoly et al., 2005) detailed a number of programs whose cost effectiveness was established through methodologically rigorous evaluation. Heckman cites the Perry Preschool Program (Schweinhart et al., 2005) as an example of the impact of a sustained intervention for disadvantaged 3-4 year olds which when traced through age 40 showed the positive effect of higher noncognitive skills on high school completion, salaries, home ownership, need for welfare assistance, out-of-wedlock births, and arrests, all of which led to an estimated economic dollar return of over 8:1. Heckman’s review informed his conclusion that society overinvests too late and underinvests in the early years (p. 1902): “Investing in disadvantaged young children is a rare public policy initiative that promotes fairness and social justice and at the same time promotes productivity in the economy and in society at large.”

    Note 2.
    B Mathews & D Bross, ‘Mandated reporting is still a policy with reason: empirical evidence and philosophical grounds’ (2008) 32(5) Child Abuse & Neglect 511-516.
    B Drake & M Jonson-Reid, ‘A response to Melton based on the best available data’ (2007) 31 Child Abuse & Neglect 343-360.
    G Melton, ‘Mandated reporting: A policy without reason’ (2005) 29(1) Child Abuse & Neglect 9-18.
    B Mathews and M Kenny, ‘Mandatory reporting legislation in the USA, Canada and Australia: a cross-jurisdictional review of key features, differences and issues’ (2008) 13 Child Maltreatment 50-63.

  • Saleem Khwaja

    Heather Payne (Baby P) is right in her remarks of professionals being victimized so readily by the public and the media. Dr. Zayyat, who has been suspended from her job and by the GMC, was only one of the paediatricians to have part managed the baby. What about the paediatricians and other health professionals before her? After all the abuse of Baby P went on for almost ’18′ months at least!

  • Colin Brown

    Dr Mathews summary is surely essential reading for anyone developing an evidence-based policy. While debate has focussed on the Social Work Depts’ capacity to manage children once they have descended to the level of the At-Risk Register, can we consider the preventive role of Health Visiting, one of the most Cinderella of health professions?

    Health Visitors can deliver prevention, by being part of the practice-based team and so giving easy non-stigmatising universal access to a local service to which nearly all families have an attitude of Trust. These assertions are both evidence-based, and self-evident enough for 22000 people to sign our petition to the Scottish Parliament – see

    http://www.holyrood.tv/popup.asp?stream=http://vr-sp-archive.lbwa.verio.net/archive/petitions_181108.wmv

    The increasing nos of children being placed on these Registers will surely swamp the SW services, as was evident in Haringey already. For an equivalent no. to be accurately declared safe enough to remove from the Register requires an effective HV service to resume family support.

    So – does anyone have any figures for the nos of WTE Health Visitors employed in each PCO in recent years, and the % of those with an effective membership of a local Primary Care Team?

    Colin Brown
    GP Glenburn Paisley

  • Catherine Bonnet

    Ben Mathews comments are excellent.
    Let me add to his point 12 that we have in France a huge problem:
    They were about 200 physicians mostly child psychiatrists, GP and others who had disciplinary suits. Not all of them got sanctions but while they get suits, they need time, lawyer for your defence, they get stressed, etc

    Myself I have been the subject of 6 disciplinary suits + 2 penals suits between 1997 to 2007. For the 3 first complaints I was sanctioned on December 1998 three times three years banned of practicing for false certificate or calomniuous denuncitation although my diagnoses were confirmed by others as it is said in the alinea 5 on the report of Juan Miguel Petit.

    These results has been launched into the media as the parents were belonging to associations which were afraid they were 30 to 70% false allegations while children disclosed sexual abuse in case of custody battle. We did not have any data in France on the subject in 1998.

    Unfortunately we had to wait until 2003 for getting the results of a study done in France, in 2001, in 3 court trials in custody battle by Viaux. They were only 5 to 7 per thousand cases of false allegations.

