GENERAL MEDICAL COUNCIL
FITNESS TO PRACTISE PANEL (PROFESSIONAL CONDUCT)
Monday 13 November 2006
44 Hallam Street, London, W1W 6JJ
Chairman:   
  
Dr Jacqueline Mitton 
Panel Members:
Mrs Leora Lloyd 
Mr Alexander McFarlane 
Dr Sameer Sarkar 
Mr Arnold Simanowitz 
Legal Assessor:   
Mr Robin Hay 
CASE OF: 
SOUTHALL, David Patrick 
(DAY ONE)
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 JOLLIFE 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) 

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I N D E X 
          
 
 
 
 
Page 
No
 
APPLICATION FOR ANONYMISATION and 
 
AMENDMENT OF THE CHARGES 
 
 
MR TYSON   
 
 
 
 
1 
 
 
MR COONAN 
 
 
 
 
2 
CHARGES 
READ 
     3 
 
ADMISSIONS 
 
 
 
 
 
7 
 OPENING 
SUBMISSION 
 
 
MR TYSON   
 
 
 
 
8 
 
APPLICATION (Evidence by video link) 
 
 
MR TYSON   
 
 
 
          45 
 
 
MR COONAN 
 
 
 
          51 
 
 
MR TYSON   
 
 
 
          54 
 
ADVICE FROM THE LEGAL ASSESSOR  
          55 
 
 
DECISION 
 
 
 
 
 
          56 

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A
THE CHAIRMAN:  Good morning, everyone.  This is a Fitness to Practise Panel hearing the 
case of Dr David Southall.  Dr Southall is present and is represented by Mr Kieran Coonan 
QC, instructed by Hempsons, solicitors.  Mr Richard Tyson, counsel, instructed by Field 
Fisher Waterhouse represents the General Medical Council.
Before we go any further, Mr Simanowitz wishes to make a short personal statement. 
B
MR SIMANOWITZ:  I have been asked about my connection with Munchausen cases.  
During my time as Chief Executive of Action for Victims of Medical Accidents we might 
have had some cases involving that, but I did not have any personal involvement and we 
certainly were not involved in any campaigns, or articles, or anything of that nature. 
THE CHAIRMAN:  I trust that statement satisfies any concerns that have been raised. 
C
MR COONAN:  Yes, indeed.  Thank you very much. 
MR TYSON:  Madam, there are a number of preliminary matters before the heads of charge 
are put to the doctor.  First of all, for the matter of the record, I do not act for the General 
Medical Council.  I act for five complainants – Mrs M, Mrs H, Mrs A, Mrs B and Mrs D. 
THE CHAIRMAN:  Thank you. 
D
MR TYSON:  Although I am also instructed by Field Fisher Waterhouse.  Secondly, next to 
your yellow sheet there may be a series of appendices.  These have been amended, and can  
I hand out the amended appendices, please.   
THE CHAIRMAN:  (Same distributed)  These are mutually agreed amendments, are they, 
Mr Tyson? 
E
MR COONAN:  If I can just clarify with Mr Tyson, they represent the original appendix with 
deletions, apparently? 
MR TYSON:  Correct.  There are no additions.  In appendix 1 under Child D, there is an item 
at the end, number 4.   
F
MR COONAN:  Yes, my copy does have that. 
MR TYSON:  Madam, I have two other applications.  First of all is that both the 
complainants and in particular the children should all be anonymised in this case, and I would 
ask that one refers to the mothers as “Mrs A”, or whatever, and the children as “M1”, as they 
appear in the heads of charge.  There is extreme sensitivity in this case.  As I understand it, 
my learned friend does not object to that course.  I make the point that in the course of the 
G
opening, or whatever, I may slip into error, and, for the benefit of the press, if I ever do, or 
anybody in this case does happen to mention a real name, I would ask for those to be 
disregarded by those in the gallery. 
The second application that I have is for two amendments to the heads of charge.  The first 
one is at paragraph 2, head of charge 2.  Can we insert the words, please, after “From 1992”, 
can we insert “and at all material times”.  I am grateful.  I do not know whether the 
H
appendices are formally put to the doctor, but there is one typographical error in the appendix 
T.A.  REED 
Day 1 -  1
 & CO. 

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A
that I have just handed out to the Panel, and that is on appendix 1, under Child D, under 
paragraph 2, which is the “Original copies of letters between third parties”, under 2.c. the 
letter should be from Dr Whiting to Professor Strobel rather than vice versa, so perhaps an 
arrow can be used to indicate that it is the other way round.  I apologise, but I do not 
anticipate that my learned friend has any objections to those courses of both anonymity and 
amendment . 
B
MR COONAN:  Madam, could I just deal with both of those.  There is no objection at all to 
the application for anonymity in respect of the children and parents, but I just echo what Mr 
Tyson said about inadvertent reference to parents’ names and children.  I think, despite our 
best human endeavours, we are bound to make some reference, I would have thought, as  
I say, inadvertently.  Secondly, and perhaps the most important, the documents that you are 
going to receive have not been anonymised, and so you will see the names anyway of the 
children and the parents.  That is where the risk of inadvertent reference may arise, 
C
particularly if one has to read from or to documents.  I hope you follow the point.  It is just to 
give you some advance notice or warning of that risk.  Subject to that, in principle no 
objection.
THE CHAIRMAN:  I would just like to add weight from the chair to comments that have 
been made about anonymity.  Should any name be inadvertently mentioned, it should be 
disregarded by members of the press. 
D
MR COONAN:  Thank you, madam. 
MALE SPEAKER IN THE GALLERY:  Madam Chair, there is a--- 
THE CHAIRMAN:  Excuse me.  Interruptions. 
E
MALE SPEAKER IN THE GALLERY:  It is just that I have interviewed two families 
already in respect of this case, so I do not understand the--- 
THE CHAIRMAN:  I am sorry, please could you be seated.  Thank you.  I think I ought to 
reiterate again quite clearly that, in connection with this case, and the reporting of this case, 
that names of individuals should not be mentioned. 
F
MR COONAN:  Madam, could I just make one observation following from the intervention 
from the press gallery.  I take it that Mr Tyson makes the application on specific instructions 
from the individual complainants.  I say that because the intervention carries with it a content 
which appears – appears – to be inconsistent with those instructions.  I say no more.  That is 
not intended to be mischievous in any way, but it may be, I do not know, Mr Tyson and  
I ought to have a word about it.  The press otherwise, of course, and I do not wish to be over-
pious about this, have a legitimate interest in reporting the proceedings, but if in fact the 
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parents have sought anonymity, then of course we should respect it, but I think I ought to 
clarify with Mr Tyson.  Perhaps you can deal with that now. 
MR TYSON:  Madam, in order for us to obtain and you thereafter to read material in this 
case, in these cases the Children’s Care Courts had the documentation, and application had to 
be made to the respective Care Courts to obtain the information for use at this Panel.  It was a 
condition in each and every case made by the relevant High Court judge who granted the 
H
applications that they would only give such if the anonymity of the children involved was 
T.A.  REED 
Day 1 -  2
 & CO. 

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A
respected, and I, on behalf of my clients when making these applications, gave that 
undertaking that the anonymity of the children would be respected.  It follows that if the 
children are made anonymous, therefore their parents should also be made anonymous, 
because otherwise one could get round it.  So I am bound by undertakings that I personally 
have given on instructions to High Court judges to preserve the anonymity of these children, 
and that is the basis on which I make the application, and I am quite happy to stand by that. 
B
MR COONAN:   Madam, that is very helpful to have that explanation.  I do not seek to 
abandon my agreement to it, in fact I adhere it, but I just leave it with this comment:  if an 
order for undertakings has been given by a High Court judge in respect of the anonymity of 
children in family proceedings, then the press ought to consider their position. 
MR TYSON:  I think my learned friend was going to go on to deal with the amendments. 
C
MR COONAN:  I am.  The second matter concerns the amendments.  Paragraph 2, there is no 
objection to that.  We agree it.  I should, I think, just invite Mr Tyson to consider what I think 
was going to be the subject of an application to amend in paragraph 18. 
MR TYSON:  My learned friend is quite right and I apologise.  I make an application to 
amend in respect of paragraph 18, to delete the last three words on the stay, so delete “in 
these respects”, and add instead “under paragraph 17”.  So that makes it clear that paragraph 
D
18 relates to paragraph 17. 
MR COONAN:  Madam, I agree with that amendment. 
THE CHAIRMAN:  So all those matters are dealt with by mutual agreement.  Thank you.   
I would now like to ask Dr Southall to stand and identify himself.  Doctor, the charges are 
quite long, so if you would prefer to remain seated while they are read out, that is fine.
E
Thank you.  I will ask the Panel Secretary to read out the charges. 
SECRETARY TO THE PANEL:  The Panel will inquire into the following allegation against 
Dr David Southall, MB BS 1971 Lond;  MRCS Eng LRCP Lond 1971 SR: 
That being registered under the Medical Act 1983, 
F
1. 
From 1982 you were a senior lecturer and subsequently also a consultant 
paediatrician based at the Royal Brompton Hospital, London; 
2. 
From 1992 and at all material times you have been professor of paediatrics at 
the University of Keele and also a consultant paediatrician at the North Staffordshire 
Hospital, Stoke on Trent; 
G
3. 
a. 
In January 1998 you were contacted by social workers from a local 
authority who had concerns about Child M2, and in particular about 
similarities between current events in Child M2’s life (including apparent 
suicide threats) and those in his elder brother, Child M1’s, life shortly before 
Child M1’s death by hanging in June 1996, when aged 10, 
b.
You gave the social workers certain advice, and on 29 January 1998 
H
Child M2 was removed from home under an Emergency Protection Order, 
T.A.  REED 
Day 1 -  3
 & CO. 

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A
c. 
Your advice was put into writing in a preliminary report dated  
2 February 1998, 
d. 
On 3 February 1998 the local authority applied for an Interim Care 
Order in respect of Child M2; 
B
4. 
On 17 March 1998 you were instructed by the local authority to prepare an 
assessment/report for them in the care proceedings.  Such report was to cover both 
Child M2 and his family; 
5. 
a. 
For the purpose of preparing your assessment/report you interviewed 
Mrs M on 27 April 1998, 
C
b. 
During the course of such interview you accused Mrs M of drugging 
and then murdering Child M1 by hanging him; 
6. 
Your actions as set out in 5.b. above, 
a. Were 
inappropriate, 
D
b. 
Added to the distress of a bereaved person, 
c. 
Were an abuse of your professional position; 
7. 
a. 
In March 1989 Child H was referred to you at the Royal Brompton 
Hospital by Dr Dinwiddie of Great Ormond Street Hospital for investigation 
and advice, 
E
b. 
Child H was admitted to the Royal Brompton Hospital, where his 
breathing was monitored, in September 1989 and again in March 1990, 
c. 
On about 22 March 1990 Child H’s parents informed you that they no 
longer wanted you to be involved in the management of  
Child H’s care; 
F
8. 
a. 
On 22 March 1990 you wrote to Dr Dinwiddie stating that, 
i. 
Child H’s parents were not acting in Child H’s best long term 
interests, 
ii. 
you were suspicious of their motives, 
G
iii. 
you viewed Child H’s long term prognosis with great concern, 
b. 
You copied the letter mentioned at 8.a. to an unnamed Consultant 
Paediatrician at the Royal Gwent Hospital even though no one there was 
involved in Child H’s care, 
H
c. 
You did not seek, nor obtain, Child H’s parents’ consent, 
T.A.  REED 
Day 1 -  4
 & CO. 

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A
i. 
to the fact of involving a local paediatrician in Child H’s care, 
or
ii. 
to any letter being sent to an unnamed local paediatrician, or 
iii. 
to the letter mentioned in 8.a., and in those terms, being sent to 
B
an unnamed local paediatrician; 
9. 
Your actions as set out in 8.b. and 8.c. above, or either of them, were, 
a. Inappropriate, 
b. 
In breach of Child H’s, and his parents’, confidentiality; 
C
10. 
In the cases listed in Appendix 1, 
a. 
You created, or caused to be created, an “S/C” File wherein certain 
original medical hospital records relating to the child were then placed, 
 
b. 
The cited medical record is not elsewhere in the child’s hospital 
D
medical records; 
11. 
The placing, or causing to be placed, of such original medical records in a 
“S/C” File, 
a. 
Amounted to tampering with the child’s hospital medical records, 
E
b. 
Caused any such item to be inaccessible to others involved in the 
medical care of the child at that time or in the future; 
12. 
Your actions as set out in 10. and 11. above were, 
a. 
Not in the best interests of the child concerned, 
F
b. Inappropriate, 
c. 
An abuse of your professional position; 
13. 
a. 
You treated both Child A and Child H at the  
Royal Brompton Hospital, and there created an “S/C” file for each child, 
G
b. 
Each such “S/C” file contained original Royal Brompton Hospital 
medical records, 
c. 
You took, or caused to be taken, the “S/C” Files relating to both Child 
A and Child H away from the Royal Brompton Hospital and to the North 
Staffordshire Hospital; 
H
14. 
Your actions as set out in 13.b. and 13.c. above were, 
T.A.  REED 
Day 1 -  5
 & CO. 

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A
a. 
Not in the best interests of the child concerned, 
b. Inappropriate, 
c. 
An abuse of your professional position; 
B
15. 
a. 
On the computer system held at the Academic Department of 
Paediatrics, North Staffordshire Hospital you maintained, or caused to be 
maintained, the medical records set out in Appendix 2, 
b. 
These computer medical records are not contained in children’s 
hospital medical records at either the Royal Brompton Hospital (for Child A 
and Child H) or the North Staffordshire Hospital (for Child D), 
C
c. 
Neither Child A nor Child H were treated at the  
North Staffordshire Hospital, but only at the Royal Brompton Hospital; 
16. 
Your actions as set out in paragraph 15. above, 
a. 
Were not in the best interests of the individual children, 
D
b. 
Amounted to keeping secret medical records on them, 
c. Were 
inappropriate, 
d. 
Were an abuse of your professional position; 
E
17. 
In the cases set out in Appendix 3 you failed to treat the respective children’s 
mothers in the ways set out below, or any of them, 
a. Politely 
and 
considerately, 
b. 
In a way they could understand, 
F
c. 
Respecting their privacy and dignity; 
18. 
Your failure/s in these respects, 
a. Were 
inappropriate, 
b. 
Were in breach of your duty to establish and maintain trust between 
G
yourself and the children’s mothers while they were acting with parental 
responsibility,
c. 
Caused distress to each individual woman;’ 
And that in relation to the facts alleged you have been guilty of serious professional 
misconduct. 
H
T.A.  REED 
Day 1 -  6
 & CO. 

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A
MR TYSON:  Madam, I am terribly sorry, but I noted when your Secretary was reading out 
the heads of charge that another error had crept into the heads of charge.  Could I refer you 
please to paragraph 15(b) and could I ask that at the end of head 15(b), when it says “(for 
Child D)” you add the words “and Child B.”  These are matters that only recently have come 
to light for reasons which I will give to you in my opening.  If my learned friend accepts the 
amendment perhaps that subparagraph can be put to the Doctor again. 
B
THE CHAIRMAN:  Mr Coonan? 
MR COONAN:  I have no objection to that. 
THE CHAIRMAN:  In that case this charge will be further amended.  So, that is “for Child D 
and Child B.” 
C
MR TYSON:  Yes, in the brackets at the end of 15(b). 
THE CHAIRMAN:  Mr Coonan, does Dr Southall admit any of the facts alleged? 
MR COONAN:  Madam, yes.  Without any comment at this stage could I just take you 
paragraph by paragraph please?
D
Paragraph 1 is admitted in its entirety.  Paragraph 2, as amended, is admitted in its entirety.  
Paragraph 3(a) is admitted, save in respect of the two words on the penultimate line “by 
hanging.”  Paragraph 3(b) is admitted in its entirety.  Paragraph 3(c) is admitted in its 
entirety.  Paragraph 3(d) is admitted in its entirety.   
Paragraph 4 is admitted in its entirety.  Head 5(a) is admitted in its entirety.   
E
I move now to head 7.  Head 7(a) is admitted in its entirety.  Head 7(b) is admitted in its 
entirety.  Head 7(c) is admitted in its entirety.  Head 8(a), the stem is admitted; (i) is admitted, 
(ii) is admitted and (iii) is admitted.  I move to head 8(c).  As to the stem of 8(c), that is 
admitted.  I move to (c)(iii); (c)(iii) is admitted.   
I move to paragraph 10.  The stem is admitted and 10(a) is admitted in this respect:  all of that 
sentence is admitted save in respect of the phrase “medical hospital.”   
F
I move to paragraph 13.  Paragraph 13(a) is admitted; 13(c) is admitted.  Paragraph 15(a) is 
admitted.  Paragraph 15(c) is admitted.  Those are all the admissions which are made at this 
stage.
THE CHAIRMAN:  I therefore need to announce that the following facts in the heads of 
charge have been admitted and are found proved:  Head 1, 2, 3(b), 3(c), 3(d), 4, 5(a), 7(a), 
G
7(b), 7(b), 7(c), 8(a), (i), (ii) and (iii), 8(c)(iii), 13(a) and 13(c), 15(a) and 15(c). 
MR COONAN:  Madam, I think you omitted to refer to head 10(a). 
THE CHAIRMAN:  Mr Coonan, you admitted that with a reservation. 
MR COONAN:  Yes, I did. 
H
T.A.  REED 
Day 1 -  7
 & CO. 

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THE CHAIRMAN:  Which means that at this stage we cannot find that proved. 
MR COONAN:  Then I understand.  Thank you. 
THE CHAIRMAN:  We should have included 15(a) and 15(c). 
MR COONAN:  You did. 
B
THE CHAIRMAN:  Mr Tyson, do you now open the case? 
MR TYSON:  Madam, this is a complainant case being heard under the old Rules.  I act for 
Mrs M, Mrs H, Mrs A, Mrs B and Mrs D.  These are all parents of children with whom 
Dr Southall has come into contact.   
C
Dr Southall’s professional history in brief is as follows. He qualified in April 1971 from
St George’s Hospital in London.  He obtained his Membership of his Royal College of 
Physicians in October 1973, medical doctor in 1981 and Fellowship of the Royal College of 
Physicians in 1991.  He was appointed to his first consultant post in 1988 at the Royal 
Brompton Hospital in London.  In 1992 he moved to North Staffordshire as a consultant and 
was made Foundation Professor of Paediatrics at Keele University.
D
I understand that Dr Southall retired as a full-time consultant in November 2004 and that 
since that time accordingly his Foundation Professorship has automatically lapsed.  So, 
formally he is no longer a professor, but I will call him a professor at the times he was a 
professor in these heads of charge. 
It is important to know at an early stage, in view of the interest that this case has aroused, 
what his case is not about.  This case is not about wrongful or hasty diagnoses of 
E
Munchausen’s syndrome by proxy, or fictitious or induced illnesses.  Nor is it about unlawful 
research involving infants with bona fide medical conditions.  There is no evidence before 
you relating to these matters.  They are not covered in the heads of charge and any 
speculation that these matters might be dealt with in this hearing and should be discounted. 
What this case is about can broadly be put into two separate areas.  The first area concerns 
the conduct of Professor Southall towards parents of children with whom he had had 
F
professional involvement.  The second main area is what we say is the inappropriate retention 
by Professor Southall, or at his behest, of documents about cases with which his department 
had had some professional involvement.
I will return to the detail in a moment, but suffice it to say that heads of charge 3 to 6, 7 to 9 
and 17 to 18 are heads of charge that fall within the first category, that of misconduct towards 
parents and children.  Heads of charge 10 to 16 are heads of charge that fall within the second 
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category, namely the inappropriate retention of documents. 
Turning to the first category of charges: inappropriate conduct by Professor Southall towards 
parents of children with which he had a professional dealing, the heads of charge break down 
into three subcategories.  First of all, heads of charge 3 to 6, in turn the M family, and in 
particular Child M2; heads of charge 7 to 8, in turn Child H; heads of charge 17 and 18, in 
turn Child D and Child M2. 
H
T.A.  REED 
Day 1 -  8
 & CO. 

