Kyle Keen was a Walsall toddler unlawfully killed by his mother’s boyfriend following catastrophic failures in basic safeguarding at Walsall Manor Hospital in 2006. His death was an avoidable human tragedy. The least we can do is try to understand why this happened and learn the lessons it teaches us.
This week a Daily Mail article by Lucy Osborne headed “Hospital says sorry for baby’s death after 7 year cover up”, revealed that the Manor Hospital’s Chief Executive, Richard Kirby, is to commission an independent review to analyse how the incident was handled.
As I was head of the paediatric department when Kyle died I do of course have a good idea of how it was handled. The answer is badly. But this will be for the review panel to judge. They will have to decide whether the Daily Mail was being sensationalist in calling this a cover-up. With my own personal experience at the time and the documents I have been allowed to see I think the term is justified.
The simple truth is that Kyle Keen was sent home to his death by a consultant who made serious errors of judgement and over rode the better judgement of medical and nursing colleagues who gave him the correct advice. Kyle was admitted under the care of a paediatric consultant, Dr Rajneesh Walia, with suspicious unexplained bruising. Dr Walia seems to have thought nothing of this. A number of nursing staff stated that this should be reported to social services. He over-rode them. His senior registrar, on two separate occasions, asked him to refer to social services. In a fundamental, and for Kyle fatal, error of reasoning Dr Walia, according to the registrar’s witness statement “said he felt this (referral) wasn’t necessary and that the child would be under his and the health visitors follow up. He suggested that the mother would be aware that she was being watched and this would deter anything further.”
Most people who know anything about safeguarding recognise the importance of Serious Case Reviews (SCR). These are conducted primarily to decide in the most serious cases if there are lessons to be learned and if so what these lessons are. Their objective is to improve the way agencies work together and improve practical safeguarding. In the case of Kyle Keen, identified by Walsall Safeguarding Children Board (WSCB) as Child K, this has been problematical for several reasons:
- Almost 6 years after the SCR was completed no doctor has yet seen it. In fact the hospital responsible for the blunders that led to Kyle’s death has only obtained a copy in the last couple of months. Why?
- In 2008 after the report of the SCR was finished WSCB held a briefing meeting to disseminate its findings. The hospital, despite having very experienced safeguarding nurses and doctors, delegated a recently appointed non-clinical manager with no knowledge of paediatrics or safeguarding to represent it at this briefing. Why?
- Prior to 2010 it was standard practice for Local Safeguarding Children Boards to publish on-line a potted version or “executive summary” of the SCR. This was delayed for 14 months after the SCR report was completed in Kyle’s case. Why?
- The executive summary contains gross factual errors. Why? Since WSCB has refused, on the grounds of data protection, to answer even one of the questions Kyle’s father has put to them we will have to wait for the review answers.
- Despite the requirements of the 2006 Working Together statutory guidance on SCRs no family member was involved in the SCR or informed of the outcomes.
- The then Chief Executive, Sue James, and Medical Director, Mike Brown, made a completely misleading press statement of what had happened. They had not seen the SCR. Their statement contradicted the findings of the hospitals internal investigation. No paediatrician was consulted. Why?
- The board minutes give no sense of what actually happened to this little boy or of where the real errors lay. Why? The board was criticised in a Royal College report in 2010 of having no way of knowing what was going on in the paediatrics department for which it had governance responsibilities.
Given this inauspicious start and 7 years of stubborn silence on the SCR it is not be surprising that there has been some resistance to learning lessons. In due course the independent review may come up with answers to my questions. I am not holding my breath given my own experience of such reviews. Meanwhile I want to fast forward to October 2008. Apart from some revisions to policy and paperwork little had been done to remedy what we now know the SCR referred to as “catastrophic mistakes”. One of the recognised vital roles in hospital safeguarding is a properly trained and qualified safeguarding nurse. The SCR recognised this. My book, “Little Stories of Life and Death @NHSWhistleblower” tells the story of the difficulties we had establishing this post at Walsall in Chapter 17 “Playing Politics with Child Protection”. The concerns I raised with the Chief Executive about this were made according to the Trust whistleblower policy. Nevertheless, this led quite specifically to my suspension as a consultant only a few months later.
17. Playing Politics with Child Protection.
“Nothing we can do will bring back the children who have died at the hands of their abusers….But we have to be determined to learn the lessons and to act now to make a lasting difference so that more children will be protected in future.”