    I have been the only one criticized in the media but it was enough for scaring my colleagues to report. Only 2% of them were known to report on 2003. Now I have not found data.

    Negative reactions after a positive step (1989 to 1996) may be called a backlash.
    The progress in the understanding of child abuse seems to provoke regular cycle of repression.

    In France, we experienced a first backlash at the end of the XIX° century. Ambroise Tardieu has been the first in Europe to describe a lot of the clinical findings about child abuse. But a group of physicians became sceptical and critical on Tardieu’s sexual abuse work. They progressively convinced the academic arenas that children were lying rather disclosing sexual abuse. They described a new clinic syndrome the ‘liar syndrome’. We have to wait the rehabilitation of Ambroise Tardieu by American paediatricians in the 60.

    Hope that the French children victims of abuse will not wait until the end of the 2000 century for being carefully protected and receiving appropriate treatment.

    That is why we need international solidarity!

    I am sure that there are other countries with such difficulties. Perhaps other colleagues can share their experiences within this debate in order to get more ideas to improve laws, policies and implement trainings.

    Catherine Bonnet

  • Catherine Bonnet

    Would please correct my sentence, i have been the subject of 6 disciplinary suits and 2 penal suits from 1997 to 2004 and not 2007.
    Sorry for this and many thanks for understanding the mistake.

    Catherine Bonnet

  • Michaael Innis

    My response to Dr Heather Payne considered point by point.

    1.“Your comment concerns me greatly. If you were working with me as my registrar and you told me that you thought that in the case of a child like Baby P Kawasaki Disease or vitamin deficiency was the likely diagnosis, I would feel I had not trained you properly”.

    That is my luck not working as your Registrar. You see I have trained several doctors for the FRCPA who are now Consultants in Haematology in various parts of the world- including the UK.

    2. “I would ask you to consider the expert witness rules that would require you to state whether your views are mainstream or not, stated in the Oldham case”.

    I declare my views are not”mainstream” and neither were those of Semmelweis when he declared doctors were responsible for spreading post natal sepsis by failing to wash their hands properly. It took his colleagues a long time to discover he was right.

    3.”Let me make it clear to all that your views are not shared by mainstream child protection paediatricians and that your views as expressed here are seen as out of touch with accepted medical opinion.”

    I would hate to be included among those ”mainstream child protection paediatricians” who believe that squeezing the chests of dead rabbits “has enabled clinicians to state with confidence that squeezing and bending an infant’s chest is the most likely mechanism for posterior rib fractures seen in child abuse” [1]

    And I abhor the suggestion that skull fractures are the result of the parent violently smashing the infant’s head against a firm object or that a fractured spine is the result of the infant being slammed down over a bent knee or banister.

    My explanation for these fractures is Vitamin K is a cofactor for an enzymatic conversion of glutamic acid (Glu) to γ-carboxyglutamic acid (Gla) by γ-glutamyl-carboxylase a process necessary for the biological activity of the blood clotting factors II, VII, IX, X protein C and S as well as bone Gla protein and matrix Gla protein which control osteogenesis(2). Vitamin K is thus necessary for both the coagulation of blood and the mineralization and strengthening of bone. When deficient spontaneous fractures and spontaneous bleeding are to be expected (3,4,5,6)

    “Please give me any evidence to consider that you feel I have missed. Also please let me know what paediatric experience you have.”

    To answer the first part of the question you will have to read my paper’Vitamin K Deficiency Disease(6)
    The second part of your question is irrelavant. You can be assured that I believe that what paediatricians call “Shaken Baby Syndrome”and “Non-acciental Injury” is a misconception if a nutritional disorder has not been excluded.

    If a deficiency of Vitamin K and/or Vitamin C has not been excluded in Baby P there has been a miscarriage of justice.