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Very broadly, heads of charge 3 to 6 deal with an incident that took place in an interview by 
Professor Southall of the mother of a child, M1, who we say had committed suicide.  There 
were concerns in respect of the second younger son, M2.  The heads of charge arise from 
what is alleged that Professor Southall said to the mother at interview, namely the accusation 
that the mother had, in fact, killed her first child. 
Heads of charge 7 to 8 arise out of a Child, H, who was referred to the hospital where  
B
Dr Southall was working at that time, namely at the Royal Brompton Hospital, here in 
London.
The heads of charge in respect of a letter that Dr Southall wrote to the referring doctor, which 
was also copied to an unnamed paediatrician and a hospital where we say had no dealings 
with this child at all. 
C
Heads of charge 17 and 18 arise from two incidents where we allege that Professor Southall 
failed to treat in an appropriate manner the mothers of children with whom he was 
professionally involved.  The particulars of those two incidents are set out in your 
Appendix 3. 
The first relates to Child D and the comments made to the mother in December 1994.  The 
second relates to Child M2 and arises out of the interview with M2's mother, referred to just 
D
now in April 1998. 
Before I take you to the documentation in respect of these three discrete matters, can I sketch 
in outline the heads of charge relating to the second category, namely inappropriate retention 
by Professor Southall involving documents and other cases. 
As with the first category, these heads of charge break down into three subcategories: heads 
E
of charge 10 to 12 are discrete, heads of charge 13 and 14 are discrete, and heads of charge 
15 and 16 are discrete.
Heads of charge 10 to 12 arise out of the creation by Dr Southall, in his department, of a 
completely separate and parallel set of medical records relating to patients who came into his 
department at the Royal Brompton Hospital and subsequently at North Staffordshire Hospital 
when he went there in 1992.  Such files are called “special cases” files, or for short “S/C” 
F
files.  They had their own separate numbering system and were kept separately from the 
child's hospital medical records. 
The heads of charge arise because within such parallel files can be found certain original 
hospital medical records relating to the patient, which are not to be found elsewhere within 
the child's hospital records. 
G
Whilst the special cases files all contain documents and information that is duplicated 
elsewhere in the child's hospital medical records, these heads of charge arise because these 
files also contain documents, and original documents at that, which contain certain 
information not duplicated elsewhere.  The importance about these original documents not 
elsewhere is that we say that these are hospital records and should be in the hospital records. 
Appendix 1 sets out the documents upon which this head of charge is brought, it being noted 
H
that it relates to four different children: Child A, Child B, Child D and Child H.
T.A.  REED 
Day 1 -  9
 & CO. 

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You will note that the heads of charge at 7 to 9, unauthorised copying of the letter, also 
relates to Child H, and that the heads of charge at 17 and 18 also relates to Child D, so 
different children appear at several times in the course of these heads of charge. 
The point which I make now, and will make it again in the course of my Opening, is that in 
Appendix 1 these are all original documents and it is a non-exclusive list of examples of 
B
original documents to be found in the special cases files. 
 The restricted heads, the Appendix to the children with whom we are involved, I understand 
that, in fact, though we are referring to four special cases files, there are at least some 4449 
special cases files in all to be found, so we are dealing with a small aspect of a large system 
of parallel files being held by the respondent doctor. 
C
In 1992, when Dr Southall was transferred from the Royal Brompton Hospital to the North 
Staffordshire Hospital and became the foundation Professor there, heads of charge 13 and 14 
relate to what we say was the inappropriate transfer of the Royal Brompton special cases files 
where they were taken to North Staffordshire. 
Heads of charge 15 and 16 arise out of a yet further set of records kept by Professor Southall, 
which were in addition to the ordinary hospital medical records and were in addition to the 
D
paper special cases files.  These heads of charge, 15 to 16, relate to the computer files which 
are detailed at Appendix 2. 
These files were found on Professor Southall's own computer held at the Academic 
Department of Paediatrics at the North Staffordshire Hospital.  These computer files include 
information about child patients who were dealt with at the Royal Brompton.  Children A and 
H were Royal Brompton Hospital patients, yet their computer records upon them were held at 
E
North Staffordshire. 
I hope this introduction has given you a general idea of the landscape which we will be 
covering in the days ahead.  I will now turn to each of the heads of charge in more detail by 
referring you to the documentation. 
Can I first refer to heads of charge 3 to 6, which relate to the M family?  Can I give you three 
F
panel bundles, please.  I will just ask for panel bundles 1, 2 and 3 at this stage.   
THE CHAIRMAN:  These will be C1, C2 and C3.  (Documents marked as such and 
distributed)  Could I take this opportunity, Mr Tyson, to ask you: could you possibly speak 
up?  We have one panel member who has some difficulty hearing.  I must admit, I find your 
voice quite quiet in this large room and I think your microphone is a bit concealed behind 
your boxes. 
G
MR TYSON:  I have never been accused of being quiet before, but I will see what I can do.   
THE CHAIRMAN:  I am assuming these are being given out in order, are they? 
MR TYSON:  They should have on their spine: 1, 2 or 3.  If they could be marked with a C 
appropriately, in due course that may assist.  
H
T.A.  REED 
Day 1 -  10
 & CO. 

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Madam, if I can give you a brief guide through the bundling.  In C1, tab 1 relates to the M 
family.  Towards the end there you will see a tab 2, which relates to the H family.  In C2, this 
contains the balance of section 2, which is the H family.  Section 3 is the A family.  Section 4 
is the D family.  Section 5 is the B family.  Section 6 relates to material produced by 
Professor Southall from time to time relating to special cases files. 
In C3 there are a number of reports from Professor Tim David, who has been instructed on 
B
behalf of the complainants, and also within C3 are various protocols from time to time 
existing relating to the storage of documents. 
So in order to tell the M story I would ask the Panel, please, to have C1 before them.  
Madam, Mr and Mrs M did not have a typical married life.  They were married in the mid-
80s, they divorced in 1986.  They remarried again in 1987, they divorced again in 1991, but 
continued thereafter to live under the same roof.  There were two children of the marriage:  
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M1, who was born in February 1986, and M2, who was born in February 1988. 
Catastrophically for the family, on 3 June 1996 Child M1, then only ten years old, was found 
dead, hanging from a belt from a curtain pole in the family home.  At a coroner’s inquest an 
open verdict was recorded with the options considered by the coroner of either suicide or 
accident.  How and why M1 died became an important feature later when Professor Southall 
became involved in this case. 
D
The mother’s version of how he died can be found by looking at tab (g) in C1, and you will 
see on the first page that this is a witness statement given by the mother on 7 June 1996, 
which was some four days after the death of the child.  I take you to page 404 at the bottom.  
I can say at this stage you will find some rather eccentric numbering in the course of these 
bundles because these are effectively core bundles from a number of other very large 
bundles.  If I can take you to page 404 and pick up the story, as we see in September 1995, 
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which was about nine months before the death of M1, and I will read it: 
 
“In September 1995, at the age of nine, M1 looked forward to going to his new class;
[his] teacher was Mrs Stones.  After his first day I asked him about his teacher and 
M1 said, ‘Yes, she’s all right’.  From September until now everything at home has 
been fine between Mr M and myself.  Mr M was working at [a firm in] Shrewsbury 
working nights and our paths would cross in the morning.  I would get the children up 
F
and Mr M would see them off to school. 
 
In relation to M1, letters began to be sent home saying that M1’s behaviour was 
unacceptable”.
Pausing there, that is letters from school 
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“I was shocked when the first letter came.  I had met Mrs Stones but this was the first 
time I actually went to speak to her about M1.  Mrs Stones appeared to talk down to 
me, she did not seem to have a very high opinion of M1.  She told me about the little 
things like not paying much attention in class, or that it took M1 an hour to write the 
day and date at the top of [the] page. 
 
M1 had told me [that] he would put his hand up to ask a question or ask for help and 
H
he used to say she would go to everyone else and leave him until last.  He said Mrs 
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Stones shouted at him for only writing the day and date;  M1 often said that she 
shouted at him for ‘stupid things’ he would say.  I was very concerned about her 
attitude towards M1 then but when I saw Mrs Stones she put it in a matter of fact sort 
of way.  It seemed like it was a case of ‘if he can’t be bothered why should I’.  I felt 
then that there would be problems to follow. 
 
I am aware from what M1 ….. said [about] the kicking under the table continued by 
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Lisa ….. and some …… members of his group.  There was also the flicking of pencils 
and rubbers and M1 would always get caught retaliating and get told off.  I was 
continuously each month back and to from school to speak with the headmaster and 
Mrs Stones about M1. 
 
M1’s behaviour got gradually worse;  he said that he felt she hated him but he never 
expressed how he felt about her until recently.  I always asked him but did not say 
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much about her. 
 
There was a point where M1 was becoming difficult at home, cheeky, stubborn and 
had a did not care less attitude as well as being difficult at school.  This is when I 
discussed M1 with the school and was in total agreement that he should be put on a 
home/school behaviour book.  I talked with Mrs Stones who suggested M1 should be 
rewarded for good behaviour and I agreed with this.  The book has pages for each 
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week and can get a maximum of five points for each day.  M1 brought the book home 
and when he had a good day I praised and rewarded him.  M1 was happy because he 
could see that we were pleased [with him] which made him feel good himself.  I knew 
1 could do it, he just needed some motivation to get him going and some reassurance.  
I also made comments at the end of the week as to his performance. 
 
From the beginning of the behaviour book the system worked very well.  I think that 
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in a way he was glad of the book as he was happier in his work and it seemed to iron 
out his problems.  M1 was on the home/school behaviour book for five weeks, during 
which time M1 could not have been more pleased in himself and his work.  He would 
be very chuffed if he came home with a ‘5’.  During this time I maintained my contact 
with Mr Stanley” – that is the head teacher – “and Mrs Stones;  we were very pleased 
with [the] progress.” 
F
I need not trouble you with the next paragraph. 
 
“M1 came off the behaviour book and things were fine.  I still maintained regular 
contact with the school.  I was not aware of any problems at school after coming off 
the behaviour book. 
 
Towards the end of May M1 came home and said that Mrs Phillips had shouted at 
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him.  He said he had put his hand up for help and did not get it;  he ended up [being] 
sent to Mr Stanley.  I asked M1 why he was sent to Mr Stanley;  he said he did not 
understand the question and was ‘stuck’ and Mrs Phillips shouted at him so he just sat 
there because he [could] not understand.  I asked M1 exactly what had happened and 
wrote a letter to Mr Stanley, writing M1’s words as he said it.” 
I need not trouble you with the next few lines. 
H
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“During the week’s holiday at the end of May everything was fine.  On the first 
weekend we all went to my mum and dad’s, the rest of the week was spent with” – the 
child there mentioned, who is not a relative – “going swimming or playing out.” 
 
On one day during the holiday M1 got up before any of us and went out.  We all 
thought he was still in bed when we got up;  M1 often stayed in bed in the morning 
when he was tired so we did not think he had gone anywhere.  He had in fact gone to 
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Richard’s and did not get home until the evening.  I thought that he would be home if 
he got hungry and if he was at Richard’s his mum would give him a butty.  It was M2, 
when he got up, who told us that M1 had gone to Richard’s so I was not worried. 
 
On Sunday, 2nd June … I took M1, M2 and [a friend] swimming at [a pool in the 
county] at about [6 o'clock];  M1 was happy as a lark, he loves swimming.  He went 
to [a] Swimming Club and really enjoyed it.  He was always eager to get up on a 
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Saturday morning to go with M2.  In the last three months M1 has seemed 
uninterested and not felt like going. 
 
M1 went to bed on the Sunday night at about 8.30 ... as it was school the next day.
Before he went up he said, ‘Goodnight Mum, I love you’, and I gave him a kiss on the 
cheek.  He then went to bed and Mr M went up after him as he has left for work in the 
morning before M1 gets up.  Mr M said he had told M1 that he would be seeing him 
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Tuesday.
 
Again, in about the last three months, M1 has begun to close his bedroom door at 
night without lights but started keeping his curtains open.  Before this he always 
[used] to keep his door open and normally the bathroom light on.  On a few occasions 
in the last couple of years, after M1 had been told off, he would say, ‘You hate me 
and you don’t love me’.  We would both reassure him and tell him we loved him more 
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than anything else in the world.  He would always say sorry after, as we did for 
shouting.  At these times he would say he was going to run away but never did. 
 
On Monday morning Mr M had already gone to work when M1 and M2 got up.  I got 
up with Mr M at about 4.00 am and did not go back to bed.  I got the kids sandwiches 
ready and their books and did odd jobs around the house. 
F
 
At about eight o'clock I got the kids breakfasts ready, Frosties, as usual, with hot milk.  
I shouted them from the bottom of the stairs, as I always do, and they got up straight 
away.  The boys came down, said good morning and ate their breakfast.  They got 
changed into their uniform and I let M1 wear his new trousers as he had asked me to.  
They did their normal everyday things and left for school together as they usually do 
unless M1’s in a bit of a mood then he goes off on his own.  Again, as always, we all 
had a kiss and told each other that we loved each other. 
G
 
I returned home from work at about 2.20 pm and went to a friend’s house and had a 
cup of tea.  At about five past three I walked to [the primary] school to speak with 
Miss Thomas, M2’s teacher;  I wanted to speak to her about M2 fighting with another 
child.  When I got to the school I saw [the head teacher] was on his own so I thought
I would speak to him.  I apologised to him about M1 and the letter that had been 
written because M1 had not told me the truth, as I thought.  We had a chat for about 
H
ten minutes and he told me that M1 had been put back onto the home/school 
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behaviour because they had problems with M1 that day.  He said that [the] problems 
had been brewing before half term.  I was not [aware] of the problems other than the 
letter that were written. 
 
I said I was going to see Mrs Stones before I saw Miss Thomas.  I saw her in the 
classroom, there were no children around, I apologised to her for misjudging the 
incident M1 had told me about.  She said M1 had been ‘particularly difficult’ that day 
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and felt he needed to go onto the behaviour book again, I agreed with this as it [had] 
worked well last time.  Mrs Stones suggested that I sit in on the class to see whether 
M1 would be embarrassed by my presence;  we arranged this for Tuesday, 11th June. 
 
I saw Miss Thomas just as she was going into a staff meeting, [and] talked about M2 
and I was quite happy.  M2 and his friend saw me talking to the teachers and waited 
outside the classroom [with] me.  I asked them where M1 was and M2 said he was 
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playing football ….. at the after school club. 
 
I walked home with M2 and his friend and stopped so we could see M1 playing 
football.  The friend of M2’s shouted to M1 who turned round and waved.  We then 
continued to walk home, M2 and I got home, M2 got changed and went out to play.   
I started to write a letter. 
D
 
M1 came home at about [4 o'clock];  he walked into the living room and was very 
quiet.  He said, ‘Hiya Mum’ but without enthusiasm.  He took his coat, bag and hat 
off and sat down on the sofa.  I said to M1 that I had been to see [the head teacher] 
and he had made me feel small because he had not told me the whole truth about what 
had happened.  I said, ‘….. we need to have a talk’, like we always used to if we had a 
problem.  All M1 kept saying was ‘Lisa did it, Lisa got me into trouble’.  I had to 
interrupt him and say, ‘Well, it’s not Lisa who’s on report, and it’s not Lisa’s 
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education I’m worried about’.  M1 then began to cry.  I said to [him], ‘We’ll finish 
talking about it when I’ve finished this letter.’  I did not shout at him and he stopped 
crying when he realised I was not angry about it.  M1 then said, ‘I’m going upstairs 
for a bit, Mum.’  He seemed all right .,… I asked him, as he was going into the 
hallway, if he would tidy up his bedroom and M1 said, ‘Yes’.  M1 often went up to 
his bedroom to watch television, read, listen to music or just have a lie down. 
F
 
I stayed downstairs, had a cup of coffee and finished writing my letter.  I did not hear 
a noise upstairs, I usually hear him pottering about. 
 
M2 came home and I asked him if he fancied some chips for his tea, and he said he 
did.  He wanted his friend to go with him.  M2 called for his friend, I gave him two 
pounds and asked him to get two large portions of chips, one for him and one for M1. 
G
 
One thing I have just remembered is that a couple of minutes after M1 had gone 
upstairs he came back down to answer the door to his friend, Richard.  M1 came into 
the front room and asked if he could go out with Richard, I said no and that he was 
grounded until we had had our talk.  On any other occasion I would have let him go 
but I wanted to speak to him before he went.  I do not know what he said to Richard, 
he did not say anything else to me and went back upstairs.   
H
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Day 1 -  14
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At about quarter to six I decided to go to the toilet upstairs.  I sat on the loo with the 
door open and could see straight into M1’s bedroom as the door was open.  I could 
see M1 in the window, I thought the other side of the bed.  I thought he was standing 
there watching me.  I realised he could not have been standing there because he 
looked too tall.  I thought it was odd that the curtains were shut.  At first I could not 
see anything else. 
B
 
I got up and ran into the bedroom as I knew something was not right.  In the bedroom 
I found him hanging from the wooden curtain rail by a belt which was round his neck.
The belt was attached to the rail tidily, not knotted;  it was as if the end of the belt had 
been wrapped round the rail over itself.  The belt had been looped through the buckle.
The buckle was digging into the front right hand side of M1’s neck.  I realised straight 
away, by his pupils being dilated, that he was dead.  His eyes were wide open, his 
arms were hanging by the side of his body and it did not look as if he struggled.  The 
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bed was pushed diagonally away from him. 
 
I felt in my own mind that I had to revive him but I knew it was too late.  I could not 
get him down at first, I tried lifting him up to relieve the pressure on his neck and 
tried to pull the curtain pole off the wall but could not.  I had to undo the buckle 
around his neck whilst still trying to hold him ... to get him down. 
D
 