Ed Balls in his Ministerial Foreword in HMG Response to Lord Laming
By October 2008 Kyle Keen had been dead more than 2 years. Tyrone Matthews, convicted of manslaughter, was in prison. Kyle’s mother Kelly McIntosh had been given a 6 months suspended sentence for cruelty by neglect and lost her other child as a result. The rest of Kyle’s bereaved family were lost to view and we had had no contact with them. His father, when I met him again 4 years later, told me the killer would be in prison for a few short years but that he had been given a life sentence by his son’s death. Kyle had been all but forgotten in the hospital. A number of people preferred it that way. Some of the nurses mentioned him occasionally and it was clear they regretted not having been better advocates. We had still seen no sign of the Serious Case Review.
Towards the end of my career I realized that I had never developed a deep understanding of how child protection services did or did not work. This was possibly because it was only a small part of my work as a paediatrician. The death of Maria Colwell had dominated the headlines as I was setting out as a doctor in the early seventies. Even then I remember the local authority trumpeting in the press that this “must never happen again.” Following our return from Africa the press was full of accounts of Jasmine Beckford’s killing in not dissimilar circumstances. “It must never happen again.” In 2000 one of the most outrageous failures of the child protection services came to light with the death of Victoria Klimbié. “It must never happen again.” In August 2007 a year after Kyle’s death Peter Connolly was killed after repeated failures by police and social services and the NHS. In a final and fatal error he was sent home from clinic despite having a broken back. Three individuals including Peter’s mother were jailed for their part in this crime. I heard no-one saying “It must never happen again.” Maybe it is now seen as inevitable, something society has to live with.
At least with all these cases there had been an acknowledgement of abject failure, an open investigation and an opportunity to learn the lessons. Apart from the criminal investigation which I had lost sight of there seemed to be little or no sign that we were addressing the central failings with Kyle’s death.
Late one afternoon I rang Elaine Hurry, the designated safeguarding nurse at the PCT, to discuss a difficult case I was dealing with. After giving me the advice I needed she asked if I knew anything about the appointment of a safeguarding nurse by the Trust. I did not. Most paediatric departments had by that time appointed properly trained safeguarding nurses. We had been requesting funding from the Trust for some years to establish this important post but had been repeatedly turned down. It was not a priority.
Elaine was probably the most knowledgeable person on safeguarding in NHS Walsall. She was a quiet, highly competent and mild mannered person but today she was mad. She told me that the post had been funded, the job description written and the appointment made without any reference to her or anyone else with safeguarding expertise. She had written to Karen Palmer, the Head Nurse who had made the appointment, to register her objections. I asked her to send me a copy of the letter. She did, that same day.
The letter rehearsed the reasons why the appointee, one of our own general nurses, was unsuitable for such an important post. Finally Elaine set this in its proper context:
“The need for this post was highlighted within the hospital in the last Serious Case Review undertaken by Walsall Safeguarding Children Board. Catastrophic mistakes had been made and the review concluded that if hospital staff had followed basic safeguarding procedures the child concerned would have survived. This can never be acceptable and highlights the need for a well trained and supported workforce, who could challenge decisions made by senior colleagues.”
It would have taken a certain level of experience and assertiveness to face down the particular senior colleague she had in mind, Dr Walia. Having read the letter my first port of call was the Divisional Director’s office. I went through every point Elaine had made and a few more. He told me this was a nursing appointment and he had to rely on the professional advice he’d been given by the Head Nurse.
“Karen can’t give you professional advice, she’s got no paediatric experience and she’s an amateur at safeguarding herself.” I said.
“Look, David, think about it like this. At least you’ve got a pair of hands that you didn’t have before. We’re making progress with this.”
“That’s nonsense Rob. You’re not listening. This is an important post. You weren’t here when Kyle Keen was killed. He’d likely still be alive if we’d had a trained safeguarding nurse; you’ve got that in writing. That means a properly trained nurse who would have over-ridden Walia’s incomprehensible decision not to get social services in. You’re just trying to keep the redundancies down with this appointment. That’s not helping the service and it’s putting children at continued risk.”
“Sorry David, we’re laying nurses off if you haven’t noticed. Politically there’s no way I could have advertised this post externally.”
“You mean this is out of your hands? OK, I’ll take it to the Chief Executive.”
I left, frustrated and angry at such bureaucratic stupidity. This was no way to run a dog’s home let alone a child protection service. It takes a lot to make me angry but I was furious. I spoke to a couple of other paediatric consultants but they knew nothing of the appointment either.