    Michael Innis

    References
    1 Sugar NF Diagnosing child abuse BMJ 2008;337:a1398

    2 Furie B, Bouchard BA, Furie BC. Vitamin K-Dependent Biosynthesis of γ-Carboxyglutamic Acid. Blood. Vol 93;1999: pp 1798-1808

    3. Koshihara Y, Hoshi K. Vitamin K2 enhances osteocalcin accumulation in the extracellular matrix of human osteoblasts in vitrio. J Bone Miner Res 1997,12(3):431-438

    4 Szulc P, Chapuy MC, Meunier PJ, Delmas PD. Serum undercarboxylated osteocalcin is a marker of the risk of hip fracture in elderly women. J Clin Invest. 1993 April, 91(4): 1769–1774.

    5. Seibel MJ, Robins SP. Serum Undercarboxylated Osteocalcin and the Risk of Hip Fracture The Journal of Clinical Endocrinology &Metabolism Vol. 82,No. 3 717-718 1997

    6. Innis MD Vitmin K Deficiency Disease. Jour Orthomol Med 2008; 23; 15-20

  • Tony Green

    Some execellent debate.

    I stand by my original point though, i.e. that a doctor who makes a catastrophic error of judgement and is then subjected to investigation by their professional body only as a direct result of media pressure, is not the same as being victimised.

    Michael Innis – Would you also have us believe that vitamin deficiency induced hallucinations are most likely to be responsible for the testimony (accepted in court and that led to convictions) of the girl who directly observed that baby P was repeatedly physically abused?

  • Heather Payne

    Dear Michael Innis
    Thankyou for responding to my questions. I do not find anything in your responses to make me change my already stated views.

    I have attempted to read your cited paper but sadly it is not available on the Journal of Orthomolecular Medicine website. I have aded the link to the journal site here for anyone who wishes to explore for themselves exactly what your publication is likely to bring to this debate.

    http://orthomolecular.org/library/jom/index.shtml

    Res ipse loquitur, as my legal colleagues say
    Sincerely
    Heather Payne

  • David Chadwick

    Dr.s Payne, Bonnet and Mathews have all made valid and important points. Missed cases of serious physical abuse are common[1] and doubtless occur everywhere. We need a method for measuring the problem so that we can detect any trend and try to ameliorate it. The application of methods of continuous quality improvement[2] is worth considering, but peer review by all involved disciplines should be routine. This work cannot be done in an atmosphere of fear such as that created by the European medical licensing agencies[3]. We should avoid measures that increase the risks of child protection work.

    The suggestion of scurvy in this case is “unique causal theory”[4, 5] Scurvy in children in developed countries had disappeared.by1950, The rediscovery of child physical abuse began in 1962[6] and reports took off in the 1970’s.

    1. Jenny, C., et al., Analysis of missed cases of abusive head trauma. JAMA, 1999. 281(7): p. 621-6.
    2. Berwick, D., A. Godfrey, and J. Roessner, Curing Health Care. 1990, San Francisco: Jossey-Bass.
    3. Chadwick, D.L., H.F. Krous, and D.K. Runyan, Meadow, Southall, and the General Medical Council of the United kingdom. Pediatrics, 2006. 117(6): p. 2247-51.
    4. Brent, R.L., The irresponsible expert witness: a failure of biomedical graduate education and professional accountability. Pediatrics, 1982. 70(5): p. 754-62.
    5. Chadwick, D.L. and H.F. Krous, Irresponsible expert testimony by medical experts in cases involving the physical abuse and neglect of children. Child Maltreatment, 1997. 2: p. 315-321.
    6. Kempe, C.H., et al., The battered child syndrome. Journal of the American Medical Association, 1962. 181(1): p. 17-24.