I lay M1 on the bed in the recovery position and ran downstairs and dialled ‘999’.
I told the operator what service I wanted saying, ‘I need an ambulance quick, my ten 
year old son has just hung himself.’  I ran back upstairs and tried to resuscitate M1 on 
the bed and could not do the chest compressions properly as the bed was going up and 
down.  I picked M1 up and carried him downstairs laying him ….. on the living room 
floor where I carried out CPR and mouth to mouth.  In the meantime food kept 
coming up from his stomach and I could not keep his airway clear. 
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I was still working on M1 when the ambulance crew arrived and took over.  I went 
with M1 in the ambulance to ….. Hospital where, on arrival, it was confirmed that 
[he] had died.” 
In the coroner’s inquest material, madam, you will find at (y) within this bundle C1.  Ignore 
the first page for the moment.  You will see the material from the coroner’s inquest and  
F
I need, alas, to take you through some of this.  Can I ask you to go to, I think it is, about the 
second or third page in, which has 187 at the bottom?   
The coroner opens the inquest saying: 
“This is an enquiry into the desperately sad death of ten year old [M1].  We shall hear 
evidence that on his first day back after the Whitsun break at School he was put back 
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on report.  We shall hear evidence from his teacher …  We shall hear evidence from 
the Headmaster … who saw him.  We shall also hear evidence from the football 
supervisor who took him for football practice, we shall also hear evidence from [a 
police officer] who had conversations with some of the young boys that [M] spoke to 
as he walked away from football practice. We’ll hear from [Mrs M] that when he got 
back from home after football practice she spoke to him about the events at school 
that day.  We shall hear that [M1] went up to his bedroom and we shall hear from 
H
[Mrs M] that at about quarter to six, she went up to [M1’s] bedroom where she found 
T.A.  REED 
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[M1] hanging by his neck with a leather belt attached to the curtain rail.  This is a 
particularly distressing case and [Mrs M], I will try and make it as easy for you as  
I can.” 
He then deals with the witnesses that are to be called, and again I am afraid I will have to take 
you, because it is material, to the pathologist’s report or evidence which is at page 188.   
B
Before I get there, madam, you will note that in various of these things there are various 
marks or lines.  Can I ask you to ignore any marks or lines on any of this documentation? 
THE CHAIRMAN:  Mr Tyson, I do not want to interrupt you at a critical point, but when you 
are ready would you like to suggest a time that it would be convenient for a short break? 
MR TYSON:  This is as good a time as any, before I take you to the pathologist’s report. 
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THE CHAIRMAN:  It is now twenty-five past eleven.  We will take a 20-minute break until 
quarter to twelve.
(The Panel adjourned for a short time)
THE CHAIRMAN:  If you are ready, Mr Tyson. 
D
MR TYSON:  Madam, I was taking you to the evidence of the pathologist at the inquest of 
M1, which is at page 188 within tab (y).  The pathologist’s indicates in the second paragraph: 
“On external examination the body was that of a boy of approximately 10 to 11 years 
of age in a good state of nutrition.  At the time of my examination rigor mortis was 
present.  I noticed that there were marks around the neck consistent with a belt having 
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been used as a ligature around the neck.  The marks were up to 3 cm wide and they 
passed from 7 cm below the left ear, across the front of the neck over the thyroid 
cartilage to 2.5 cm below the right ear.  The belt had been removed, previously, but 
this was 112 cm and 3 cm wide entirely consistent with this being the belt that had 
passed around the neck.” 
For those who have not quite reached the decimal age, 112 cm is about 48 in. 
F
“I noted there was a small amount of dried vomit in the mouth and on the clothing and 
I am sure this had been brought up during resuscitation attempts.  Again, as a result of 
attempted resuscitation, there was a needle puncture at the inner side of the right 
elbow, defibrillator marks in the centre of the chest and the left mid chest and 
electrodes below the left and right clavicles and on the left lower chest.  I noted there 
were small bruises at the front of the right lower leg, a small bruise either side of the 
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left knee.  These were very minor bruises such as any 10 year old might have in just 
day to day living.  There was an old appendecectomy operation scar. 
On internal examination, I found that the brain was swollen with excessive fluid and 
the carotid arteries, the main arteries passing to the brain in the neck had been 
compressed by the belt.  This had cut off the blood supply to the brain and I am sure 
death would have occurred, well loss of consciousness would have occurred, in a 
H
matter of seconds with death following with no regaining consciousness.  This 
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wouldn’t have been painful, the neck was intact and there was no evidence that [M1] 
had attempted to unloose the belt after he had suspended himself so I think loss of 
consciousness was extremely rapid and painless.  Elsewhere, I found no evidence of 
natural disease process or of any injuries.  There were scattered petechial 
haemorrhages as a result of the asphyxial changes of hanging.  I noted these were 
around the heart and in the chest cavities and over the thymus gland in the front of the 
chest.  Again, I noted in the airways there was a small amount of inhaled gastric 
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contents, presumably as a result of attempted resuscitation.  There was no evidence at 
all of the airways being significantly restricted by the belt and I am sure he didn’t 
choke or anything like that.  In conclusion, I consider that death was due to 1(a) 
Cerebral ischaemia due to 1(b) Compression of blood vessels in the neck due to 1(c) 
Hanging.”
Turning a few pages on to page 193 you will see the post mortem report.  I need not repeat 
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that to any extent.  I just point out this page because it may be (and I stress the “may”) that 
these marks are in fact the marks made by Professor Southall rather than any other person. 
Then between pages 198 to 204 is the evidence of the mother, which is broadly in terms of 
the witness statement which I read out to you, and the decision of the coroner is at the end of 
the bundle, internal numbering 223. We are still in section (y); it is almost the last two 
documents within section (y). 
D
The coroner says: 
“On that evidence, I find that [M1] died [in the place there mentioned] on 3rd June 
1996 between 4.45 and 5.45 p.m.  The medical cause of death is 1(a) Cerebral 
Ischaemia, (b) Compression of blood vessels in the neck and due to (c) Hanging. 
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Before I give my verdict, I offer my sincere condolences to you, Mr and Mrs M, and
I hope that you and [M2] can sometime come to terms with these events. 
My duty today is to reach a positive conclusion, if I can, as to [M1’s] death.  Of the 
conclusions open to me, positive conclusions, one is that he killed himself and the 
other is that it was an accident.  There are factors and pieces of evidence pointing both 
ways.  In favour of suicide verdict and I would emphasise that to record that, I have to 
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be satisfied beyond reasonable doubt that he did commit suicide.  In favour of a 
suicide verdict would be the statement which he made to his young friends as he left 
the football pitch that he was going to do it and as we have just heard, indeed 
something which he had said in the past.  Not only did he say he was going to do it,
I say it in inverted commas, within an hour or so he hanged himself.  It cannot have 
been an accident that the belt became wound round the curtain rail, it cannot be an 
accident that it was placed round his neck, there is no sign of struggle, [Mrs M] heard 
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no noise and the bed appears to have been pushed away.  [Mrs M] also thought that 
[M1] did or was capable of understanding his actions.  Those are the factors pointing 
to suicide.  Against that, there are factors pointing to an accident, strange as it may 
seem.  The most notable is [M1’s] age.  He is only 10 and one must be very, very 
cautious indeed in giving a 10 year old intention and if this was a criminal case he 
would barely be over the age of criminal intent.  [The teacher] thought he was not 
capable of understanding the finality of his action, [M1] had left the bedroom door 
H
open, it was normal, perhaps he thought maybe someone would come across him.  He 
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told his father he was looking forward to Disney world, he’d enjoyed playing football, 
he said to the teacher although he may not have told the teacher/supervisor what was 
in his mind that he was going to play next week and he would have gone out to play 
with his friend had he not been grounded nor did [M1] leave any note or message for 
his family.  These factors support both views and in my judgement no set of 
circumstances exclude the other.  I do not believe there is evidence to substantiate a 
verdict of either suicide or accident and in the absence of that evidence, I must return 
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an Open Verdict.” 
The point I make here, and it is relevant in view of matters that come out, that in no way in 
the course of the inquest was a third alternative suggested, namely that Mrs M had murdered 
M1.
Mrs M has always believed, and indeed stated so at the time, that suicide was the true verdict, 
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a suicide brought about by bullying at school and seemingly, it was felt by her, reinforced by 
the teacher at the time. 
The death of M1 was in June 1996.  In early 1998 Child M2 was nearing the same age that 
his brother had been when he died.  The local authority became involved.  The reason for the 
local authority’s involvement was there was concern about the similarities going on in Child 
M2’s life compared with those going on in Child M1’s life just before he died.  The basis of 
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these concerns is set out in a local authority document called an Interim Initial Assessment 
Report, which was prepared by a lady called Francine Salem, who is a senior social worker in 
the local authority.   
Madam, this report can be found at (b) in section 1, so it is the second tab in C1.  I need only 
take you to see that the subject matter of this was M1.  It gives M1’s date of birth and where 
he lives.  It sets out the household contribution and the significant others, who are of course 
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M1, and gives M1’s date of birth and date of death.  It indicated that the assessment team had 
no involvement with the M family and that a Part 8 review (that is a sort of social services 
review) was undertaken in 1996 following the death of M1, who was found hanged in his 
bedroom.  I need not take you through this.  It is a document which I suspect we will have to 
come back to in the course of evidence.  I just need to take you to page 358 of this report and 
take you to paragraph 8 of the report, where the social worker says:
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“Ultimately, there appear to be a lot of similarities between M1’s life and now M2ss.  
I do not believe that 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 a victim of parent 
induced illness, which in turn placed a large question mark over M1’s experiences and 
ultimately his death.” 
G
Parent induced illness is another label for Munchausen syndrome by proxy, which is in turn 
another label for FII or Fabricated an Induced Illness.  The broad definition of that is where 
a child is caused harm by a parent either fabricating illness in a child or exaggerating illness 
in a child or causing illness in a child, and through that came attention for the mother.  That is 
a very broad description of a very difficult concept. 
Following that preliminary assessment by the social worker, she then contacted 
H
Professor Southall and she wrote to him.  We see that at tab A in the bundle, where she 
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indicates that she had a telephone conversation with him and she enclosed a copy of her 
report, which is the one I have just made reference to, the chronology from the Part 8 review, 
the review itself and the witness statements, the magazine interview of Mrs M and her contact 
sheets and look forward to an early response. 
Again, there is manuscript on this; it may or may not be, we cannot say which way, whether 
this is Professor Southall's manuscript.  That is on the 23rd.   
B
The next event happened, or marketing event, happened on 26 January where the local 
authority had a strategy meeting where they sought to decide what to do.  The minutes of this 
strategy meeting are at tab (o) in C1.  You will see from the manuscript page 1 on that that 
a number of people attended who may have roles to play subsequently in the story.  I draw 
your attention to the third name down, who was the director of nursing at the local hospital 
where Mrs M worked.  You will see two names after that: Francine Salem, who is the author 
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of the report I have just read.  You will note that there is a Miranda Garrard, legal division 
there.  She is relevant in view of the documents which I am going to take to you which has 
her initials on it as the author, and there is a Dr Solomon, from three lines up from the 
bottom, who I will be calling as a witness in this matter, albeit she has now changed her name 
to Dr Cornfield. 
There is a general discussion about the child over the pages. If I can take you to in turn 
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page 6, we pick it up in the middle where it says “a document has been prepared by a senior 
social worker”.  She has prepared a number of hypotheses.  If we go to page 17 of this tab we 
see the three hypotheses on page 17.  The first hypotheses was MDBP, but I think that should 
be MSBP.  It sets out all the factors that supported that hypothesis.
Then the second hypothesis is dealt with at page 18, which was: “M2 was being emotionally 
abused by his mother through commission and omission”.   
E
Hypothesis 3, which is the best case scenario, that all was effectively well. 
Going back, please, to page 6, and we see under the mention of the hypothesis in the middle 
of the page, we see item 1, which is effectively the first hypothesis:
“Ms Salem informed the meeting that she has grave concerns about the similarities in 
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which the boys live.  The threats should be taken seriously.  The hospital 
presentations are another concern, are they parentally induced?  The presentations 
themselves are very unusual.  She is awaiting feedback from Professor Southall in 
North Staffordshire.  He is to provide a preliminary report on information already 
submitted.  He has already advised to take the concerns very seriously.” 
At a subsequent statement that Ms Salem made in some court proceedings that thereafter took 
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place she expands on that.  Can I take you to tab (u), please, in the same bundle?  This, as we 
see it from page 1, is a witness statement by the social worker on 3 February.  Just to put it 
into context, can I take you on page 2 to the third paragraph, where the witness says: 
 “I first became aware of the M family on 20 January 1998 following a referral from 
the director of nursing at the local hospital where Mrs M works.  It is my 
understanding that Mrs M has been spoken to regarding her high number of absences 
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from work, the reason given for these absences by Mrs M was that she was looking 
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after her son, M2, who was being bullied at school and had threatened to kill himself.  
In light of the nature of the death of M1's brother in 1996 the director of nursing felt 
concerned enough to contact the initial assessment team.”  
Over the page, under the words “continuation sheet” and under the second paragraph, page 3, 
she says:
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“At this time I believed that there was a similar pattern being established with M2 as 
there had been for M1.  I was concerned at this and contacted Professor Southall at 
the North Stafford Hospital to request his opinion.  He suggested to me that on the 
basis of the information I had given that he believed Mrs M had Munchausen 
Syndrome and that this would have serious implications for M2's welfare.  In light of 
the concerns raised a multi agency strategy meeting that was held on 26 January”,  
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which I have just taken you to.
“On 28 January myself and the team manager visited Professor Southall who had the 
opportunity to read all the relevant documentation.  He confirmed his belief that 
Mrs M had Munchausen Syndrome and that she presented a high risk to M2.  It was 
his opinion that we should remove him the same day.”  
D
She then goes on to make reference to a strategy meeting held on 29 January; we can see that 
strategy meeting can be found in tab (r).  You can see from the list of attendees that the 
principal person involved in this case, Ms Salem, was not initially at that meeting because at 
the same time as this meeting was being held she was at the local court getting an order for 
the removal of the Child, M2, from his parents' care. 
Going back to looking at the background at page 2, we are now familiar, looking at the 
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central paragraph:
“It had been agreed that police and Social Services would make some individual 
enquiries and also some joint enquiries.  An approach would be made to the GP and to 
the Headteacher.  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.” 
F
In the next paragraph, we pick up a mention of a Dr WS, a GP.  W 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 action should be taken to 
protect M1.  He had not been to school for three days.  Various calls have been made to 
further the investigation.  
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At the bottom of the page, it says that the person then mentioned told the meeting he had 
spoken to, I think the CB person is a senior social worker,
“... spoken to them on the telephone and was able to give information about the 
meeting with Professor Southall.  During the interview with Professor Southall 
contact had been made with Dr Arnon Bentovim and he felt that action should be 
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taken and also he would wish to see M2 himself.  Both Professor Southall and 
Dr Bentovim confirmed that they would be prepared to put their advice in writing.” 
Over the page, to the GP confirming that she had spoken to Professor Southall to run through 
information concerning the mother.  At the top of page 3:  
“He felt that this supported his feelings.  At lunchtime today a call came through from 
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Mrs M to say that she had heard from a neighbour who had been listening to Citizens 
Band radio that Social Services and police were arranging to pick up M2 and she was 
very agitated.” 
Then going to the third paragraph, the lady there mentioned, that is the director of nursing 
who reported the concerns at the beginning,
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“... had spoken to Professor Southall on Tuesday when he said he had limited 
information but felt that M2 was at risk and should be removed immediately.  He 
asked her as much information as possible.  She then contacted Francine Salem and 
the mother and suggested they have a direct link with Professor Southall, which they 
did.  He did not directly say why he thought the child was at risk.  He asked how 
Child M1 had died; he had not received a report.  He also inquired about the referral 
of M2 was told that there were a number of attendance at Accident & Emergency.  
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There was concern because M2 had been talking about suicide.  He also about Mrs M 
in terms of working at the hospital.” 
There are recommendations at page 6 and Child M2 would be placed with foster carers and 
police and Social Services would jointly plan further enquiries. At 4, as part of the enquiries 
the police would be linking with Professor Southall and Dr Bentovim. 
E
There was, as I said, an application for an emergency protection order, which I need not take 
you to, but you may care to note that the application was made on 29 January and it is at (p).
The order itself was granted on the same date, that is at (q).  I will take you to (q) and you see 
that it relates to: an emergency protection order was given to the applicant, Francine Salem.  
The court authorises the applicant to remove the child to accommodation provided for or on 
behalf of the applicant. 
F
For those of you not familiar with the operation of the Children Act, this is a draconian order 
which if there are particular concerns the child can be removed at a moment's notice from the 
home and it is an order of limited duration.   
Thereafter, Professor Southall provided a very preliminary report under cover of a letter of 
30 January, albeit the report was dated 2 February.  By now, returning to the heads of charge, 
you will see that I have dealt with head of charge 3(a), that you were contacted by social 
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workers from the local authority who had concerns about M2, and in particular about 
similarities between the current events and Child M2’s life, including apparent suicide 
threats, and those in his elder brother, Child M1’s life shortly before Child M1’s death by 
hanging in June 1996 when aged 10.
Note as it were my eyebrows raising at the way in which the admission or lack of admission 
was made to the words “by hanging” in 3(a) in view of the material that have seen from the 
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inquest.
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3(d) has been admitted.  I am just taking you to 3(c) which is the preliminary report which we 
find at tab (t). 
I am just going to highlight various matters in that.  The Professor went through the various 
documentation with which he had been provided, and this is a document on page 177.   
He records at paragraph 1 that he had read the interim initial assessment report, which is the 
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document that you have seen, and over the page at 2 he records he read Mrs M’s police 
statement, part of which I have read to you.  He records at 3 a list of injuries to M2, and at 4 
he records a list of injuries to M1.  At 5 on page 179 he records that he had seen a 
chronology, and at 6 he records what he has seen from the social services’ notes.  At 7 he 
records an article written presumably by or with Mrs M about her experiences.  Over the page 
at 8 he records a note from the police about Mr M, and then at 9 he deals with the statement 
of Mrs M, which I read out to you in some considerable detail earlier on.   
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What is intriguing, if I take you to page 181, is where he is commenting on this statement 
about the death of M1, which I read out to you, and he says, if you see it in the paragraph in 
the middle of page 181: 
 
“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.  
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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.” 
He then goes on to look at other statements that had been provided, from the statement of  
Mr M;  the statement (11) of the head teacher;  the statement (12) of the school teacher;  the 
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statement at 13 of the lunchtime supervisor;  the statement (14) of the teacher in charge of the 
football training, which Child M1 was doing just shortly before he came home on the night 
that he died.  He deals with a report at 15 of the Director of Nursing and ultimate employer of 
Mrs M.  He then at 16 deals with the minutes of the strategy meeting held on 26 January, 
aspects of which I have taken you to.  Then he deals with his initial and very preliminary 
opinion, at paragraph 17 on page 183, where he says: 
F
 
“In the light of all the above information I contacted Dr Arnon Bentovin, a Child and 
Adolescent Psychiatrist who [is particularly interested] in life threatening child abuse.  
He informed me that suicidal hanging of a child of only 10 years [old] is a very rare 
phenomenon.  He felt that the history now surrounding M2 and the very sinister 
similarities between what [was] 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. 
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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 and provide a high quality foster [home] for him.  
He wondered [about] an independent fostering agency such as the [one there 
mentioned]. 
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I ... discussed the situation with the family’s GP.  I was informed by the GP that  
Mrs M ... [was] a regular attendee at the GP surgery.” 
He sets out the matters there involving matters. 
 
“I asked about sick notes from work and apparently she [has] only had 2 sick notes in 
the past year.  This [was] despite [the Director of Nursing’s] reference to the fact that 
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she is frequently off work. 
 
From the family history she pointed out that Mr M was a rare attendee at the surgery 
…
 
Turning now to the GP records on M2, the family doctor reported … that he had 
recently been alleged to have [been passing] black stools over a 3 day period.  Mrs M 
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had not presented him to the hospital or to the doctors with this at the time.  The GP 
records also reveal information on the injuries but, as with the hospital records that we 
have to date, these are very scanty. 
 
Returning to the mother the GP felt that her attitude was unusual and the GP also 
commented on the fact that following M1’s death the neighbours had collected a lot of 
money for her family and she had used it to go on holiday.” 
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Advice, paragraph 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 emergency protection 
order and place M2 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
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Dr Bentovin.  I also felt that the mother should be offered psychiatric support.  I feel 
that all medical records relating to the children in [this] family, including M1, should 
be examined.” 
He lists the hospitals from whom he would like to see the records.  Then importantly: 
 
“Information about M1’s death needs to be identified, in particular the post mortem 
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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.” 
Then he made the declaration that are made. 
We can see, and I need not take you to it, but it is at tab (w), that there was an application in 
early February for an interim care order, and that is head of charge 3(d).  It is a matter of law 
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that an emergency protection order lapses after I think it is seven days, and unless you apply 
for an interim care order, then the child will return.  That was in the February an interim care 
order was made, and in the beginning of March, following a contested hearing in the local 
County Court, Mr and Mrs M were successful in obtaining the return of Child M2 to their 
care after an absence of about forty-odd days. 
In the care proceedings Professor Southall was formally instructed to provide a report in 
H
respect of Child M2.  I need to take you to that, which is at tab (x) in the bundle, and it is the 
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subject of the admitted head of charge 4.  We see the local authority is instructing Professor 
Southall, and the subject of the assessment is Child M2: 
 
“Thank you for agreeing to provide an assessment/report in this matter.” 
It sets out who the solicitors were representing all the parties.  It sets out in page 2 a brief 
history of the matter, including the fact that the child had been returned to the parents, and at 
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page 3 asked for the issues that Professor Southall was asked to address.  They are at page 3, 
1-7, and they included: 
“1. 
The implications of the family’s (including both parents and M1) medical 
notes in the context of the functioning and history of this family and the 
possible implication for the care of M2. 
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2.
Whether the children’s ([i.e.] M1, M2 and parents) presentations at GPs and 
hospitals are unusual and if so consideration of the impact of the presentations 
to [the] hospitals on [the children’s] physical and emotional development. 
3.
The concerns raised in the papers. 
4.
Is it possible for you to comment on M2’s condition as a Consultant 
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Paediatrician and bearing in mind that he will [also] be examined by a 
Consultant Child Psychiatrist, the reasons for it and your diagnosis if possible. 
5.
Attribution in relation to this condition. 
6.
Advice on any management plan, treatment and prognosis … 
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7.
Please look at the Local Authority’s concerns [about] M2’s pattern of medical 
history [which] shows similarities to that of M1.” 
Importantly, you may think, is the next paragraph: 
 