I counted to ten and took my time before writing to Sue James. Everything about this appointment was wrong. The nurse appointed to the post was a very good general paediatric nurse who I had known for years. I did not want to criticize her but she had no safeguarding training or experience and in my view was temperamentally not suited for the role. I concentrated on the facts that Karen Palmer had made the appointment by stealth without reference to the local experts including Elaine. If any of us had been involved the appointment would not have been made.
The post had not been advertised externally. HR failed to provide any evidence that it had even been advertised internally. Three nurses had apparently been given the choice of redeployment into this role or redundancy. The press was beginning to take notice of our nursing redundancies and these had to be minimized. The paediatric matron who had considerably more experience in safeguarding had wanted to apply for this post. He had been so badly bullied himself by the middle managers that he was forced to agree to a redundancy package. He was quickly snapped up to work as a safeguarding nurse at the largest childrens hospital in the country. Our loss.
Dear Lord, I was still a baby in those days. Naïvely, I expected a responsible answer from Sue James by return. Two weeks later, having heard nothing from her, I asked Rob Hodgkiss what the Chief Executive had made of my letter. He rolled his eyes. “I think you’ve got a good idea.”
Over the next two months a number of child abuse stories were aired in the national media. In nearby Birmingham the Kyra Ishaq case had shocked many who were used to hearing of such tragedies. Birmingham City Council’s safeguarding arrangements had been judged inadequate in every way following an Ofsted inspection; a fate Walsall would also suffer at a later date.
We knew that the Health Secretary had ordered a review of NHS hospital safeguarding services. This was about the only thing in my experience that would get those at the top of the organization to take notice. Even then the main concern would be that we ticked all the boxes. So, in December, almost 2 months after I had written my original scorcher to Sue James I wrote again to remind her that she had not even acknowledged my concerns. With respect to the anticipated Department of Health review I wrote:
“We are not well placed. Neither the medical lead (a gynaecologist), the head of nursing (a midwife) nor the non-clinical manager has any experience or knowledge of paediatrics or child protection. We have appointed a child protection nurse for the wrong reasons. The person in the department who best understands Laming has been bullied and has taken redundancy.”
Sue James’s PA emailed me to say they had not received my letter. I was able to respond immediately that this was not true. I had considered this letter so important that I’d had it hand-delivered by my secretary. The PA then emailed to say sorry but the letter had been lost, could I re-send it. The final story I heard from Sue James’s office was that the letter had arrived when she was on holiday and so it had been sent to the Divisional Director to deal with. I am afraid that story did not check out either. In the context of a child protection investigation we tend to get suspicious when the story keeps changing in this way. It would of course be unthinkable, possibly fatal, to challenge the integrity of a Chief Executive in these circumstances.
It was not until July the following year, nine moths after my original letter, that I got a definitive answer. This letter was possibly one of the finest examples of spin I have seen and relied heavily on information from the middle managers I had with justification criticized for this mess. Elaine Hurry, the safeguarding expert, had not been involved in the appointment, Sue James informed me, because “Karen Palmer was unaware that Elaine wished to be involved.” The post was, she said, a “good redeployment opportunity for interested nurses.” Everything had been done in line with Human Resource Policy at the Trust, I was assured. “It is always pleasing to note that our own staff are highly qualified to be able to apply for such posts and that it is not always necessary to search outside for such talent.” I laughed aloud at the absurdity of this self-justification. “The successful applicant had extensive knowledge and skills within the field of child protection,” she claimed presuming I was some kind of dimwit. This was all untrue and even a superficial reading of Elaine Hurry’s letter would have shown this. Sue James preferred, as Rob Hodgkiss had, to take her advice from Karen Palmer. Advice that was wrong but so much more comforting.
“Thank you for your interest in this matter, and apologies again for the delay in responding to your letter. Yours Sincerely, Sue James”
After six stressful months and many tears the foundation safeguarding post holder gave up the ghost and with some relief went back to general nursing duties. She had, no doubt, benefited from the experience, painful as it had been for her. But the service had not developed and a replacement was needed. Sue James may still have believed the department was bursting with native talent but I was pleased to see the post advertised externally. None of our own nurses were qualified to apply. I had contributed in a small way to developing the service but made enemies in the process. There followed a time of quiet but it would not be long before I found myself in a pitched battle to ensure the Trust was forced, once again, into taking its responsibility to protect children seriously.