    David L.Chadwick, M.D.
    Direcror Emeritus
    Chadwick Center for Children and Fanilies.
    The Rady Children’sHospital
    San Diego, California

  • William

    In answer to Heather Payne, Michael Innis says that paediatric experience is ‘irrelevant’ (curiously spelt ‘irrelavant’ in his communication – perhaps an Antipodean variation) in the context of diagnosing child abuse and Kawasaki disease in childhood. It could be argued that taking a history from the parents and examining the child, and skills and experience in this are important, or, on the other hand, that this experience seems to be in the eyes of Dr Innis, ‘irrelavant’ in the context of paediatric diagnosis, but it seems that that modern medicine has accepted that paediatricians have an important role in the diagnosis and treatment of children who require medical care. It is possible that paediatricians will eventually be judged to be ‘irrelavant’, when it comes to the diagnosis and treatment of childhood illness but at present it seems that Dr Innis is swimming against the tide.

    By the way, Dr Innis, I am sure the readers of the BMJ are longing to know the details of your experience in acute clinical paediatrics (outside the laboratory!). Perhaps you could supply us with the details of your medical school, when you qualified, and your posts and training in paediatric medicine even if you are convinced that this is ‘irrelavant’.

    William

  • Michaael Innis

    Dear Heather Payne,
    I did not expect to change your opinion or the opinion of any doctor who believes non-accidental injury to infants is characterised by acute encephalopathy with subdural and retinal haemorrhages, occurring in a context of inappropriate or inconsistent history and commonly accompanied by other apparently inflicted injuries. [1].

    My objective was, and is, to present alternative views (2,3) to that which is currently “orthodox”.

    Unless nutritional deficiencies are considered in these cases of alleged child abuse errors of judgement are likely to occur.

    I have several copies of my paper “Vitamin K Deficiency Disease” and can send you a copy if you wish.

    Michael Innis

    References:

    1.Harding B, Risdon RA, Krous HF Shaken Baby Syndrome BMJ 2004;328:720- 721 (27 March), doi:10.1136/bmj.328.7442.720

    2.Innis MD. Vitamin K Deficiency Disease Jour Orthomol Med 2008;23:15-20

    3.Clemetson CAB Vitamin C Volume 2. CRC Press, Inc.
    Boca Raton, Florida

  • David Carr

    I remember being told of an experiment to demonstrate the power of “20/20 hindsight” in deciding the optimal management of a patient who had a stroke. Two groups of doctors were given the history of the newly admitted patient with hemiplegia and impaired consciousness, but group A were told that during the night after admission to hospital the patient fell out of bed and fractured his femur, while group B were given the same history but without mentioning the fall. The groups were asked to state what correct management on admission would have been (? nasogastric tube for feeding, treament of BP etc.). Also asked was whether cot-sides be used. There was a much greater usage of cot-sides recommended by group A, who were given the hindsight that the patient fell out of bed, than by group B who had to decide only on the information available at the time of the admission. I don’t necessarily wish to judge the correctness or otherwise of using the cot-sides, but clearly the choice was heavily influenced by hindsight.
    I wonder if similar experiments have been done with health professionals attempting to decide on aspects of management of children at risk of abuse, to see whether “hindsight” is influential in this context too.

  • David Murray

    Michael Innis,

    My explanation for these fractures is Vitamin K is a cofactor for an enzymatic conversion of glutamic acid (Glu) to γ-carboxyglutamic acid (Gla) by γ-glutamyl-carboxylase a process necessary for the biological activity of the blood clotting factors II, VII, IX, X protein C and S as well as bone Gla protein and matrix Gla protein which control osteogenesis(2).

    Vitamin K is thus necessary for both the coagulation of blood and the mineralization and strengthening of bone. When deficient spontaneous fractures and spontaneous bleeding are to be expected (3,4,5,6)”

    Neither the explanation of the physiology of clotting and osteogenesis nor the references supplied support in any way the premise that fractures of the spine and ribs in a clearly abused child who was punched so hard in the face that a tooth was found in his stomach, aquired these lesions because of Vitamin deficiency.

    Does Innis still maintain that Victoria Climbie died of Kawasaki Disease and that the Home Office Pathologist who examined her was incorrect when he commented that it was the worst case of child abuse he had ever seen?