“Could you please ensure that your Opinion is confined to the medical issues:  the 
question of disposal of the [local authority’s] application is of course a matter for the 
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Court at the final hearing.” 
They were pretty wide-ranging issues that Professor Southall was asked to address, but not, 
you may think, a full-ranging quasi criminal inquiry into the cause of M1’s death.
In the course of preparing the report, Professor Southall requested and obtained an interview 
with the mother.  This interview took place on 27 April 1998.  This interview is the subject of 
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head of charge 5 and 6, and also head of charge 17, 18 and Appendix 3.  At the interview, 
present when my client Mrs M arrived for this assessment was Professor Southall, who she 
did expect, and the social worker, who she did not expect, as this was, as it were, a private 
medical assessment for Professor Southall to assess the child. 
She will give an account of how she saw that interview when she gives evidence before you, 
but effectively she will tell you that, in her view, Professor Southall put pressure on her to 
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admit that she had drugged and then murdered M1 by hanging him, and effectively accused 
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her of committing homicide, and that virtually the entire interview, or consultation, or 
assessment in her view was concerned with the Child M1 and hardly at all covered Child M2.   
The kind of questioning she will tell you that she heard was what did her job entail.  She 
worked in the theatre of the local hospital as some low order auxiliary nurse person.  She was 
asked what her job entailed;  did she have any access to any drugs;  had she seen injections 
being given;  was she ever left alone with patients?  She was asked extensive questions about 
B
M1, including how tall was he; how heavy was he;  why was she stating that he was being 
bullied;  what proof was there to substantiate the bullying;  had she made up the bullying;  
had M1 reached puberty;  whose belt was it that M1 had used;  why had the mother not heard 
anything?  
There came a point in the interview where it got to a stage where she was being asked very 
close questions about the death of M1, and there came a point where she advised Professor 
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Southall that she had been in turn advised by her solicitor not to say much more, and she will 
tell the Panel, I anticipate, that Professor Southall told her that if she did not answer the 
questions, then she must be guilty of murdering M1.
She will tell you, I anticipate, that there was extensive discussion about how M1 had tied the 
belt round the curtain pole and his neck, and she will, I anticipate, tell you that Professor 
Southall repeatedly said that if she was innocent she should have no problem answering all 
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the questions that he was putting.  She will tell you that she attempted to answer about how 
the belt had been tied round the curtain pole, demonstrating with a pencil and a shoe-lace to 
indicate.  If I had a shoe lace I would show you, but I have not.  When she demonstrated how 
the belt had been tied round the curtain pole, she will tell you, I anticipate, that Professor 
Southall indicated somewhat sarcastically, “Ah, very clever”, or words to that effect. 
Then there came a point at which she will say that Southall said to her that M1 must have 
E
died in one of three ways.  He said that either it was an accident because he had been 
experimenting sexually, or it was a suicide, and then I anticipate that Mrs M will say that, 
before they got to the third option, Professor Southall said, “I will tell you how M1 died.  
You drugged him, after obtaining drugs from the operating theatre where you worked, as M1 
would not have allowed you to kill him.  You waited for M1 to go to sleep, and you then 
wrapped the belt round the curtain pole, lifted him up and then buckled the belt around M1’s 
neck and waited until he had died”.   
F
Not unnaturally, Mrs M was extremely distressed at that interview, at the manner of the 
questioning, the rather hectoring tone of Professor Southall, the fact that the interview 
seemed to be entirely concerned not about M2 but about M1, and in particular she was 
extremely upset by the accusation made to her face that she had murdered her own child.  
She returned to where she lived, and very shortly thereafter she went to see her solicitor,
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Mrs Parry, from whom you will also hear.  Mrs Parry made some notes of that interview 
which you will see at (gg), and they are at internal page 13.  That document is the manuscript 
note made by the solicitor at the time which goes from page 13 to 15.  Thereafter is an 
attendance note dictated by the solicitor arising out of the same interview with both her and 
my client, which is at page 16 and 17.   
In the manuscript note, if I can take you to that at page, 13, because the manuscript is 
H
reasonably easy to read, Mrs M is describing the interview.  She says: 
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“Went in & found Francine was there …  I asked her what she was doing there. 
He [that is Professor Southall] kept saying to me I know this is going to be very 
painful as I have to ask Q’s. 
He got me 1st of all to draw a picture of the upstairs of the hse … as he wanted to get 
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it clear from my mind.  Nor could I see through from the toilet into the bedroom.    
I did this, he wanted me to tell him where the position of the bed was before & after, 
how long the curtain rail was & how thick was, how it was fixed in.  I said it was 
screwed in.  He then wanted to know if it was my belt …  I told him [M1’s].  He 
insisted it was … I told him it was [M1’s], asking me how many holes.  I told him  
I didn’t know or what width it was.  He then x-examined me accusing me of lying that 
the pole didn’t break.  I answered them as best I could, he asked how I got on with 
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Dora Black”, 
and that is a child psychiatrist involved in the case, 
“& asked if I could get my … [something] .. at work.  I told him I wasn’t a nurse, 
asking me if I’d seen the anaesthetist saying I would know how to inject s’one. 
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He said did I know no toxology report, he mentioned about [Mr M] going to prison 
after assault. 
[M1] was cremated. 
He questioned me about the bullying, he said serious allg [allegation] … 
[M1’s] accident with scold. 
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He was looking at Francine, who just stood there smirking. 
He said if it can’t be proven. 
He asked if I’d spoken to any of the other children about committing suicide.  I said 
no … 
F
At end he said you don’t like Mrs Stones. 
The only question asked about M2 was about the bruise at 9 months old.
 – I can’t remember. 
He said if nobody can prove that [M1] did or didn’t kill himself through bullying. 
He suggested that I kill him & that I either suffocated him, drugged him and then 
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hung him. 
He eventually pressurised me. 
He said it was very comments. 
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That she’s been questioned by [M2], he’s asking why is there a court hearing in May, 
and what happens after that.  He’s saying he doesn’t seem to know that there is still an 
application for a care order & is unhappy he hasn’t been told.” 
So within a day the mother reports her concerns about the nature of that interview to her 
solicitor, and in addition within a day she attended a pre-arranged appointment with  
Dr Solomon, now Dr Cornfield, who is a consultant in charge of adolescent psychiatry.  At 
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that meeting Mrs M also made her concerns clear about the nature of the consultation that she 
had and we can see this at tab (ee).  This is the manuscript note of Dr Solomon dealing with 
this matter.  You can see on page 2 that it is a note of Mr and Mrs M attending with the child 
and dealing with matters, but about two-thirds of the way down you see “re Dora Black”, and 
then two lines after that you see, “re Professor Southall.”  It is about two inches from the 
bottom: 
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 “Mrs M went yesterday.  Mr M not there: job.  Saw Mrs M on her own. She found i/v 
offensive and upsetting.  F. Salem also present which she didn’t like – questions like 
“they didn’t do toxicology – quite possible you drugged him first.”   
Felt accused of killing [M1] & it wasn’t about [M2] at all.” 
Professor Southall also made notes about this meeting and they can be found at tab (bb), of 
which there is a typescript account at tab (cc), in the next tab.  Of interest before we get to the 
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wording is that at page 161 is the diagram, which I anticipate my client will say that it was 
hers, and you will see that she was on the loo in the bathroom with the open door and she 
could see across the landing to the bed there placed and that the window was directly 
opposite in her view from the loo.  I think the manuscript says: 
“Front door.
Hanging middle of the rail. 
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Thin pole, 3cm wood. 
Screwed into wall at both ends – No middle support.   
Wooden brackets.” 
Then I think it gives the store where the curtain was bought from.   
“Curtain stopped at radiator.
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Nets on the windows.” 
Then at page 163 is a picture of the belt and a picture below that of how the belt was double-
looped round the pole in the way there set out. 
Then we have rather posher versions of the same diagrams at page 164 to 165, a continuation 
of Professor Southall’s notes setting out the matters. 
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I am taking you now to tab (cc), which is the typescript version of the notes dealing with the 
key issues about M1, about bullying, other children kicking and hitting him, the teaching 
picking on him and shouting at him.  M1 had twisted the story and in fact mum apologised to 
one of the teachers.  Dealing with matters: 
“At the time of the appendix Mum was living in a nursing home …   
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18/m – 2 yrs before [M1] dies was the last violent incident.  Worst thing had been 
rape, pushed over and slapped. 
Not seen by children/likely to have been heard by the children. 
Rang 999 from downstairs.  [M1] was already downstairs.  Told woman that my son 
has hung himself and she said Oh and put the phone down.  Then Mum started 
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resuscitation. 
Ambulance arrived, men ambled down garden path.  They said ‘We didn’t realise 
how serious it was’.  Can’t remember whether a drip was put up or not.  In the 
ambulance they were doing some form of resuscitation.  Mum was present. 
Ambulanceman said he was sorry because one of his friends had hung himself 1-2 
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weeks earlier …”. 
Then we go through the interview.  There is another account of this interview taken by the 
social worker and it is rather confusing to go through it this way, except I merely ask you to 
flick through it – you have ample time to do it in due course – and you will find that the 
mention of M2 was extremely scanty.  There is one mention of M2 at internal page 3, two 
mentions of M2 at internal page 3, and a mention of M2 at page 5 and a checklist at page 6 – 
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various checklists which Dr Southall made where he says: 
“Wrong belt 
Needle (denied seeing injection) 
Toxicology
Phone by ambulance put down 
Check ambulance report on this 
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Football time was ok 
2 friends told kill himself (1 has since had nervous breakdown and tried to kill 
himself). 
10/12 prior to death police involved with domestic dispute.” 
He deals with M1 and sets out matters about M1’s medical matters, and deals with M2 and 
sets out medical matters relating to that, and Mrs M, and sets out matters relating to her. 
F
Also, in relation to this meeting, the social worker who was present produced an account and 
that account is in a number of places in the bundle, but I would like you to look at tab (gg) 
please, page 23.
Madam, I will have to read this into the record because what I would ask you to note is that 
each and every paragraph appears really to relate entirely to M1and not to M2.   It says: 
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“Following a request by Pfr Southall I agreed to be present during his discussion with 
[Mrs M] on 27th April at City General Hospital, Newcastle Under Lyme. 
Pfr Southall began the discussion by talking with [Mrs M] about the suggestion that 
[M1] had been bullied by both students and a teacher.  [Mrs M] confirmed this, 
suggesting that [M1] had sorted the children’s bullying out by retaliation and this had 
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stopped it.  She stated that the key areas relating to this type of bullying were [M1] 
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being kicked, having his clothes pulled about and books kicked across the ground.
[Mrs M] did not feel that any school would acknowledge that bullying was going on 
within their school.  With regard to the kick that [M1] sustained from Lisa … [Mrs 
M] stated that [M1] had been complaining of pain two days later, not all the time, but 
it had been niggling him, so she had decided to take him to hospital. 
When discussing the alleged bullying by the teacher, [Mrs M] suggested  … 
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MRS LLOYD:  I am sorry, we do not seem to have the correct reference. 
MR TYSON:  Hopefully you are in tab (gg) at page 23.  I am sorry.  I have reached about the 
third paragraph of that: 
“When discussing the alleged bullying by the teacher, [Mrs M] suggested that there 
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had been problems from the very beginning of [M1] being in [Mrs S’s] class and that 
she wouldn’t listen to him.  [Mrs S] was alleged to have reduced [M1] to tears and 
ignored him when he had his hand up (asking for help) for half an hour – [Mrs M] had 
witnesses to this …”, 
and she gives some names. 
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“[Mrs M] went on to acknowledge that on one occasion [M1] had twisted his version 
of events leading his mother to apologise to a member of staff, having written a letter 
to the school. 
Pfr. Southall referred to [M1’s] appendectomy.  [Mrs M] confirmed that she was 
living at the nursing home at that time and it was [Mr M] who called the GP. 
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[Mrs M], when questioned, stated that the last domestic violence incident was 
approximately 18 months prior to [M1’s] death.  She went on to say that the worst 
incident of violence between her and her husband was when he ‘pushed her over, 
slapped and raped her.’  She assured Pfr. Southall that the children had not witnessed 
these incidents. 
With regard to [M1’s] death [Mrs M] recalled that when she had found [M1] the 
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curtains were drawn and there was also netting at the window. 
[Mrs M] stated that the belt [M1] used to kill himself was a brown leather belt, it was 
his own and was a belt to his jeans.  This was returned to [Mrs M] following the 
inquest.
When asked about phoning the ambulance, [Mrs M] stated that when she rang 999 
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and told the woman that her son had hanged himself, she just said ‘Oh’ and put the 
phone down on [Mrs M].  When the ambulance men did arrive, [Mrs M] described 
them as ‘ambling down the garden path’, and that they seemed more concerned about 
the family dog biting them.  The ambulance men are then alleged to have said ‘We 
didn’t realise how serious it was’.  [Mrs M] didn’t see the ambulance crew working to 
resuscitate [M1] as she was taken into the kitchen by a Police Officer.  [Mrs M] stated 
that she went with [M1] in the ambulance.  One of the ambulance men said that he 
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was very sorry to her, because one of his friends had done the same thing a few weeks 
T.A.  REED 
Day 1 -  29
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previously.  At the hospital [Mrs M] was taken to the relatives room.  Pfr. Southall 
then referred to the O/D taken by [Mr M] and [Mrs M] suggested that this had been 
accidental as he had been drinking as well as taking painkillers for his back.” 
Pausing there for a moment.  The entirety of this interview so far is connected with M1, not 
M2.
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“When Professor Southall asked Mrs M about the magazine article she stated that she 
had typed the letter herself, sent it to the magazine there mentioned.  She had not kept 
a copy and had declined the £200.  Mrs M recalled she received a call from the 
researchers of the television programme there mentioned out of the blue and said that 
she had not wanted to go on it.  It was a programme on bullying.  Regarding the 
scalding incident to M1, Mrs M stated that she was with a friend called Mrs Stage, 
who is no longer friendly with Mrs Stone, who had declined to come to the court 
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in March.  Mrs M was aware that M1 had told two boys that he was going to kill 
himself although she had not spoken to them herself.  Mrs M stated to 
Professor Southall that one of the boys had had a nervous breakdown and tried to kill 
himself shortly after the inquest.  He tried to cut his wrists.  His name was the name 
there given.  He subsequently moved to live with his gran.” 
There was then a discussion about M1’s height and weight.
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“It is then indicated that M1’s feet were not far from the floor where he was hanging.  
Mrs M confirmed that M1 was aware of the forthcoming holiday to Disneyland 
booked for September 1996.  Mrs M then gave an explanation of the tyre blow injury 
to M1, suggesting that it had just exploded as the school bus pulled away.  The driver 
got out and rubbed M1’s leg.  Mrs M reported the incident to the school.  Mrs M 
stated that her husband had taken the curtain rail down and put it in the bin along with 
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the curtains.  He had to use a hammer to get it down.  Regarding the occasion when 
M1 was out all day during the school holidays, Mrs M said that she was aware of his 
whereabouts because he had rung from his friend's home.  Also, M2 had seen him go.  
He knew where he was going.  Mrs M stated that she had not seen M2's black stools 
but had taken him to the GP when M2 had told her of them.  She suggested she was 
not aware of the significance of black stools.  Professor Southall asked Mrs M about 
a bruise to M2 at 9 months old.  She stated that he had toppled over and hit his face on 
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the settee.  She had gone to the GP because it swelled up.  Mrs M violently denied 
that M2 had ever said he wanted to kill himself.  Only on one occasion did he say to 
her he felt like he wanted to hurt himself.  Mrs M acknowledged that she may have 
been the one to interpret this as killing himself.  Mrs M said that she did not feel that 
M2 was being bullied at school as that sort of thing is nipped in the bud at that 
school.”
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With regard to Mrs M’s absences from work prior to M1’s death, eg 1995 to May 1995, she 
had 38 days off.  “Mrs M stated that she must have been fed up with her job at the time.  
Mrs M indicated that she and her husband did not attend the child and family service 
appointments together because of work commitments and they believed the appointments to 
be for M2 only.  Mrs M was adamant that the woman there mentioned was lying in her 
statement which says that Mrs M had told her on four occasions that her son was threatening 
to commit suicide but states that she said this only for once, for which she was given care 
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leave to sort it out.” 
T.A.  REED 
Day 1 -  30
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Professor Southall then went through three scenarios with Mrs M as follows: 
“1, that M1 died accidentally through experimentation.  2, that he intended to kill 
himself.  3, that he was murdered.  Professor Southall asked Mrs M about her 
knowledge of syringes and injections.  She said she didn’t know how to inject 
someone.  She had never seen it done in theatre as she was the other end of the patient 
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from the anaesthetist. Mrs M said she had tried to pull the rail down when she found 
M1 hanging but she could not.  She also stated that the pole had never come down 
before.  Mrs M was adamant that M1 had taken his own life because he was being 
bullied at school, not because things were bad at home.  She states that life at home 
was good for M1.  Mrs M believes that there had been a cover-up at the school and no 
one would admit that bullying is and was going on.  Mrs M had several witnesses 
regarding the issues of bullying, one lady there mentioned her son has threatened to 
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kill himself and said ‘now I see how M1 felt’.  To the lady there mentioned, her eldest 
daughter was in Mrs S’s class.  She had lost weight and hair and was put on 
tranquillisers.  The Head Master was approached but kept saying ‘leave it with me’.  
Quite a few other parents, approximately 40, were all willing to make similar 
allegations about Mrs S and had apparently written to the local newspaper to 
complain about this teacher.  Mrs M said that it was Mrs S who led M1 to kill himself.  
Mrs M initially declined to talk Professor Southall about how the belt was tied round 
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M1's neck.  Mrs M said that she would be pleased to talk about it if it cleared her 
name, but she had been advised not to by her solicitor.  Professor Southall told Mrs M 
that he felt that this was a crucial piece of information and was needed.  Mrs M did 
tell Professor Southall that she felt she wanted to prove her innocence and that she 
could do this through explaining how the belt was tied.  Mrs M confirmed that the belt 
did belong to M1, Professor Southall suggesting that it was, in fact, an adult's belt and 
Mrs M maintaining that it belonged to her son, M1.  Mrs M demonstrated the way the 
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belt was fastened using a piece of wire.  The belt was folded in half.  The middle was 
then folded over the pole and the two ends were brought up in the middle leaving the 
two ends of the belt dangling down.  These were fastened around his neck.” 
THE CHAIRMAN:  Mr Tyson, have we reached a point where it might be convenient to 
break?  
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MR TYSON:  I have reached a point, thank you very much.  I just looked to see what the 
time was. 
THE CHAIRMAN:  As you anticipated, the names did slip out there.  I just have to reiterate 
what was said at the beginning this morning.
It is now coming up to ten past one,, so we will break until ten past two. 
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(Luncheon Adjournment)
MR TYSON:  Just before the lunchtime adjournment, Madam, I had read to you the 
attendance notes of the social worker involved at the interview, which is the subject matter of 
head of charge 5.  As you can see, there is, to this extent, broad agreement between Mrs M 
and the social worker in that the vast majority of the time spent in this interview was spent 
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considering the circumstances surrounding the death of the eldest child. 
T.A.  REED 
Day 1 -  31
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Also, to a limited extent, the social worker agrees, as it were, that the three options were put, 
the essential difference, of course, is that we would say that when the third came to be put it 
was not put as an option, it was put as the Professor's view. 
That the Professor carried on in what we would say the role more of a detective or a Crown 
Prosecutor in relation to this matter, rather than dealing with the medical aspects of this case, 
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can be shown at a subsequent file note made by the social worker when she listed the 
follow-up matters that she is asked to deal with.  This we see at tab (v) in C1.  These are her 
contact sheets which we may have to go to in the course of the evidence, but need not deal 
with it at this stage, save as to take you to page 101 in these contact sheets and take you to the 
entry at 27 April, at the bottom of page 101, where it indicates: 
“Professor Southall contacted the assessment team this morning.  He requested I be 
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present during the discussion with Mrs M today.  This was agreed.  See report.”   
I have read to you her report.  Over the page:
“The reasons that Professor Southall suggested I be present during the discussion with 
Mrs M was because he would be addressing the following issues: who the belt 
belonged to, how was it wrapped round the pole, was toxology done, question needle 
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mark in M1's arm.  Felt it would be useful if a social worker was present.”   
These are matters as we would say with Professor Southall wearing his, as it were, detective 
hat rather than his medical hat. 
The matter is made clearer, we would say, if one looks in the same bundle, C1, at (dd), at 
internal page 71 and 72, which are the first two pages, which again shows we would say 
Professor Southall's state of mind at this time.  This is an attendance note by the lawyer, the 
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one that I indicated on one of these strategy meetings was present, the lawyer Miranda 
Garrard, as we can see from her initials on page 72.  She had a telephone conversation with 
Professor Southall.  She dates the attendance notes the 27th.  I do not know where the 
conversation was.  It is headed “related to Child 2, telephone call out to Professor Southall”.  
Then can I take you to the third paragraph.  Professor Southall spoke to Francine regarding 
the curtain rail.  He feels that M1 would have weighed about 30 kilogrammes.  He does not 
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feel that any pole could take that weight.  With the additional G force 30 kilogrammes 
suddenly being pulled downward by gravity he feels the force would be about 100 
kilogrammes and cannot believe that a curtain pole could carry that.  Professor Southall's 
understanding is that the police had no real concern whatsoever that there may have been foul 
play involved in M1's death, and apparently the pole was subsequently burnt by the family.” 
The paragraph after that:
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“He was concerned if evidence comes from the police investigation that Mrs M could 
have killed M1, then M2 will be at risk because she has nothing to lose in terms of 
punishment.  She could argue she was mad if she killed two children. 
Over the page, at page 72, the last paragraph: 
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T.A.  REED 
Day 1 -  32
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“He was most insistent to have whatever information was possible that police had 
managed to glean about the curtain pole.  He is anxious that some serious 
investigations were done and the effect of a 30 kilogramme person hanging on a 
curtain pole.” 
After the interview, again the matter, the criminal aspects we would say, were pursued by 
Professor Southall.  We have at page 77, which is the next page, a plan of action.  This is 
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a plan of action drawn up by the social worker, Ms Salem, (1) involvement of forensic 
pathologists, (2) speak to other persons identified, check details of statement with the person 
there mentioned and check the feasibility of being in the toilet of M's address or being able to 
see the middle of M1's curtain rail.  Check the contents of the 999 call.  Check with the 
person there mentioned if Miss M could see syringes used.  (7) Check if ambulancemen, A & 
E, injected M1.  Did the ambulanceman really have a friend who had done the same thing 
recently?  Did Mrs M decline the £200.  Check the boy who cut his wrists.  Measure the 
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height of the rail, window, from the floor.  All these matters go, in our submission, to 
Professor Southall’s state of mind at the time, what he was thinking, and he was clearly 
thinking highly along criminal matters which we would say make it more likely than not, 
indeed overwhelmingly likely, that he was going almost blindly down one track, namely to 
suggest that there had been an unlawful death in the case of M1, and that accordingly Mrs M 
says what she does about the way the interview went.  These documents show how 
preoccupied with this aspect the Professor was. 
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Finally on this subject, can I take you to page 84, which again, as I understand it, is an 
attendance note from the local authority solicitor when she made a call out to the Professor on 
15 May, this is about a fortnight after the interview, and asked him about his report and when 
it would be available.  He said he would do his best but his report was only preliminary as he 
had four questions and was still awaiting reply: 
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“1. 
One was that he was waiting for information regarding the issue of the curtain 
rail.  He found it hard to believe that 30 [kg] couldn’t break this curtain pole.  
In his experience he finds it hard enough to believe that curtains stay on the 
curtain poles by themselves.  He understood that the Police were looking into 
this.  He also said that the belt with which [M1] hanged himself was an adult 
belt.  He also indicated that jumping from the bed to hang himself would also 
have broken the curtain rail and that mother’s attempts to try and pull him off 
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the curtain rail would also have broken the curtain rail.  I said this really was a 
matter for the Police but would chase them up ... 
2.
The toxicology [reports] should have been done by the Pathologist.
I informed Professor Southall that I had been told by the Coroner’s [officer] 
that the toxicology tests had not been carried out by the Pathologist.  Professor 
Southall indicated that this may have been negligent on the part of the 
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Pathologist ... 
3.
The injection in the right arm he does not believe that mother has … no 
experience of administering injections or seeing injections being administered 
he wondered if it was possible to check with the hospital and the ambulance 
crew whether there was already a needle mark in the arm [or] whether or not 
they had administered an injection to M1.  That was really why a toxicology 
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T.A.  REED 
Day 1 -  33
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test was needed in order to ascertain whether or not M1 may have been 
administered drugs by a third party. 
4.
With regard to [the teacher] he wanted to know what information with regard 
to the other parents that were being involved against [the teacher] was being 
instigated by Mrs M. 
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Again, we would say this doctor is basically on one track here.  He is on a murder 
investigation, he is not carrying out, as it were, the full assessment asked of him by the local 
authority, but he is pursuing one particular theory with vehemence and assiduously, and it is 
in those ways that you should look, we say, at the allegations that are made by Mrs M in 
relation to head of charge 5, in particular 5.b. 
Madam, the same circumstances come to be considered when you are considering heads of 
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charge 17 and 18, because we see that at head of charge 17 we say that:  “In the cases set out 
in Appendix 3 you failed to treat the respective children’s mothers … Politely and 
considerately … In a way they could understand … [or] Respecting their privacy and 
dignity”, and Appendix 3 relates to the allegation made in respect of this interview that we 
say that it is inappropriate for Professor Southall to act with his accusatorial, aggressive and 
intimidating questioning and his dismissive attitude to the answers.  Again, these are clearly 
matters of fact for the Panel to find whether or not or to what extent matters occurred in that 
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interview as alleged by the mother. 
Madam, can I take you now, please, to heads of charge 7 to 9, which relate to another child, 
which is Child H, and effectively relates to the unauthorised copying of a letter to an 
unnamed and unknown paediatrician. 
Madam, Child H was born in September 1985.  From an early age he suffered ill health.  By 
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the time the child saw Professor Southall, or Dr Southall as he then was, the child was aged 
about four and had had numerous hospital admissions and operations.  The procedures that 
the child had undergone by then included an inguinal hernia repair, a bronchoscopy, a 
microlaryngoscopy, a tracheostomy (which is where you open the windpipe at the front and 
you put a tube in to assist the breathing), he had that aged five months, and he had had 
grommets, he had had various repair of gastric volvulus, and a diaphragmatic hernia, and a 
Nissen’s fundoplication, and that, as I understand it, is an operation to stop refluxed food 
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coming out of the stomach and down into the lungs and thus causing breathing difficulties.
Over time Mrs H had become increasingly concerned for Child H about breathing and 
respiratory matters, including noisy breathing, choking, numerous apnoea attacks (and that 
means when a child suddenly stops breathing), and cyanosis (which is a child going blue).
For about two or three years before Dr Southall became involved in this case, Child H’s care 
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was being handled at Great Ormond Street under the care of a Dr Dinwiddie, who is a 
consultant paediatrician.  Numerous tests and procedures were carried out on the child at 
Great Ormond Street. 
At about the time when the child was referred on to Dr Southall, Great Ormond Street were 
looking at the possibility of using a home ventilator for Child H.  In particular, the search was 
on for a ventilator that would only cut in when Child H stopped breathing.  This is what they 
H
call a trigger ventilator.  Mrs H happened to see Dr Southall on a television programme, 
T.A.  REED 
Day 1 -  34
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where he was talking about a new monitor that he was developing, whereby it gave a warning 
sign that the child’s oxygen levels were falling.  Mrs H considered that this might be a safer 
option than her current apnoea alarm as that would warn her before Child H had stopped 
breathing as opposed to an apnoea alarm which sounds when the child stops breathing.
Accordingly, she will tell the Panel that she mentioned this to Dr Dinwiddie when she next 
saw him and asked for a referral to Dr Southall, who was then at the Royal Brompton 
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Hospital.  She was not, however, aware of the terms of such referral when Dr Dinwiddie did 
agree to refer her.  This referral took place by letter dated 7 March 1989 and can be found 
again in Panel bundle C1, but now we are right at the end under section 2, which is the 
section dealing with Child H.  It is the letter after tab (a) with internal numbering page 17.  It 
is a letter from Dr Dinwiddie to Dr Southall relating to Child H: 
 