    1.Michael Innis, Rapid Response to:
    James R Le Fanu, Rosemary Neary, and Denise Bartlett
    “Unexplained” fractures
    BMJ 2008; 337
    “It was not that the child had skin lesions but the type of lesions and other clinical features which were typical of Kawasaki disease in my experience.”

    2.Michael Innis, Rapid Response BMJ 2007
    “Kawasaki Disease unrecognised”

  • Heather Payne

    Evidence, Experience and Expertise

    Blog update Heather Payne 8 Dec 2008

    I think we all understand by now that child protection work raises strong emotions. Any potentially life threatening condition in a child is a source of enormous worry to parents. Which is why, when we see a child with bruising (which might be leukaemia, ITP, viral infection, child abuse, etc…) we establish a differential diagnosis with a careful history, examination and necessary investigations. We interpret these data using the best possible evidence base (eg NICE guidelines on febrile illness, the Welsh child protection systematic review group website http://www.core-info.cf.ac.uk/ ). This process helps us to exclude the impossible, and then we are left with the dictum of Sherlock Holmes:

    “Watson, as I have said, when all other avenues have been exhausted, whatever remains, however unlikely, is the answer”.

    If Michael Innis has evidence of Vitamin deficiency causing fractures here and now, then please, let’s see it. If it’s robust evidence, like the papers I and many other paediatricians have reviewed for the published systematic reviews, then bring it on – we’d all love to identify a treatable condition which has a simple medicinal cure. So yes please, Michael Innis, email me your paper via the BMJ and I will be happy to perform a critical appraisal of it and post the results on this blog. If the findings are valuable I will say so honestly, but if the paper is unsound, invalid or irrelevant then you can equally expect me to be truthful.

    The reluctance of many individuals and societies to recognise, and act to prevent, child abuse is traced in the Lancet series of papers published this week.
    http://www.medpagetoday.com/EmergencyMedicine/DomesticViolence/12015
    Some of the views expressed by posts on this blog seem to me to be in denial that child abuse – physical, sexual, factitious or induced illness, or neglect – really exist. Unpalatable as the facts may be, it’s time for the public to face up to the truth, that while most parents love and nurture their children, a small proportion cause them severe harm. To be convinced, I recommend they read those Lancet papers, or the Laming report, or any serious case review, including Baby P’s. Or just this blog.

    Our medical education is based on the ‘apprenticeship’ model in the different branches of medicine – you work in paediatrics to become a paediatrician, you work in pathology to become a pathologist. Each has a certain basic level of knowledge about the other, but expertise resides in the one who has the experience in that field. Or hindsight if you want to call it that. I have learned about child protection by seeing it a first hand, so that I can recognise a slap mark or a Mongolian blue spot or a concerning pattern of behaviour suggestive of sexual abuse. I’ve made mistakes too- but generally only once. The fancy name for hindsight is risk assessment, which is what child protection is all about.

    The ‘diagnosis’ of abuse is never made by me in isolation – I always work with social workers and police to share information. And the ‘diagnosis of abuse’ is not an end in itself, it’s a means to the end of improving matters for the child.

    So we continue to walk the tightrope of child protection; verbally (and sometimes physically) attacked for making a diagnosis, as with Professor Sir Roy Meadow and David Southall (http://paca.org.uk/ ); pilloried and disciplined for allegedly missing it (before all the facts are clearly known) .(http://news.bbc.co.uk/1/hi/england/london/7752231.stm).

    We are professionals and have a duty towards every single child, to try and get it right every single time. Training and experience in a supportive but rigorous peer group (‘critical friends’) is vital to good, effective child protection work. Nobody should ‘go it alone’, it’s too risky for the child and also for ourselves.

  • Mark Struthers

    Heather Payne aptly quotes from Sherlock Holmes,

    “Watson, as I have said, when all other avenues have been exhausted, whatever remains, however unlikely, is the answer”.

    I wonder if Dr Payne would care to comment on the content of a rapid response (a rare fish that only in part escaped the censor’s net) …

    http://www.bmj.com/cgi/eletters/337/oct13_2/a2069#203542

    … with which I countered an extraordinary letter most extraordinarily published in the BMJ by paediatrician John Bridson (13 October 2008).

    http://www.bmj.com/cgi/content/full/337/oct13_2/a2069

    Can Dr Payne explain what the modern paediatrician is doing to discover the nature of those serious illnesses where a nosebleed might presage disaster for an infant? Is it possible that the paediatric sleuth has yet to exhaust all avenues other than the parental abusive one?

    PS. The long and winding road of due process has followed Professor David Southall to, not one, but two findings of serious professional misconduct and a striking from the medical register. Have those dismal facts yet registered with Heather Payne?

  • Mark Struthers

    The Sherlock Holmes quote reminded me of a notable saying by a former Israeli foreign minister. Abba Eban once said,

    “History teaches us that men and nations behave wisely once they have exhausted all other alternatives.”

    It strikes me that the professional leaders of the British forces for child protection have not yet reached the point of exhaustion.

  • Heather Payne

    Pigs might fly – but in my experience they don’t

    Heather Payne Blog update 10 Dec 2008

    I do find giving evidence in court the most coruscatingly effective CPD known to (wo)man. It is amazingly educational to have a highly intelligent and articulate mercenary pose questions that I have sworn on the Bible to answer honestly. I know it’s nothing personal- a barrister’s obligation is to pursue their client’s case. In fact, I’m quite happy when they start to have a go at me personally, because I know they can’t find a chink in my standard of care, notekeeping or opinion.

    A ploy commonly used in court is to ask hypothetical questions to introduce doubt. This is what I mentally label the ‘pigs might fly’ line of questioning, and is a sign that the barrister is worried because there is no clear coherent history of a child’s injury, such as being run over by a bus or something that would realistically account for multiple severe injuries.

    In child protection we have to focus on what DID happen, not what might have happened. Bleeding and bruising do not just come out of thin air, there is always a reason. If they are caused by minimal trauma then there should be a clear identifiable cause eg virus, clotting, blood dyscrasia, medications. Pigs might fly, but there is no evidence that they do, and I have never yet seen one whistling past.

    Mark Struthers has asked me to comment on his link, and I quote from it:

    ‘Christopher Blum and Christopher Clark died from a rare, undetermined disorder, heralded by nose bleeding.’

    This reminded me of the ‘transient osteogenesis imperfecta’ argument propounded by a Dr Paterson. It too had all the hallmarks of a ‘rare, undetermined disorder’ and is now thoroughly discredited by the Judiciary.
    It was good to quote the paper on infant nosebleeds, but even better to take notice of the punchline that nosebleeds should always be evaluated by someone with child protection expertise.

    Happily, I am well able to agree with the next sentence:

    The proper investigation and accurate diagnosis of such serious illness is necessary for the future protection of all children and their families’

    This is spot on: child abuse is a serious condition, and I remind you of Lord Laming’s recommendation that we should not fail to include it in our differential diagnosis. The recent Lancet papers on child maltreatment tell us that abuse is commoner than we think. The head of Ofsted (giving evidence today on how Haringey Social Services managed to get inspected as ‘good’ at the time the Baby P case was happening – but that’s another story) has confirmed that an average of 3 children die per week from abuse in the UK.
    http://www.itv.com/News/Articles/Ofsted-head-faces-Baby-P-grilling-799598238.html

    This is a different order of magnitude to the 23 children who died in the UK from asthma in 2002 ( BMJ 2007;335:198-202 (28 July), doi:10.1136/bmj.39234.651412.AE)
    So please, can we all have grown up conversations about this from now on?

    The issues around David Southall and Roy Meadow have already been rehearsed by me and others. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2254460
    If you haven’t lost the will to live about this matter, go to the PACA website and read everything ( I mean everything- all the GMC transcripts in particular) and judge for yourself. http://paca.org.uk/2008/01/
    (update of facts here) http://www.bmj.com/cgi/content/full/337/sep24_1/a1811

    I stand by my comments in these articles. I’m just an ordinary jobbing paediatrician who wants to do a good job, tell it like it is, and sleep at nights.
    This is life at the coalface of paediatrics, spookily like children themselves, hard work, mostly just good basics, occasional rocket science, often messy, and amazingly rewarding. I can recommend it to anyone.