“I would be most grateful if you could please see [Child H] at his parent’s request.
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He has been having a number of unusual apnoeic attacks particularly associated with 
hypoxaemia and they are very keen to know if any of your new monitoring equipment 
would be helpful for him. 
 
His history is very long and complicated and I think it best to enclose copies of the 
case summaries from his numerous admissions here. 
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We have had him on the ward on a number of occasions for sleep studies and have not 
been able to document serious hypoxia during these episodes although he has 
certainly been pale at times.  He has had various treatments as you will see including 
tracheostomy and more recently Nissen’s fundoplication, but according to his mother 
the apnoeic spells continue.” 
Then there is an important bit in manuscript:  “The question of Munchausen by proxy has 
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also been raised.” 
 
“He is also asthmatic and has been treated with Salbutamol nebulised on a regular 
basis and previously had Becotide but this has been stopped recently without any 
obvious detrimental effect. 
 
I would be very interested if you could see him and arrange the necessary further 
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investigations and advise any other treatment which you think might be helpful in this 
particular situation.” 
In due course the child was admitted to the Royal Brompton Hospital for sleep studies and 
was admitted for the first series of sleep studies in September 1989.  The results of the 
overnight monitoring were found to be normal, and we can see this in the discharge summary 
at 2(c): 
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“[Child H] was admitted for overnight monitoring.  He has had difficulty in breathing 
since birth with intermittent apnoeas and cyanosis.  He has a diagnosis of 
laryngomalacia made in Great Ormond Street in the past together with fundoplication.
On examination he was well.  Tracheostomy tube was in place.  There were no other 
abnormal signs. 
H
T.A.  REED 
Day 1 -  35
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Treatment and Progress:  Overnight monitoring was carried out which was normal 
and the plan is to readmit him when he is actually having cyanotic episodes for repeat 
recordings.”
After further attendances and admissions to Great Ormond Street, the Child H was returned 
to the Royal Brompton for further night observation from 15-17 March 1990.  The clinical 
notes relating to this admission are at (d), and we have the clerking notes, which I need not 
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take you to in any great detail, but after (d) you see he was admitted on 15 March: 
 “Routine admission for overnight monitoring under [the] care of Dr Southall.
[History] from parents.  Problems (1) cyanotic episodes [and] abnormal breathing;  
coughing ….. stridor, jitteriness, developmental delay, cow’s milk/soya intolerance”.   
The history is basically given there, and if I take you to page 9 we see the summary, that this 
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is a four year old with numerous problems but particularly abnormal breathing pattern, 
cyanotic episodes and apnoea spells for overnight monitoring and lung function tests. 
I need now for you to put away C1, and we pick up the story of Child H in C2.  If I can take 
you, please, to (f), and you will see a document which later on in this case you will become 
fairly familiar with, the outline of it, but these are the results of the tests carried out by  
Dr Southall, whose signature is at the bottom.  It basically says that the result of 
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cardiorespiratory monitoring was breathing pattern normal, oxygen saturations normal, 
carbon dioxide normal, other investigations normal, and it says that, “A letter will follow 
describing our suggestions for [Child H’s] future management.”   
There was a formal discharge, which we see at the next tab, tab (g).  It sets out the formal 
history of this child, which indicates the child was born by elective caesarean section;  it 
gives his birth weight;  it says he was breathless from birth;  he had bilateral inguinal hernia 
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repair;  stridor has been noted – “troubled with intermittent stridor and abnormal breathing 
[patterns] with episodes of hyperventilation and apnoea”.  It deals with the tracheostomy 
being inserted.  It deals with cyanotic episodes frequently throughout the day: 
 
“It can occur spontaneously or be precipitated by exercise.  The child may lose 
consciousness.  There is no diurnal variation and the baby is resuscitated with an 
ambubag.” 
F
As I understand it, what the parents are doing, they will use the tracheostomy tube and the 
ambubag to seek to resuscitate successfully the child.
 
“They have ... noted the baby to be jittery since birth ... severe developmental delay”. 
It deals with his medication, and deals with, at the bottom, that he has had a volvulus hiatus 
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hernia and another hernia operation.  On examination they found that he was pink and no 
other abnormal signs. 
 
“He was monitored overnight and the results will be sent on to you.  Follow up will be 
by Dr Southall’s [Department].” 
You will hear evidence from Mrs H that following the observations on the morning of  
H
T.A.  REED 
Day 1 -  36
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17 March she met with another doctor, a colleague of Dr Southall, called Dr Samuels.  It 
would appear that Dr Samuels explained to her that the plan was to give the child a monitor 
for home use together with additional oxygen and nebulised budesonide, with the plan of 
removing the tracheostomy in due course. 
At bundle 2, tab (h), is a note with the initials MS at the bottom right-hand corner.  We would 
say that this is the note of that conversation, but one of the many significant things about this 
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note is though it is a clinical note, it was not found in the original hospital medical records, 
but it was found in the parallel file kept by Dr Southall which is known as the S/C or Special 
Cases file, of which the Panel will in due course hear a great deal more. 
It is believed, as I say, this note is 17 March.  It gives a history of cyanotic episodes and the 
like.  It sets out the previous treatment, it sets out the fact of the tracheostomy and says, “still 
needs it for ? laryngomalacia ? resuscitation.”  It deals with cyanotic episodes which were 
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bagged, the need for the tracheostomy.  Then: 
“? central control defect, but normal Sa02 and TCPCO2
Shunting episodes aggravated by airway hypoxic ? trache, ? asthma. 
Parental view – trache ‘needed’ 
See ventilation as being answer 
D
Consider [Child H] neurologically normal, but has obvious tremor/ataxia. 
Mother does not want him as a ‘cabbage.’ 
Impression:  Mother used to [H/s] sickness: ‘sick role’. 
wants trache/ventilator 
likes rare disease/illness 
treats [H] as he was an infant – re: cyanotic attacks 
E
 
re: trache/laryngomalacia, re: general care. 
Needs:  PO2  monitor … 
 Neb. 
budesonide 
 Trache 
closed”, 
and there may be some other matters under there, but I have not had the opportunity of seeing 
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the original note of this.  I know it is available and it is my fault rather than anybody else’s.  
It just looks as though it is a typical photocopying job where there are some other words 
there.
As suggested in that note, the child was discharged on 17 March.  The mother was provided 
with one of these TCP02 monitors and she was trained in its use.  She was concerned about 
this new way forward as it seemed to her to contradict with the way that she was being 
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treated and the treatment plan at Great Ormond Street Hospital.  She will tell you that she had 
a telephone conversation with Dr Dinwiddie at Great Ormond Street and as a result of that 
conversation she decided that she would not go down, as it were, the Brompton path, she 
would return the monitor and continue with the Great Ormond Street treatment plan.   
Having had the conversation with Dr Dinwiddie of Great Ormond Street, Mrs H will tell you 
that she spoke to Dr Southall on the phone, advising him of her decision to continue with Dr 
H
Dinwiddie’s treatment plan. She will tell you that it was a brisk conversation where she was, 
T.A.  REED 
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in effect, ordered to return the monitor and thereafter the conversation ended abruptly.  It 
would appear that Dr Southall was upset that the course of action being suggested by the 
Royal Brompton ended abruptly. 
Evidence that Dr Southall did not approve of the course of action being taken by Mrs H can 
be seen in the contents of a letter that he wrote, dated 23 March 1990, which is the letter the 
subject-matter of head of charge 8(a).  This letter can be found at Panel bundle C2 at tab (i).
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I have to read it as it forms the head of charge.  This is a letter, as you can see, addressed to 
Dr Dinwiddie from Dr Southall: 
“RE:  [CHILD H] … 
I thought I had better write to you about our latest contact with [Child H] and his 
family.  The upshot of it was that we wasted a lot of valuable time, at the end of 
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which the parents decided that they would like to continue along their own route 
basically with the parental belief that [H] has a severe, rare illness which warrants 
intensive care treatment at home. 
I would just summarise his past history as we saw it, to try and put into context our 
recommendations.  [H] has a had a history of cyanotic episodes, wheezing and cough 
and has variably been diagnosed as having bronchomalacia with, or without, 
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additional reversible airways obstruction.  His previous treatments include nebulised 
intal, Ventolin, becotide and acetylcysteine.  A nubuhaler was suggested by the local 
consultant paediatrician in Cardiff, Dr Weaver, but was refused by [H’s] mother.  He 
has had a Nissen’s fundoplication and a tracheostomy.  The tracheostomy was 
performed for laryngomalacia but the parents now believe that it is most valuable for 
resuscitation purposes.  The cyanotic episodes are intermittent and are treated by 
positive airway pressure applied through the tracheostomy.  The parental view is that 
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the tracheostomy is essential for resuscitation, that some kind of trigger ventilator is 
needed to cope with apnoeic episodes.  They consider that [H] is neurologically 
normal, although it is pretty obvious that he has a tremor and central ataxia. 
Our impression is that the parents are used to [H] being chronically sick.  They want 
the tracheostomy.  They want the ventilator.  They like the idea of him having a rare 
illness and they treat [H] as if he was a baby. 
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Our suggestion to them was that firstly, they use a transcutaneous PO2 monitor 
whenever he is asleep, that they get used to his baseline values and that in the 
eventuality of him showing lower baseline values, they institute temporary additional 
inspired oxygen.  Secondly, we felt that reversible airways obstruction is a component 
of his problem and that maybe nebulised budesonide would help.  In the long rung, 
we feel that if his cyanotic episodes can be controlled by monitoring and additional 
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inspired oxygen, that he might not need the tracheostomy and that this could be 
closed.  We also feel strongly that his neurological state has not been adequately 
investigated.  We feel that his tremor and ataxia could go along with a brainstem or 
posterior fossa problem, which in itself could be related to it’s cyanotic episodes.  We 
also feel that it is vital that [H] has his overall care managed by a local paediatrician. 
We put this regime to his parents last week and they initially said that they would like 
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to accept it.  We therefore spent 24 hours training them in the use of the monitor.  
T.A.  REED 
Day 1 -  38
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A
They were discharged with this on Friday night of last week. In communication with 
them today, they have decided to reject this advice and go for the triggered ventilator 
approach.  They are therefore returning the TCP02 monitor to us by registered post. 
Martin Samuels and I both feel that these parents are not acting in the best interests of 
[H’s] long term future.  We feel that they have become involved with 2 special health 
authorities rather than their local hospital intentionally.  We are very suspicious of 
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their motives and view [H’s] long term prognosis with great concern.  I have left it 
with the parents that should they change their mind we are here and willing to 
implement the approach outlined above.  Please do not hesitate to contact us again if 
you feel that we can be of assistance.  I am sorry that we do not seem to have been 
able to get through to these parents.” 
You will see at the bottom that it is copied to Dr Bailey, who is the GP of the family, to  
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Dr Weaver, who has been mentioned in this letter as consultant paediatrician at Cardiff, and 
thirdly, the consultant paediatrician at the Royal Gwent Hospital.   
The heads of charge in this case relating to this child arises because at no stage was there 
anyone at the Royal Gwent Hospital who was involved in the care of Child H and it arises 
because we say – and here I am acting for Mrs H – there was never any discussion that there 
should be involvement of a local consultant paediatrician, whether at the Royal Gwent 
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Hospital or anywhere else.  Indeed, in the file note that I have read out to you of Dr Samuels 
you will have noticed that there is no mention that I have seen there to that effect. 
Hence, I ask you to look at head of charge 8(c) where it says that: 
“…you did not seek, nor obtain, Child H’s parents’ consent, 
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i.
to the fact of involving a local paediatrician in Child H’s care, or
ii.
to any letter being sent to an unnamed local paediatrician, or 
iii.
to the letter mentioned in 8.a., and in those terms, being sent to an unnamed 
local paediatrician.” 
F
You will have noted in the body of the letter that it is stated that it was vital that a local 
paediatrician become involved.  I understand, and have seen a document to that effect, that 
Dr Southall will say that it had been agreed by Mr and Mrs H that such a person would be 
involved in Child H’s care.
The issue of consent to such a course is an issue which you will have to resolve.  You will 
hear evidence from Mrs H, who will state that in the March 1990 admission she never saw 
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Dr Southall at all.  She wanted to see him after the conversation with Dr Samuels where a 
different treatment plan was put, but was told, she will tell you, that he was too busy to see 
her because he was appearing on Sky television.  Furthermore, as we said earlier, the issue of 
the involvement of a paediatrician at the Royal Gwent Hospital was not even mentioned, let 
alone consented to.  You will also hear evidence from Mr H to similar effect. 
H
T.A.  REED 
Day 1 -  39
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A
Looking at head of charge 9, we say that not only was sending such a letter out into the ether, 
to an unnamed paediatrician at a hospital that the parents had never used, inappropriate, but 
also in breach of their confidentiality.   
Sir, the complainants, and particularly in this case, Child H’s parents, have engaged the 
services of Professor Tim David, who is a consultant paediatrician and Professor at 
Manchester University.  He has advised them on various aspects in this case.  I anticipate that 
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in relation to this letter he will have a number of observations for you.  These observations 
include statements to the effect that it seems highly implausible that parents, knowing of the 
highly adverse nature of the letter’s contents, would consent to such a letter being distributed 
to their local hospital.  He makes the point known to all of us, the general view that obtaining 
consent without providing information to what is being consented to renders that consent 
invalid.  He goes on to speculate various reasons as to why this letter could have been sent in 
the form that it was, but one matter that he does state, and I anticipate that he will say when 
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giving evidence on this matter, is that there are considerable difficulties in accepting the aim 
of this copy letter was to get a local paediatrician  to take over the care of Child H.  If the 
intention of the letter was for a local paediatrician to take over the care, then he should have 
written a letter to a named paediatrician, if necessary after making local inquiries as to who 
that person should be.  There should also, I anticipate Professor David will tell us, have been 
a covering letter actually referring the patient and providing a lot more background than was 
contained in the copy letter, and sending a copy of a letter between two other clinicians to an 
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unnamed clinicians found sitting in a local hospital in the middle of Wales is not going to do 
much good, we would say, if the purpose was for a formal referral out of the third tier 
hospital back to the local letter. 
Those are the allegations in respect to the heads of charge regarding child H. 
The third matter relating to the first major category that I told you about, which is the conduct 
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of Professor Southall towards the parents of children, arises out of an incident that occurred, 
we say, in December 1994 in relation to the treatment of Child D.  This arises in and looks at 
heads of charge 17 and 18, which is a head we have already looked at in relation to Mrs M 
which is alleged failure to act politely and considerately in a way that they could understand 
and respecting privacy and dignity.
If we go to Appendix 3, you will see that the allegation is that on 15 December 1994 in 
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relation to child D, Professor Southall, as he then was, at Keele, acted with raised voice, 
dismissive manner, walking away and not giving mother any opportunity to ask questions; 
simple particulars, but I am afraid the history that leads up to this is somewhat complicated.  
I will give it to you as briefly as I can. 
Child D was born in November 1988.  His mother, Mrs D, is a qualified nurse and she 
completed her training in specialist paediatric nursing at Great Ormond Street.  From a very 
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early stage, the child suffered from a multiple of allergic difficulties.   
Remaining in bundle C2, can I take you to section 4, which is about two thirds of the way in 
the bundle, and we come to the reference in relation to this child.  The first record we have is 
at (a) and is at a time when this child was only 8 months or so old.  It is a letter from the GP 
referring this child to the paediatric dietician at the local general hospital where it starts off:  
H
T.A.  REED 
Day 1 -  40
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A
“Thank you for seeing this baby.  He would appear to be one of the most allergic 
children I have come across.” 
Later that year, the GP referred the child to the paediatric consultant at the local general 
hospital and again he starts with this letter, which is at (b): 
“Relating to this child, I would be grateful if you could see this young boy, who is one 
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of the most allergic specimens I have come across.” 
It goes on about the issue of difficulties with immunisation in respect of the child. 
The paediatric consultant wrote back to the GP at the letter at (c), and indicates, at the top of 
the page: 
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“Thank you very much for referring this 9 month year old boy with a rather 
complicated problem with multiple allergies.  The main symptoms of these are 
episodes of apparent abdominal pain with colic and screaming, swelling of the eyes 
and urticarial skin rashes with eczema.  In addition, there was, as you say, a severe 
febrile reaction to his first DPT immunisation”,  
which is the diphtheria, pertussis and tetanus immunisation. 
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It deals with the family background but over the page at the second paragraph he says:
“I would agree with you that the history leaves little room for doubt about the allergic 
nature of his problems.  I think in practice his parents have done extremely well and 
instruct me that they have an extremely well-balanced and sensible approach to the 
problems of his diet.” 
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The child was then referred by Dr Connell, the paediatrician at the hospital there mentioned, 
to Great Ormond Street to a Professor of Great Ormond Street in the department of 
haematology.  We see the beginning of that letter under (d) and he says:
“Dear Professor, I would be very grateful if you could give your opinion on this child 
who suffers from multiple allergies, the main clinical manifestations of these are 
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recurrent urticaria eczema with current abdominal pain, swelling of the eyes and also 
a rather severe reaction to his immunisations.”   
Over the page, the bottom of the large paragraph: 
“He is not a child who is particularly prone to infections and has not any features of 
immunodeficiency as such, but I think he does generally have a lot of problems with 
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multiple food allergy.  His mother has an extremely sensible and balanced approach to 
the problem and copes with him very well.  I would be very grateful for your advice 
in general and also specifically to know whether you feel he needs investigation for 
any underlying immunological disorder.  Secondly, for any particular advice you 
might have about his dietary management.” 
That letter was responded to not by the named clinician, who had retired, but we see that it is 
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from Dr Strobel at Great Ormond Street, and that is under tab E.
T.A.  REED 
Day 1 -  41
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A
It relates to the letter from Dr Connell:  
“Thank you very much for your letter”, accordingly because of his retirement.  “D's 
history is quite fascinating. I do not think there is any doubt that most of his problems 
have been food related possibly from an allergic background.  The mother seems to 
cope very well with managing his diet.  The next step, obviously, would be to 
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re-introduce food items which have been excluded and not to unduly restrict his diet.” 
Then over the page, he says:
“With your permission I have sent the parents a direct appointment and will let you 
know as soon as I have seen them and the results of my investigations are back.” 
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As a result of that, there were numerous attendances over the months and years by Child D at 
Great Ormond Street.  Amongst other things, where, because of various allergic incidents and 
for various tests and food challenges to be undertaken, there came a time, about four years 
after this letter which I have just referred you to, and during those four years Child D was in 
and out of Great Ormond Street Hospital, having various tests and investigations there, there 
came a time when Mrs D will tell you that she wanted a monitor to monitor Child D's 
breathing at night.  At that time, Child D was sleeping in the same room as her and she 
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wanted him to return to his own room but she felt that she had to be aware of his breathing 
difficulties so that she could safely have him in another room.  She got hold of 
Professor Southall's name from an organisation and asked the GP to refer her child for 
assessment of his suitability for a breathing monitor.  She asked the GP to refer Child D to 
Professor Southall. 
This letter of referral can be seen at (f) in C2.  As we see it is a letter dated 6 October 1994:
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“Dear Professor, re Child D, I would be very grateful if you could see the above child 
who is the most allergic patient I have ever seen.  His mother is an SRN and copes 
very well.  There are relationship problems in that his father has an alcohol problem.  
He attends Dr Strobel at Great Ormond Street Hospital.  His mother is very worried 
about him at night as he gets frequent episodes of becoming pale, shuts down and 
query hypothermic.  Would he be suitable for a PO monitor or meter?” 
F
As I understand, that is something that measures oxygen saturation. 
Following that letter of referral, Child D was seen at out-patients by Professor Southall at the 
Academic Department of North Staffordshire Hospital 29 November 1994.  Mr and Mrs D 
accompanied their, by now 6-year-old son.  An interview was taken and the notes of this 
meeting can be found under tab (g) and within (g) at 601.  You will see there, this is an 
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attendance on 29 November.  The history of the present complaint was: low body 
temperature, multiple allergies.  The first injection caused a high temperature and unwell for 
a week.  The second injection was delayed until two years ago.  His face had swelled.  His 
temperature had dropped and he was flushing but the temperature was still low.  He went into 
shock with loss of consciousness, blue lips and was unrousable.  Then the third injection was 
in hospital and the same thing happened: loss of consciousness, blue and irregular breaths. 
H
T.A.  REED 
Day 1 -  42
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A
A similar incident happened whilst he was at home, keeps happening at home, over the last 
two years.  He gets very pale.  He has irregular breathing.  He stops breathing for 7 seconds.
His pulse drops.  He gets low temperatures, slight difficulty in view of the photocopying of 
the left-hand side here, but the temperature goes down.  That is his axilla temperature, which 
is under the armpit, and also I think when it says ace blanket I think that should be space 
blanket.  No help.  The child has adrenaline and steroids at home and lists a number of 
medications that the child is on and that he, the anaphylactic shock to the matters there 
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mentioned: egg, milk, apricot, strawberry and wheat, has a very restricted diet, has eczema.  
Eczema under control at the moment.  I am now on page 605.  He is allergic to animals.  He 
is under Dr Strobel at Great Ormond Street.  He is not worried about these drops in 
temperature.  Mum and the GP are concerned.  He is under a dietician.  The skin is very 
sensitive to many things.  He is under a dermatologist.  The fits are related to high 
temperature.  The last one was two years ago.  It is seen by Professor Southall dealing with 
the rashes, urticarial and I suspect it is imethis rash, concern that recording not showing 
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anything because of lack of allergies in hospital.  It was agreed that he would come in for 
admission for continuous tape recording on 12 December. 
Mrs D will tell you, as I understand it, that she asked that he was going to return so he could 
be further assessed as to his suitability for some kind of monitor in order to enable her to 
sleep apart from him at night. 
D
The notes relating to that admission, the clinical notes are at 606, within tab (g) where we 
have just been.  They start on about the third line down.  That should be “12/12/94, RA”, for 
ONA, and a further history was taken like the previous history, setting out what has happened 
to the child.  Over at 607, about half-way down, after the description of the third injection.
The temperature kept going down and swelling to the face.  At home the temperature goes 
down to 34.  He is pale and he is unrousable. Before he started having low temperatures he 
had 3 febrile convulsions.  He has some very severe allergic reactions.  At the bottom of the 
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page: life-threatening reactions in the past year needing adrenalin. 
Over the page, he now has hypothermia attacks and gets cold and pale three times a week.  
The medication is there set out.  We can see that after the history was taken, at page 604, that 
the child was admitted for recordings. 
On the next day, which I think is cut off, the child was admitted on the 12th, I think is for the 
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13th review: “had episode of cold, pale saturation last night.  Tape was saved, needed 
analysis”. 
THE CHAIR:  I think that although we are turning the pages we had some difficulty 
following you at some stage here. 
MR TYSON:   I went to 607, 608, and I have just been reading from 604, which follows 603, 
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and which in turn is followed by 609.  I do apologise for the rather eccentric numbering, but I 
will not make any cheap digs about that is how they were provided.  Would it assist if I 
started at the beginning of this?  It goes, at the beginning of tab (g), 599, 600, 601, 602, 605, 
606, 607, 608, 603, 604, 609, 610 and 611.  They are in chronological order even if they are 
not in paginated order. 
THE CHAIRMAN:   Mr Tyson, I think it might just help us if in future you are turning over 
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pages that are not consecutive, you can draw our attention to it. 
T.A.  REED 
Day 1 -  43
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A
MR TYSON:   Certainly, and I apologise for losing the Panel in my enthusiasm to tell the 
tale, and of course it is always a problem when one is very familiar with this documentation 
and others have never seen it before, and I do apologise for that. 
I had got you, I hope, to 604, which is a very indistinct 604 in the bottom right hand corner. 
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THE LEGAL ASSESSOR:   Admitted for recordings I think was the last--- 
MR TYSON:   Yes, and then I read the entry below that for the next day, where there had 
been an episode “last night”, and “[discussed with] Dr Samuels – to stay for ….. [overnight 
recordings]”.  You see another reference to Dr Samuels.  He was a doctor with Professor 
Southall at Royal Brompton and came with Professor Southall to North Staffordshire 
Hospital.
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Then we can see over the page, which is 609, there was a discussion with Professor Strobel 
from Great Ormond Street about the child, which said that he had a highly complex history 
and was a highly allergic child, and a few lines down, “[Mother] is very anxious”.  About the 
nocturnal hypothermia episodes (that is where the child gets very cold):  “possibly due to a 
minor anaphylactic reaction, but highly unlikely.”  It is recorded that the parents were 
worried about SIDS, and that Professor Strobel had seen an acute urticarial reaction.  On the 
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next day, the 14th, it is recorded that there was a review, and that when the monitor was 
attached “last night” something went down to 19 and the oxygen saturations were 98 per cent, 
“well in himself”, became hypothermic, and then “This morning dipped down to 17” but 
oxygen saturations normal, “[and Child D] well ….. to [discuss with] Professor Southall”. 
Then over the page at 610 it indicates there was a ward round with Professor Southall, that 
mum was worried about the temperature, and mum had taken a rectal temperature and it was 
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found to be 35.6, and that the lowest axillary temperature (that is the under the armpit one) 
was 34.2 – “he is ice cold – no colour.  Mum is concerned because he does this when he is 
about to have an anaphylactic reaction.  He has delayed anaphylactic reactions”, and perhaps 
you would just make a note of that phrase, that is his mum saying he has delayed 
anaphylactic reactions and therefore mum is worried. 
It goes on to deal with the medication.   
F
“He has nocturnal hypothermic events 3 [times a] week – feels icy cold [and] pale ….. 
other problems during [the] day – [he] starts shaking, [gets] pale [and] cold.  Only 
needed [intramuscular adrenalin [once]”.  In the last two lines it says, “he’s only been 
dropping [temperature] since he started school”. 
Over the page at page 611, “Mum [and] child sleep in same room.  Mum can’t sleep.  [He] 
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has had blind challenges to wheat [two months] ago – reacted [very] badly”.  I think it says:
“Mum has asked nursing staff if these events could be due to low blood sugars – [has 
asked] for random [blood sugar measurements] – nursing staff refused.  Mum also 
asked nursing staff last night to do rectal [temperature] – nursing staff refused”. 
Then there is a note which I think would be admitted is in Professor Southall’s writing 
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thereafter, which says “[Discussed with] Professor Strobel” – that is the Great Ormond Street 
T.A.  REED 
Day 1 -  44
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A
Professor – “Agreed that Mum is exaggerating symptoms.  Example of fabricated illness.  
Needs [social service] strategy meeting.  To invite Professor Strobel”, the consultant at the 
local district hospital, the people there mentioned I think, as I understand it, that is David 
Southall and Martin Samuels, et cetera, and then it says somebody else is contacted – I think 
that is the gentleman from social services.  “[Child D] to go home in the meantime.” 
The complaint detailed in Appendix 3 arises from an incident that occurred during Child D’s 
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final morning at North Staffordshire Hospital.  Mrs D will tell you, I anticipate, that she was 
standing in the corridor when Professor Southall told her that she wanted Child D to be seen 
by a Professor Warner, who Professor Southall said was an allergist.  I anticipate that Mrs D 
will say that she was agreeable to such a referral for extra help with Child D’s food allergies.  
She will then say, I anticipate, that Professor Southall’s manner towards her changed.  He 
told her that his overnight observations had shown that everything was normal.  He started to 
walk away and then turned back, and with, she will tell you, a sharp and angry voice, she 
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stated he (Professor Southall) stated, “There is no such thing as a delayed reaction”.  At the 
time when Professor Southall said these words, he waved his hand at her dismissively, and he 
then walked away, giving Mrs D no chance to ask about that which she felt the child had 
been admitted for, namely whether she could have a monitor at home. 
There is another matter relating to this child which I will come to later, but that completes the 
first category of charge, namely the inappropriate conduct of Professor Southall towards 
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parents of children with whom he had professional dealings. 
THE CHAIRMAN:   Mr Tyson, would this be a good time for a tea break? 
MR TYSON:   An excellent time, madam. 
THE CHAIRMAN:   You are going on to the other – yes.  We will take fifteen minutes now 
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then.  It is just before half-past on my watch, so if we assemble about quarter-to or a moment 
or two after. 
(Short break)
THE CHAIRMAN:  Mr Tyson, I understand you are probably going to make an application 
to us.  Is that right? 
F
MR TYSON:  I am going to indicate that we have a practical problem, and I am going to 
suggest two possible alternatives to the Panel if the Panel wishes to deal with it. 
The practical problem is this.  In the normal course of events, I have seen how – regrettably – 
I have taken overlong on my opening.  My opening is unlikely to finish tonight.  I was going 
to make an application at the end of my opening.  That is, that my first witness, Mrs M, could 
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be called by video link.  I anticipate making that application this evening, with a view that if 
the Panel is minded to grant the application, that the witness concerned could give her 
evidence by video link tomorrow morning.  The witness is a nurse.  She has recently had to 
emigrate to Adelaide because she could not get employment in this country.  She started her 
new employment out there in September and has not been granted leave, even unpaid leave, 
by her employers to permit her to come back to this country to give evidence.  So she cannot, 
for good and practical reasons, be in this country.  My application was therefore going to be, 
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subject to the authorities, that her evidence from Adelaide should be given by video link. 
T.A.  REED 
Day 1 -  45
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A
The ways forward to deal with this matter in my respectful submission are two alternatives.  
One is that I can, as would be normal, make my application at the end of my opening, which I 
would anticipate would be some time tomorrow morning.  I make the application.  Were you 
minded to grant it, then the matter could go over to Wednesday and you could spend the 
balance of tomorrow reading the Professor’s reports and the like – have a reading day.  That 
is option one. 
B
The difficulties about option one is that, after discussions with my learned friend, there is a 
danger that this witness may take more than one day.  The practicalities of the matter is that if 
we start at 8.30 a.m., that is her 6 p.m.   If we stop at 1.30 at our lunch time, that is her 
midnight.  So that was why we were minded to ask that the Panel sat early at 8.30, so one 
could have five hours.  There is a risk that this witness will actually go over and that two days 
will be needed.  I think it would be unfair to the witness to ask her to give evidence after her 
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midnight.  That means one has a risk if option one of my options are taken of her going over 
to the Thursday. 
That puts me in extreme difficulties about my witnesses because I only have Professor David, 
who is listed for three days this week.  He is not available to give evidence next week, so I 
have insuperable problems if this witness takes two days to deal with.  That is the first option. 
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The second option is that I have reached a natural stage in my opening.  I can make my 
application now that there be a video link hearing of Mrs M’s evidence.  You determine it 
now.  If the matter is going to be opposed and you determine the issue now, if you determine 
it in my favour, then we can go back to the first option, and have this witness at 8.30 
tomorrow.  I would then call this witness and then, having dealt with this witness and one 
other short witness relating to her, go back to my opening on the matters concerning Special 
Cases files.  I have opened the case on Mrs M, so you are fully aware of that, and though it is 
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irregular, as you know, in rule 50 of your rules irregularities can be dealt with provided it is 
felt that it is in the interests of everybody to deal with them. 
On balance – and I say it is on balance because it is a matter for the Panel – my personal 
preference, or the complainant’s personal preference, is that you hear and determine the 
application now in respect of Mrs M and you either grant it or not tonight.  If you were to 
grant it tonight, and if you were to grant it, then we would be back on track to deal with Mrs 
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M’s evidence tomorrow, which would have to be an early sitting.  Though it is a fine-tuned 
matter, on balance my application is that you should cut my opening in two, hear the 
application in respect of the video link and then determine the matter and, if successful in the 
application, we shall hear the witness tomorrow morning.  My learned friend may have other 
views.
THE CHAIRMAN:  On the matter of how we should proceed, Mr Coonan. 
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MR COONAN:  Yes, indeed.  The proposal of option two is, I agree, irregular.  I am not 
going, as it were, to object to that course simply because it is in the interests of everybody 
that the matter proceed.  So the mere fact of that irregularity, as a matter of fact that does not 
cause any prejudice to Professor Southall.  Ultimately, that is a matter for you to determine 
whether you proceed now at half past four with option one or option two.  I do, however say 
this.
H
T.A.  REED 
Day 1 -  46
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A
If you proceed with the second option, you hear my learned friend’s application, you have to 
hear from me my opposing arguments.  As I say, it is now half past four and you have to 
make a determination, come to a decision acting judicially in such a time, this evening, in 
order to indicate to my learned friend what his position is for tomorrow morning.  That is the 
stark reality.  That is not said in any way to be unhelpful.  It just sets out, as I say, the 
realities.  I see my learned friend nod. 
B
I should also say, and it may be relevant and certainly may be relevant to any argument on 
the merits of this application, that you should know two things, whether you decide to go for 
the first option or second option this evening. 
The first is that this opposition by the defence was indicated to my learned friend’s solicitors 
on 31 October, which was the first time we were told that this witness was available. 
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Secondly, we had no idea, as I understand it, as you have been told, that there had been an 
allocation of five hours for this video link.  Even assuming you granted it, we have had no 
part in any estimate of time at all.  That estimate, as we understand it, and I accept my learned 
friend for his part had no part in estimates of time.  It appears for some reason to have 
emerged from the General Medical Council.  I think my learned friend would agree with that. 
Those are realities.  As I say, not intending to be difficult, but I know not what time you 
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intend to rise tonight.  Apart from those brief observations, it is a matter entirely for the Panel 
as to how you wish to proceed this evening. 
THE CHAIRMAN:  Thank you.  I think there is a general appreciation that we are in a 
difficult situation, whichever course is taken at this time.  It might be helpful to us if you have 
any indication as to how long your speech in opposing the application might take. 
E
MR COONAN:  I am not entirely sure how long my learned friend’s application is going to 
be.   It rather depends on that, although since you have asked me – I do not wish to duck it – 
it will not be overlong.  I do, though, have a few observations to make.  It may be my learned 
friend may wish to draw your attention to a number of authorities.  If he does then, of course, 
that job is dealt with.  I may require to highlight a number of other aspects of the authorities.  
It is not something – if I can put it this way – that can be over and done with in ten minutes. 
F
THE CHAIRMAN:  I think the Panel is very acutely aware of the need to do full justice to 
any application as to the entirety of the case.  I think on balance my understanding from 
earlier discussion with the Panel is that, in this difficult situation, we were minded to go 
ahead and hear the application now.  I would round to the Panel and see if someone wishes to 
discuss this in private, whether we should go ahead, if they would like to indicate.  Then we 
will go into private, but if you continue with the view that we should go ahead and hear the 
application now, would you indicate.
G
I see the Panel is still minded that way.  I think all we can do is give you the reassurance that 
we fully understand the obligation on us to hear this properly and not in a rushed manner. 
MR COONAN:  Thank you very much. 
THE CHAIRMAN:  But we will start and see how we get on. 
H
T.A.  REED 
Day 1 -  47
 & CO. 