  • george lithco

    Having “read the thread”, I think the decision goes to Dr. Payne, and I thank her and all pediatricians who look after the well-being of children. However, I am saddened that so much time and effort goes into analyzing the consequences of such tragedies and attempting to sort out blame for those who were present at the scene. If equivalent effort and energy was put into devising social systems that could not only effectively and efficiently educate new parents and caregivers about the factors that contribute to abuse – the don’ts – but the opportunities for them to help protect their children – the do’s – society would be better served.
    How many parents believe that the anger and frustration they direct at a colicky baby or an ill-tempered toddler is just proof that they are an uniquely “bad” parent, and never share that frustration with anyone else? Based on my conversations with parents about SBS after our son was shaken, quite a few…
    As a few of the folks who commented note, home visiting programs offer considerable hope for prevention. In the US, the RAND study and the work of Dr. Heckman have done quite a bit to move forward legislation in Congress to establish federal support for home visiting programs.

    The House report on EBAH and home visiting is at
    http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=110_cong_reports&docid=f:hr818p1.110.pdf

    House testimony on EBAH is at http://edlabor.house.gov/hearings/fc-2008-06-11.shtml

    I wish Dr. Payne well.

  • Catherine Bonnet

    Thank you George Lithco for your information about home visiting. I have read the websites, they are quite interesting.

    I agree it may be very helpful to help parents to manage their difficulties if they ask for.
    If you go reading on the first comment that I posted on this blog, the first study 20 years ago that I conducted was to understand the psychodynamic of women who unwanted their baby at birth.
    From 1987 to 2002,I followed up 100 pregnant women/teenagers with these difficulties, 9 of them have killed their newborn babies at birth. None were psychotic, all have been the subject of sexual abuse, mostly in childhood, sometimes they were pregnant as the results of rape as described in the British Frizl case.

    I really think that to offer brief psychodynamic therapy to pregnant teenagers/women at a perinatal time may prevent early abuse/neglect.

    We also have in France, the anonymous delivery, which is a law that helps women to be followed before the birth without telling their identity. There are some similarities with the USA Safe Haven Law, except that they can receive a support in particular for making their decision to keep or give up, or place their baby before the birth.

    Prenatal time is a real good time for women/teenagers to sort out their difficulties/fears to start an attachment with a baby.

    But it is also necessary to detect abuses in young children. I have been convinced how it is important when some pregnant teenagers/women who made the decision not to keep their baby explained to me that they were unable to disclose their child abuse or if they disclosed it, their family denied their sufferings. They never received any legal protection if they disclosed. One of them said: ‘how can I become a mother if I never been able to be a child.’

    While the abuses are detected early, if the children are protected, then it is necessary they receive a psychodynamic therapy in order to go through the sufferings and being able to become an happy adult. This may be possible.

    We certainly need to work in the two areas: detection/protection/ therapy in children/adolescent
    and follow up of parent/prevention of the risk of the repetition of the past abuse.

    In UK, I am sure that Roy Meadow and David Southall would have brought a lot of new researches, new ideas to support the parents if they have not get so many obstacles in their work.

    It is sad that British paediatricians are forced to spend a lot of energy to fight for stopping this haemorrage of disciplinary suits.
    It would be so much better if they would be able to get mandatory reporting with full immunity guaranty as it is in USA for continuing their wonderful work, research, training for improving the life of the children victims of abuses.

    Catherine Bonnet

    I have written 2 books but they are in French.
    1. Geste d’amour, l’accouchement sous X. Odile Jacob, Paris 1990.
    2. L’enfant cassé, Albin-Michel, Paris, 1999.

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