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A
MR TYSON:  Thank you.  I anticipate I will be about twenty minutes. 
This is an application that my client, a claimant, who is also a witness, Mrs M, should give 
her evidence through a video link.  There is learning in the Criminal Justice Act 1988, s.32, 
that enables you to grant such an application, wearing your hat sitting in a primary criminal 
jurisdiction.  S.32 says: 
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“1)  A person other than the accused may give evidence through a live television link 
in proceedings to which subsection 1A …applies if – 
(a)  the witness is outside the United Kingdom;  
but evidence may not be so given without the leave of the court.” 
C
I need not take you to 1(a) because it deals with matters with which we are not concerned, but 
the broad parameter is that yes, the criminal justice system has woken up to television, VCF, 
video links, permits it provided that there is leave. 
The matter in my submission goes a bit further than that because it has come to a state on the 
authorities basically that these applications are granted unless there is an extremely good 
reason why not.  The principal reason I say that is due to the House of Lords authority in a 
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case called Polanski.  This is the Roman Polanski case when he was suing Condé Nast 
Publications Ltd.  This is a House of Lords case for which the official reference is [2005] UK 
HL 10. 
You may be aware of two matters:  a publication called Vanity Fair published an alleged libel 
against the film director Roman Polanski.  Roman Polanski wanted to sue Vanity Fair in this 
country, but he wanted to give his evidence by video link because he was a fugitive from 
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justice.  He lived in Spain, I think it was, and had he come to this country to give evidence 
there was a distinct fear, he felt, that he might be extradited from this country back to the 
United States, where he was wanted on various charges.  That is the background. 
The judge granted his application for video link evidence, and the Court of Appeal rejected it, 
so the matter came up to the highest court, the House of Lords, who had to consider this 
issue.
F
A number of Lords gave speeches but, as is quite often in the current House of Lords, it was 
the woman, Baroness Hale, who cut to the quick as to what the issues were.   
Before I get there, can I just say this.  The broad issue was that everybody was agreed that 
VCF evidence or video evidence would be appropriate but for the fugitive from justice point, 
which is not here in this case.  They are all saying, “Yes, technology is now so good, etc. etc., 
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we grant these things except in particular circumstances.  Here we have the worry about the 
public interest about are we helping somebody who is a fugitive from justice.”  That is not the 
issue you have to deal with. 
What Baroness Hale said at paragraph 69 is this: 
“(1)  As between the parties to this action, there is no doubt that this order” 
H
T.A.  REED 
Day 1 -  48
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A
that is the order made by the judge – 
“was correctly made. The respondent will suffer no prejudice from the appellant's 
evidence being given in this way;” 
In my submission it is not open with the technology being what it is for Mr Coonan to argue 
prejudice.  The respondent will suffer no prejudice from the appellant’s evidence being given 
B
in this way.
“it is common ground that any prejudice will be suffered by the appellant,” 
i.e. that is Mrs M in this case: 
“not least because the jury will be forcibly reminded of the reasons why he is not 
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present … 
(2) 
As between the competing public interest arguments, there is a strong public 
interest in allowing a claim which has properly been made in this country to be 
properly and fairly litigated here.” 
So they are saying, all other things being equal it should be litigated here, and if it has to be 
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by video link, so be the matter.   
She then said: 
“(3) 
Against that, there is also a strong public interest in not assisting a fugitive 
from justice to escape his just deserts. But the appellant will escape those deserts 
whether or not the order is made. He will continue to be outside the reach of the US 
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authorities in any event. All the refusal to allow his evidence to be given by VCF will 
do is effectively to deprive him of his right to take action to vindicate his civil rights 
in the courts of this country.” 
This is the passage which I rely on, sub-paragraph (4): 
“(4) 
If this were almost any other cause of action, I venture to think that the 
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outcome would not be in doubt. Suppose, for example…” 
And these various other applications. She says as a general rule is (5): 
“(5) 
Generally, therefore, I agree that this should be an acceptable reason for 
seeking a VCF order, although there may be cases in which the affront to the public 
conscience is so great that it will not be a sufficient reason.” 
G
So the test for not granting video link evidence in 2006 is that it is an affront to the public 
conscience so great that it will not be a sufficient reason. 
The other Lords, and particularly Lord Nicholls, the senior Law Lord at paragraph 15 made 
the point about the quality of these video links being extremely good.  Paragraph 14: 
H
“(14)  Improvements in technology” 
T.A.  REED 
Day 1 -  49
 & CO. 

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A
this is the Lord Lords saying this: 
“enable Mr Polanski's evidence to be tested as adequately if given by VCF as it could 
be if given in court. Eady J” 
the trial judge – 
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“an experienced judge, said that cross-examination takes place 'as naturally and freely 
as when a witness is present in the court room'. Thomas LJ said that in his recent 
experience as a trial judge, giving evidence by VCF is a 'readily acceptable 
alternative' to giving evidence in person and an 'entirely satisfactory means of giving 
evidence' if there is sufficient reason for departing from the normal rule that witnesses 
give evidence in person before the court:” 
C
I say there is sufficient reason in this case for departing from the normal rule that a witness 
gives evidence in court.  That sufficient reason is that the witness is that the witness is out of 
the country for good reasons.  It is not as though she is on holiday and not wanting to come 
back.  She has emigrated.  She has a responsible job out there.  She has recently started the 
job and her employers will not let her come back.  The quality of this kit these days – and a 
number of us have experience of it within Panels – is extremely good.  Bearing in mind the 
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quality is good, the reasons are good;  there is no prejudice, we would say, to Professor 
Southall and it is permitted by the rules provided the witness is outside the United Kingdom.  
We tick all the boxes.  We are all familiar with it and the only reason it should not be granted 
is if, in Lady Hale’s expression, that it would be an affront to the public conscience so great 
not to allow it. 
There are additional authorities to the same effect.  There is a case called R v Camberwell 
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Green Youth Court, again in the House of Lords.  It is [2005] UKHL.  I need not trouble you 
with that.  It is a case involving witnesses under 17, where the order is that they require what 
are called special measures and young witnesses have to give evidence by video link.  It was 
held that that was Article 6-compliant.    The barristers who wanted to see the eyes and 
reactions of the under 17-year old witness face to face was not regarded as a sufficient not to 
have special measures. 
F
Lastly, there is the case of the Bank of Credit and Commerce International v. Ramin, which is 
a case held before Mr Justice Lewison on 11 November 2005, where there was an ill litigant 
in Pakistan who wanted to give evidence in a big commercial case.  It was held by the judge 
that evidence given by video link was not a revolutionary departure from the norm.  He relied 
on the Polanski case in granting the application. He said that the process of having witnesses 
giving evidence by video link was well recognised in the court and was little difference from 
the experience of seeing the witnesses in the court itself, and thus it should be granted. 
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The law is on my side; the merits are on my side.  The case of Mrs M is important and you 
have to deal with equality of answer.  She has got a right to be heard.  You have heard of her 
evidence.  It is of the utmost seriousness and of the utmost importance and if you deny her 
the right to be heard by video link that means you cannot consider heads of charge 2 to 6 at 
all, because there is no way that she can come to this country.  That would be unfair to her 
and to her case which she is enabled to bring before this Panel.  For all those reasons I ask 
H
you to grant my application. 
T.A.  REED 
Day 1 -  50
 & CO. 

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A
THE CHAIRMAN:  The Legal Assessor has a legal question. 
THE LEGAL ASSESSOR:  Mr Tyson, it is the case I think that under the Rules which we are 
operating in this hearing, the 1988 Rules, there is no provision either way in regard to using a 
video link? 
B
MR TYSON:  When I said the Rules, I meant the Criminal Justice Act 1988, section 32, and 
the Criminal Procedure Rules 2005. 
THE LEGAL ASSESSOR:  In the Rules of this Panel there is no provision. 
MR TYSON:  No, under the old Rules this Panel had not grown up to the idea of video link. 
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THE LEGAL ASSESSOR:  It is right to say under the new Rules there is such a provision. 
MR TYSON:  Yes, but under the old Rules there is no particular provision, save your 
provision under rule 50 to judge your own procedure. 
THE LEGAL ASSESSOR:  Yes. 
D
MR TYSON:  And under the old Rules many people in this room are familiar with the fact 
that these applications are frequently made and equally frequently granted, both under the old 
and the new Rules. 
THE LEGAL ASSESSOR:  Yes, thank you very much. 
THE CHAIRMAN:  Mr Coonan? 
E
MR COONAN:  Could I say straight away that there is no point taken as a matter of principle 
that you do not have power to receive this evidence.  The fact that the 1988 Rules do not 
specifically provide for it is no bar, so I do not take any point about that.  All you need is to 
have regard to rule 50 of the 1988 Rules in order to aggregate to yourselves the power to 
receive the evidence.  The question is whether or not on the facts of this case you should 
receive it. 
F
True it is that in some cases applications are made for Fitness to Practise Panels to receive 
video link evidence, live video link evidence, and applications are granted.  But, it depends 
on the circumstances.  You are concerned here with a witness who is abroad in Australia.
I will come to the reasons why it is said she cannot be here in a minute, but it is said that she 
will need to give evidence at 8 o’clock in the morning (her 6 o’clock in the evening), and that 
she will be available to give evidence for some five hours. 
G
The importance of this case to Dr Southall is self-evident.  The allegation is, as you have 
heard from Mr Tyson in his opening, that Dr Southall accused this witness of murdering her 
child.  That is denied.  You, as a body sitting judicially, are going to have to decide, 
according to the criminal standard of proof, whether that is true or not.  You are going to have 
to decide by reference to the demeanour of the witness and her general attitude, and indeed 
the content of her answers, all those factors, when you determine whether or not this 
H
allegation is made out.   
T.A.  REED 
Day 1 -  51
 & CO. 

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A
Mrs M is a complainant.  She is not, if I may say so, a mere witness.  She it is who brings this 
allegation.  One would have expected her to be here, to be able to give, in the normal way, 
evidence in support of this allegation which is made by those who represent her.  The normal 
way of dealing with evidence in this country, and in particular in criminal or quasi criminal 
proceedings (as this sort of allegation is, I think, rightly categorised) is by hearing and 
receiving oral evidence, not by video link. 
B
The case that you have had cited to you is a case in the civil jurisdiction and a case decided in 
the context of the Civil Procedure Rules.  That said, I accept that this is a case where you 
have to weigh up the question ultimately whether, by giving evidence by video link, 
Professor Southall’s position may be prejudiced.  I suggest at this stage that it might be.  That 
is all I think I have to show at this stage, that it might be. 
C
It is all very well to say, as you have heard quotations from the case of Polanski, that the 
quality of video evidence is very good.  Indeed, in some cases it is.  I do not know what the 
quality of the video evidence is going to be tomorrow morning, or whenever, from Adelaide 
in Australia.  I do not know the degree to which there is going to be the usual time delay that 
one sees when one is engaged in a discourse with a witness by video link, and all of you no 
doubt are familiar with video links.  Those of you who may have given expert evidence in 
cases may have had to engage in that sort of medium.  But, it cannot be said, can it, that it is a 
D
wholly satisfactory medium for the purposes in every case of receiving evidence and, in 
particular, cross-examination, which is going to such an important and serious allegation. 
Let me just stand back and give you a little of the history of this.  This is an allegation which 
is made in 1998.  It arises out of events in 1998, eight years ago.  As I have already said, Mrs 
M is the complainant in this case.  We are told for the first time on 31 October that she is not 
turning up and we are told that her lawyers are going to make arrangements for her to give 
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evidence by video link.  Of course, that depends on whether you allow it.  But, we are told 
that the reason why she cannot be here is that she has emigrated – and I am reading from the 
letter dated 2 November, sent to Messrs Hempsons, who instruct me – and I quote: 
“In advance of her departure and immediately on arrival she discussed with her line 
manager the possibility of taking leave, wholly unpaid, to fly back to the UK for the 
hearing.  She was told that she would not be able to take such leave so early in her 
F
contract.”
That is all we know.  I venture to pose the following questions which may be of some interest 
to you.  There is no confirmation from her employers that this is the case.  We do not even 
know who the employers are.  There is no indication whether or not Field Fisher Waterhouse 
have sought to persuade the employers, if I may say so, to see sense in the interests of justice, 
to enable Mrs M to attend here.  There is no indication that the employers have been told that 
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the matter concerns a matter at the General Medical Council of the United Kingdom.  This is 
not a case where there is a problem about flying back because of money.  It is not an issue in 
the case.  This is not a case of a witness who is a vulnerable witness.  In other words, if she 
was, then different considerations may apply, as they do, borrowing again from the parallel 
legislation in the criminal sphere.  We do not know how long her employer was told she 
would need to be away from work.  As it turns out, as I have been told today, she is taking the 
whole of tomorrow off anyway.  It sits uneasily with the explanation that we have been given 
H
that she was not able to take any time off to give evidence in these proceedings. 
T.A.  REED 
Day 1 -  52
 & CO. 

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A
This case has been fixed for months and Mrs M must have known of this date for months, 
and yet no warning, no indication that she was going to be unable to come and give evidence 
up till, as I say, 31 October.  So, all we have and all you have is the barest of explanations as 
to why she is not turning up. 
I really put it in two ways:  If you grant this application, it is an application which will mean 
B
that the video link evidence will be given subject to all the imperfections in the transmission 
which will arise.  They may be great, they may not be, but in any event those factors must not 
be permitted to prejudice Professor Southall.   
Nobody is suggesting that she should be shut out from giving evidence.  She is the 
complainant.  She can come here if arrangements were made with her employer and if 
arrangements were made for her to come in terms of travel.  That was a matter which could 
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have been sorted out earlier.
As I say, Professor Southall is entitled, in our submission, to see her in this room and to see 
and hear her make this allegation directly in your presence.
The authority of Polanski to which my learned friend referred of course is a helpful authority, 
but as I say, I have already indicated it referred to the application of video link evidence in 
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the context of a civil case where the burden of proof is different, the standard of proof is 
different, I should say.
My learned friend referred to paragraph 14 of the judgment of Lord Nicholls and I just go 
back to it. 
“Improvements in technology enabled Mr Polanski's evidence to be tested as 
E
adequately if given by VCF as it could be if given in court.” 
Mr Justice Eady, an experienced judge, said:  
“Cross-examination takes place as naturally and freely as when a witness is present in 
the Court Room.”   
F
That may well be right in terms of the technology used in those cases at the High Court.  It 
may well be, since as I understand it nobody took the point in that case, that there may be 
a question mark over the technology. 
I move, in fact, to a further quotation in paragraph 43 of the judgment of Lord Slymm:  
“It seems to me, however, that as a starting point it is important to record that 
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although evidence given in court is still often the best as well as the normal way of 
giving oral evidence.”
Then this: 
“In view of technological developments, evidence by video link is both an efficient 
and an effective way of providing oral evidence both in chief and in 
H
cross-examination.” 
T.A.  REED 
Day 1 -  53
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A
I pause there:  on the facts of that case in terms of the facility which is used at the High Court.
As I say, at the moment, I do not know what the quality is going to be in relation to this one. 
In paragraph 84 in the judgment of Lord Carswell, this was said:  
“Certain matters are not in dispute.  The technology used in giving evidence by VCF 
B
is good, so that there is little disadvantage to the other party.  As Mr Justice Eady said 
in his ruling to which I shall refer that disadvantage has not, however, been entirely 
eliminated and it is to be noted that in paragraph 2 of the VCR guidance set out in 
Annex 3 to the Practice Direction”,
that is the Practice Direction attached to the Civil Procedure Rules, he referred to 
section 32(b) and 33, it is stated after the advantages have been enumerated the following:   
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“It is, however, inevitably not as ideal as having the witness physically present in 
court.  Its convenience should not, therefore, be allowed to dictate its use.  In 
particular, it needs to be recognised that the degree of control a court can exercise 
over a witness at the remote site is or may be more limited than it can exercise over 
a witness physically before it.” 
D
I rely on that passage from the VCR guidance document. 
There are other features which at the moment I do not know whether Mrs M will have before 
her the Panel bundle.  I am told soto voce that she has; that deals with that point.  Then, of 
course, there is the difficulty or potential difficulty of adequately referring to documents over 
the video link.  Certainly if I may be bold to suggest certainly in my experience there are 
frequently difficulties. 
E
Given a choice, either a video conference or in other circumstances between seeing 
somebody face to face and being able to make a measured judgment of their response to 
suggestions being put to them it is far, far better that the witness is there live as opposed to 
giving evidence via a video link. 
In effect, the opposition to this is founded, in a nutshell, upon actual or potential prejudice to 
F
Dr Southall's ability to have his case properly articulated and responded to in 
cross-examination by me.  
Madam, that is the contrary argument that I lay before you. 
THE CHAIR:  Thank you, Mr Coonan.  Mr Tyson?  
G
MR TYSON:  Just very briefly in response to that, the question of technology is a question of 
technology.  We all have our experience of it.  My personal experience, for what it is worth, 
is that the GMC technology is considerably better than the Royal Courts of Justice 
technology, but there it is.
The learning is that technology is equally good and that technology should not be of a reason 
of itself to stop these applications.
H
T.A.  REED 
Day 1 -  54
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A
Much more serious you may think is the issue of prejudice.  My learned friend says that his 
client might be prejudiced by this.  He gave the ground for prejudice that the technology 
might be good or not good.  Set against that is the enormous prejudice to my client, Mrs M, if 
she is not able to present her case.  It is, as my learned friend acknowledged in his remarks, 
an important and serious allegation that has been made.  Mrs M should, in my respectful 
submission, be allowed, under equality of arms procedures, to give that evidence.  It is 
important the evidence is heard and it is important the evidence is determined.  She has good 
B
and proper reasons not to be here; I will not repeat them.  She has, I am instructed, bundle 
C1, so should be able to deal with all matters arising out of her evidence because within 
bundle C1 is the entirety of the M material. 
In my respectful submission, this should be dealt with fairly to everybody and the 
overwhelming fairness is to complainant in this case, that she should be able to pursue her 
allegation as best she can.  She wanted to be here in person, she cannot.  She had to ask for a 
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week away because it was a 24 hours flight either way and that simply was not granted.  
THE CHAIR:  We will turn to the Legal Assessor. 
THE LEGAL ASSESSOR:  A matter addressed really to both counsel. 
No reference has been made in either submission to Article 6 of the European Convention on 
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Human Rights.  Does any point arise? 
MR COONAN:  It arises in terms of the question of prejudice.  It probably does not add 
anything to it.  The question of a fair trial has within it the absence of prejudice caused by the 
medium in which it was delivered.  So it is implicit in that argument. 
MR TYSON:  As is equality of arms implicit in Article 6. 
E
THE CHAIR:  Do the Members of the Panel require any clarification before the Legal 
Assessor gives his advice?  Apparently not.  The Legal Assessor will give advice to the 
Panel.
THE LEGAL ASSESSOR:  Ma'am, there is no express provision in the 1988 Rules, to which 
this hearing is subject, which empowers the Panel to admit evidence through television link.  
F
This is in contrast to the position under the New Rules.  However, in ordinary course where 
there is no specific provision in the Rules the procedures of the criminal courts are 
customarily followed, moreover Rule 50 of the 1980 Rules allows the Panel to do precisely 
that.  No point is taken to the contrary. 
The Criminal Justice Act 1988 at section 32 enables a court to admit evidence through 
television link where it is in the interests of justice for this to be done.  The application of the 
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statute is not in any way inconsistent with Article 6 of the European Convention on Human 
Rights, which is to the effect that evidence must be produced at a public hearing.  This 
condition is satisfied if the evidence is produced at trial and the defendant, in this case the 
doctor, has the opportunity to challenge and question the witness at the trial.  It follows that 
a contemporaneous transmission satisfies that requirement.  I therefore advise the Panel that it 
should adopt the procedures of the criminal courts. 
H
T.A.  REED 
Day 1 -  55
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A
In deciding whether to give a direction that evidence may be given by television link, the 
Panel should consider all the circumstances, in particular: the availability of the witness, the 
need for the witness to attend in person, the importance of the witness's evidence, and 
whether such a direction might inhibit the effective testing of the evidence or otherwise cause 
prejudice to the doctor. 
When considering this application, the Panel will doubtless have in mind that the witness 
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statement will have been served upon the doctor and his advisers before this hearing.  The 
Panel will be aware that modern technology is such that the television link does not put 
a party or the Panel at any significant disadvantage when hearing evidence in this way.  
Moreover, the Panel, which is made up of experienced professional people, is unlikely to be 
in any way inhibited in questioning a witness, nor indeed in assessing the witness's evidence. 
It is, of course, a matter for the Panel to decide on the merits of this application, and in doing 
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so it will need to consider whether the doctor's case will be in any way prejudiced if the 
application were to be allowed. 
THE CHAIR:  Does either counsel have any other comment on the legal advice just given?  
MR COONAN:  No, thank you, Madam. 
D
MR TYSON:  One small rider: in considering all the circumstances of the case you should 
principally here take into account the prejudice to the accused, but you can also take into 
account prejudice to the complainant. 
THE CHAIRMAN:  The Panel will now retire into private and consider the application. 
STRANGERS THEN, BY DIRECTION FROM THE CHAIR, WITHDREW
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AND THE PANEL DELIBERATED IN CAMERA
STRANGERS HAVING BEEN READMITTED
DECISION
THE CHAIRMAN:   Mr Tyson:  You have made an application for the Panel to receive the evidence 
F
of Mrs M by video link under Section 32 (1) of the Criminal Justice Act 1988 and Rule 50 (1) of the 
General Medical Council Preliminary Proceedings Committee and Professional Conduct (Procedure) 
Rules Order of Council 1988.  
The Panel is satisfied that in the interests of justice it should accede to your application and 
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hear the evidence of Mrs M by video link.
In reaching its decision, the Panel has taken into account that: 
H
T.A.  REED 
Day 1 -  56
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A
 
1. 
Mrs M is unavailable to give evidence in person, as she is not in the United 
Kingdom, nor is it practicable for her to attend; 
 
2. 
Modern technology is such that that a video link does not put a party or the 
Panel at any significant disadvantage when hearing evidence in this way. There is 
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nothing to indicate that hearing this evidence by video link would inhibit its effective 
testing or otherwise cause prejudice to the doctor; 
 
3. 
Video link is now a common means of hearing evidence and the Panel is able 
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to consider and determine the appropriate weight that it should give to any evidence 
that is put before it; 
 
4. 
The allegations against Dr Southall, made by Mrs M, are serious and it is in 
the public interest for the allegations to be tested. 
D
The Panel therefore accedes to your application. 
So we will assemble at eight-thirty, if that is still the time at which you wish us to be here to 
hear your witness. 
E
MR TYSON:   Yes, please, madam.  Can I say one thing before we finally depart, and that 
concerns the issue of publicity in this case. There has been, as you are aware, considerable 
press interest, and other media interest, in this matter.  Can I remind you, though I am sure 
you do not need reminding, that you have to judge this case by the evidence that you hear in 
this room and not by what you see or read outwith this room.  It may be advice to try not to 
read papers or articles concerning this case, or watch any television programmes about it, 
because it is in the interests of everybody, and in particular I would say the doctor, that you 
F
judge this case by the evidence before you. 
THE CHAIRMAN:   Thank you, Mr Tyson.  I am sure the Panel is very well aware that that 
is what we must do, but it is good that you have stated it publicly.  So we adjourn now until 
eight-thirty in the morning. 
(The Panel adjourned until 8.30 a.m. on Tuesday, 14 November 2006)
G
H
T.A.  REED 
Day 1 -  57
 & CO. 

---

GENERAL MEDICAL COUNCIL
FITNESS TO PRACTISE PANEL (PROFESSIONAL CONDUCT)
Tuesday 14 November 2006
44 Hallam Street, London, W1W 6JJ
Chairman:   
  
Dr Jacqueline Mitton 
Panel Members:
Mrs Leora Lloyd 
Mr Alexander McFarlane 
Dr Sameer Sarkar 
Mr Arnold Simanowitz 
Legal Assessor:   
Mr Robin Hay 
CASE OF: 
SOUTHALL, David Patrick 
(DAY TWO)
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 JOLLIFE 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
MRS M, Sworn 
  Examined 
by 
MR 
TYSON 
    2 
 
 
Cross-examined by MR COONAN   
 
          18 
 
 
Re-examined by MR TYSON  
 
 
          43 
 
 
Further cross-examined by MR COONAN   
          53 
 
 
Further re-examined by MR TYSON  
 
          54 
 
 
Questioned by THE PANEL   
 
 
          54 
 
 
Further re-examined by MR TYSON  
 
          63 
 
 
Further cross-examined by MR COONAN   
          64 
 
ALISON CORFIELD, Affirmed 
 
 
Examined by MR TYSON 
 
 
 
          66 
 
 
Cross-examined by MR COONAN   
 
          75 
 
 
Re-examined by MR TYSON  
 
 
          79 
 
 
Questioned by THE PANEL   
 
 
          79 
 
 
Further cross-examined by MR COONAN   
          82 
Further re-examined by MR TYSON  
 
          84 

---

A
(The video link was connected)
MRS M, Called
THE CHAIRMAN:  Good morning, everyone.  We reconvene the case of Dr Southall.  I do 
not know whether the witness can hear me at the present time.  Are we in contact with 
B
Australia? 
THE WITNESS:  Yes, I can. 
THE CHAIRMAN:  You can hear us.  Thank you. 
THE WITNESS:  I can, yes. 
C
THE CHAIRMAN:  Thank you, Mrs M.  At the moment we cannot see you on the screen but 
bear with us just a moment.  We have a menu up that is obscuring our view of you. 
THE WITNESS:  Okay. 
THE CHAIRMAN:  (After a pause)  That is it.  We can now see you.  Mrs M, can you see 
D
us? 
THE WITNESS:  Yes, I can. 
THE CHAIRMAN:  Very good.  I think it is evening where you are – I should say good 
evening to you – and it is morning here. 
E
THE WITNESS:  Okay.  Good morning. 
THE CHAIRMAN:  Before we begin your evidence can I just explain to you who there is in 
the room here.  I am the lay Chairman of the Panel that is hearing the case today who is 
speaking to you now.  There are in fact four other Panellists sitting with me and they are 
either side of the room here. With me I have a Legal Assessor and a Committee Secretary.  
Then we also have the Doctor, his legal team, his counsel Mr Coonan, and on the other side, 
F
for you and the General Medical Council we have Mr Tyson and the legal team.  There is 
also a shorthand writer here who is making the record of the hearing.  The hearing is in public 
and we are calling you Mrs M, as you know.  I think that is probably all I need to mention.  
There are also some people in the public gallery here. 
THE WITNESS:  Okay, thank you. 
G
THE CHAIRMAN:  We need I think to arrange for an oath to be taken.  As well as calling 
you Mrs M, of course I think you are aware we are going to call your children M1 and M2.
You are aware of that? 
THE WITNESS:  Yes, I am. 
H
T.A.  REED 
Day 2 -  1
 & CO. 

---

A
MRS M, Sworn
Examined by MR TYSON
Q 
Do you have access to a piece of paper there, Mrs M? 
A 
I can get one. 
Q 
What I want you to do is can you write down on that bit of paper please your full 
B
name and address? 
A 
My Australian address? 
Q Yes, 
please. 
A 
Okay.  (The witness wrote her name and address on a piece of paper)
Q 
Now comes the difficult bit.  At the end of the evidence I am going to ask you to fax 
C
that note back to us in London, but is there any way that you can hold it up to the screen so 
that it can be read by anybody? 
A 
(The witness held the piece of paper to the screen)  I do not know if you can see it. 
MR TYSON:  I can see a bit of paper, certainly.
THE CHAIRMAN:  Stay there for a moment and someone will come and look.  I can assure 
D
you that it cannot be seen by the public gallery here.
(Mr Tyson’s instructing solicitor wrote down the 
witness’s name and address)
THE CHAIRMAN:  It has been confirmed I think that that has been read.  The solicitor is 
just copying down what you have written.  Are you able to hang on a few moments longer, 
E
Mrs M? 
MR TYSON:  (After a pause)  Thank you, you may go back. 
Mrs M, I am going to ask you some questions about an interview that you had with Professor 
Southall.  After I ask you questions, you are going to be asked some questions by Professor 
Southall’s barrister and then I might be able to ask you some more questions.  After that you 
F
will be asked some questions or may well be asked some questions by the members of the 
Panel, and following that you may find that Professor Southall’s barrister or I might ask some 
more.  That is how it is going to go. 
A Okay. 
Q 
I see you have a bundle of documents in front of you. 
A Yes. 
G
Q 
Can I ask you please, just to see that we are looking at the same bundle, to go in this 
bundle to section 1 at tab (gg)? 
A 
I am sorry, (gg)?  Okay. 
Q 
I am sorry, members of the Panel I am going to ask you to be looking at section (gg) 
at page 23, which I am going to be taking this witness to.  The witness will have it in a 
H
slightly different place.  Do not worry about yours, Mrs M, at the moment. 
T.A.  REED 
Day 2 -  2
 & CO. 

---

A
A Okay. 
Q 
I am just asking the Panel to locate that they have got a document at (gg) at page 23.
Could you please look at tab (ii) at page 23? 
A Okay. 
Q 
Could you just please read the first four words on that document to see if we are all 
B
looking at the same document? 
A 
“I am the above named person …”. 
Q 
I want you to be looking at something that says page 23 in tab (ii)? 
A 
Sorry, I have got (ii) but there are no page numbers. 
Q 
If you go through tab (ii) until you come to a letter from a county council, dated  
C
18 May 1998, then following that there should be a document from the social worker 
Francine Salem.  It is towards the back of tab (ii).  I am not asking the Panel to look at tab 
(ii).
A 
I have got it. 
Q 
Could you just read the first three words of that document? 
A 
“Thank you for your letter …”. 
D
Q 
Yes, and then the next page says ---? 
A 
Do you want me to read it? 
Q 
Just read the first three words so we can see we are all looking at the same document. 
A 
“Following a request …”. 
E
Q 
That is fine.  Could you keep that page open and I will come back to that in a 
moment.  It might be helpful if you sort out the file so that you can keep it open permanently. 
A Okay. 
Q 
I am not going to take you to that directly but we will come to it in a minute.  I want 
to take you back to 1998 and to a time when your youngest child, who we are calling M2, 
was taken away from you.  You recall that period no doubt? 
F
A 
Yes, I do. 
Q 
We know that your child was taken away and we know that you got a solicitor to 
assist you with getting the child back.  Can you remember the name of that solicitor? 
A 
Yes, her name was Beth Parry. 
Q 
Can you recall when you first became aware of the name “Professor Southall”? 
G
A 
It was not till quite a few days later on when we had the first case conference. 
Q 
Did his name come up at that case conference? 
A 
Yes, it did. 
Q 
Can you recall in what connection it came up? 
A 
Yes, I do. 
H
T.A.  REED 
Day 2 -  3
 & CO. 

---

A
Q 
Perhaps you can tell the Panel? 
A 
I am sorry, do you want me to tell ---? 
Q Yes, 
please. 
A 
Okay.  We went to the case conference and it was basically outlined why my son was 
taken away on the request of Professor Southall.  That was the first time his name came up, 
and what his qualifications were, at the case conference. 
B
Q 
Can you just pause there.  Did you say the child was taken away at the request of 
Professor Southall? 
A Yes. 
Q 
I am sorry, perhaps you can continue.  We are at the case conference.  You say his 
name came up, the child had been taken away --- 
C
A 
Yes, it was. 
Q 
-- at his request, you heard, and just take us through that case conference in 
connection with Professor Southall please? 
A 
At the case conference what was talked about was the nursing director who had been 
in touch with Professor Southall about her concerns and then the social services were 
involved and got an emergency protection order on the advice of Professor Southall to take 
D
my son away. 
Q 
Just pause there a moment.  You talked about a nursing director.  Were you employed 
at a hospital? 
A 
Yes, I was. 
Q 
Do not mention the name of the hospital, but what was your occupation at that 
E
hospital? 
A 
I was an operating department orderly. 
Q 
Could you tell the Panel, please, what an operating department orderly does? 
A 
Yes, it cleans the operating theatres, it stocks the shelves, I get the equipment read for 
the operations. 
F
Q 
In such a role did you have access to any drugs? 
A 
No, I do not. 
Q 
Are you taught or do you know how to do injections or the like? 
A No. 
Q 
You told us that the director of nursing got in touch with social services, as a result of 
G
which --- 
MR COONAN:  I think the evidence was “got in touch with Dr Southall.” 
MR TYSON:  I am obliged.  Then going back to this case conference at which you were, you 
have mentioned that Professor Southall’s name came up and that your son had been taken 
away.  Was there any discussion at that case conference that you can recall as to why your 
H
youngest son had been taken away? 
T.A.  REED 
Day 2 -  4
 & CO. 

---

A
A 
Yes, there was. 
Q 
Could you please tell the Panel what you recall of that conversation? 
A 
Yes.  There was mention of Munchausen’s syndrome by proxy and it was thought that 
I was suffering from it and that my son was in danger from me. 
Q 
Was there any discussion of the factors that made that diagnosis be made? 
B
A 
Yes, there was. 
Q Carry 
on. 
A 
It mentioned all the accidents that my son had had.  There was also a mention of the 
way he was feeling, which I discussed with one of my managers where I work, and that 
apparently is how it all came about. 
C
Q 
At that case conference was there any discussion about your elder child who had did? 
A 
Well, there was mention of – there was a similarity in what [M1] was saying he felt 
like.  Sorry, what child number two was saying. 
Q 
Call the child either your eldest child or your youngest child. 
A Okay, 
sorry. 
D
THE CHAIRMAN:  Can I just at this point remind any press present that we are anonymising 
the names in this case and the actual names, even if mentioned, should not be reported.  I just 
make that reminder.  Thank you. 
MR TYSON:  (To the witness)  Do you recall at the end of the case conference whether it 
was decided that you should go anywhere to see any people? 
A 
No, it was not mentioned at the case conference, no. 
E
Q Carry 
on. 
A 
No, there was not. 
Q 
Subsequently was it arranged that you would have to see any people? 
A 
Yes, it was, and that was later on in the court appearance. 
F
Q 
Who was it who arranged that you should go and see? 
A 
Professor Southall and Professor Dora Black, and that was it. 
Q 
And did you go and see both Professor Dora Black and Professor Southall? 
A 
Yes, I did. 
Q 
When you went to see Professor Dora Black were you accompanied by any social 
G
workers, or anything like that? 
A No. 
Q 
You said that you went to see Professor Southall.  Can you say why you had to go and 
see Professor Southall? 
A 
I was told it was going to be for a medical to see if I was actually suffering from 
Munchhausen’s syndrome by proxy. 
H
T.A.  REED 
Day 2 -  5
 & CO. 

---

A
Q 
Did you go there, as far as family members, by yourself or with any other person? 
A 
Yes, I went with a social worker. 
Q 
But did a particular social worker take you up there just to help assist with the 
transport? 
A 
Yes, they did. 
B
Q 
And when you got into the room, who was there? 
A 
Professor Southall and another social worker, Francine Salem. 
Q 
Were you expecting Francine Salem to be there? 
A 
No, I was not. 
Q 
Had you been told that she was going to be present? 
C
A 
No.  Nobody told me at all. 
Q 
When you were in the room, did she explain why she was there? 
A 
She never talked to me at all. 
Q 
Did Professor Southall explain to you why she was there? 
A 
No, he did not. 
D
Q 
Was this interview in Stoke on Trent? 
A 
Yes, it was. 
Q 
And was it in what you understood to be Professor Southall’s own room? 
A 
Yes, it was. 
E
Q 
And apart from you and Professor Southall and Francine Salem, was there any other 
person in the room at the time? 
A 
No, just the three of us. 
Q 
And in preparation for that interview, what were your own emotions like at this time? 
A 
Very high.  Very high indeed. 
F
Q 
In what way, and why? 
A 
I mean, I was just getting over….  Coming to terms with the death of my eldest son, 
and my youngest son was taken away also. 
Q 
If you had known that there was going to be someone else at that meeting, apart from 
Professor Southall, what would you have done? 
A 
I would have taken by solicitor with me, or somebody else with me.  Yes, I would. 
G
Q 
A note of that meeting has been taken by Francine Salem.  What I am going to do, 
Mrs M, is to take you through that not and see what you agree with and what you disagree 
with and to try to bring the words alive so we can see how things were said.  You understand? 
A 
Yes, I do. 
Q 
And the note that I am going to take you through is the note that we eventually found 
H
that starts with the words, “Following a request…”.  Do you see that? 
T.A.  REED 
Day 2 -  6
 & CO. 

---

A
A 
Yes, I do.  Got it.  Sorry. 
Q 
Looking at the second paragraph it says: 
“Pfr. Southall began the discussion by talking with [you] about the suggestion that 
[your eldest child] had been bullied by both students and a teacher.” 
B
Is that how you recollect the interview beginning? 
A 
Yes.  He did talk about my eldest son being bullied, yes. 
Q 
Were there any preliminaries or did he go, as it were, straight into the bullying? 
A 
Straight into the bullying. 
Q 
Ms Salem records your response to those questions as here she says that you 
C
confirmed this – 
“… suggesting that your eldest son had sorted the children’s bullying out by 
retaliation and this had stopped it.” 
Do you recall saying that? 
A 
Yes, I do. 
D
Q 
She also says that: 
“... the key areas relating to this type of bullying were [your eldest child] being 
kicked, having his clothes pulled about and books kicked across the ground.” 
Is that what you said? 
E
A 
Yes, because she asked me what type of bullying went on.  Sorry, Professor Southall 
asked me about the type of bullying. 
Q 
It is recorded that you said that you did not feel – 
“… that any school would acknowledge that bullying was going on within their 
school.”
F
A 
Yes, that is right. 
Q 
It is recorded here: 
“With regard to the kick that [your eldest son] sustained from Lisa … [you] stated that 
[your eldest child] was complaining of pain two days later, not all the time …  So 
G
[you] had decided to take [the child] to hospital.” 
Was there a discussion about the “Lisa kick”, as it were? 
A 
I cannot remember precisely if I mentioned that but, yes, it was mentioned somewhere 
in the conversation. 
Q 
The note goes on to discuss bullying by the class teacher.  Was there a discussion 
H
about that? 
T.A.  REED 
Day 2 -  7
 & CO. 

---

A
A 
Yes, there was. 
Q 
And it is recorded that you said that there had been problems from the very beginning 
of your child being in that lady teacher’s class? 
A 
There had been problems, yes, but I cannot remember exactly, but I am sure 
I mentioned it during the course of the conversation. 
B
Q 
We are in the third paragraph now, Mrs M.  Do you see this? 
A 
Yes, I do. 
Q 
It says in the third line in the third paragraph that the teacher – 
“… was alleged to have reduced [your eldest child] to tears and ignored him when he 
had his hand up (asking for help) for half an hour.” 
C
Is that what you told Professor Southall? 
A 
Yes, that is right.  Yes. 
Q 
And that you also gave Professor Southall two witnesses of school friends that had 
told you about this.  Is that right? 
A 
That is correct, yes. 
D
Q 
Francine Salem has recorded that there was a discussion about you having to 
apologise to a member of staff about your eldest child’s behaviour.  Was there a discussion 
about that? 
A 
I cannot remember.  I am sorry. 
Q 
I am just asking you to look --- 
E
A 
I remember apologising. 
Q 
To the school? 
A 
Yes  I remember apologising to the school. 
Q 
It is recorded here that there was a discussion about your eldest child’s appendix 
operation.  Can you recall there was a discussion about that? 
F
A 
I cannot remember that conversation, no.  Just that there was a discussion about his 
injuries that he sustained. 
Q 
At the time when your eldest son had to go for an appendix operation, were you living 
at the family home? 
A 
No, I was not.  No. 
G
Q 
In the next paragraph can you pick up the words, “Mrs M, when question…”.  Do you 
see that? 
A 
Yes, I can.  Sorry. 
Q 
It is recorded in that paragraph.  Perhaps just read that little paragraph to yourself for 
a moment. 
A 
Okay.  (Pause for reading)
H
T.A.  REED 
Day 2 -  8
 & CO. 

---

A
Q 
Was there a discussion along those lines about the relationship between you and your 
husband? 
A 
Professor Southall asked me about my relationship with my husband, and I assured 
him that the children had not seen anything or heard anything.  He initiated the conversation 
about that bit. 
Q 
Just read the next two little paragraphs, please, together.  Then I will ask you some 
B
questions about those. 
A 
(Pause for reading)   Okay. 
Q 
Was there a discussion about your eldest child’s death? 
A 
Yes, there was. 
Q 
And who brought it up? 
C
A Professor 
Southall. 
Q 
And can you recall in general terms how that conversation went, and what kind of 
questions he was asking you about it? 
A 
He started by asking me why I thought my eldest son had done it, and he gave me 
three scenarios as to what he thought, and he got a bit annoyed about the fact that I would not 
show him how he actually did it. 
D
Q 
We will come onto that in a moment.  We see in this little note that I showed you, was 
there a discussion about whether the curtains in your eldest child’s room were open or 
closed? 
A 
Yes, there was. 
Q 
And was there a discussion about the belt that had been used by your eldest child? 
E
A 
Yes, there was.  Yes. 
Q 
Do you recall whether Professor Southall made any comments about that belt? 
A 
Yes, he did. 
Q 
What were the comments that you recall? 
A 
Professor Southall stated that he did not think it was my son’s belt as it was too big, 
F
but it was very clever of him. 
Q 
Very clever of him in what way? 
A 
In the way he tied the belt. 
Q 
Were you asked about how the belt had been tied? 
A 
Yes, I was. 
G
Q 
And did you demonstrate that to Professor Southall? 
A 
Yes, I did.  (The witness was distressed)
Q 
Do you have a glass of water or a hanky there at all, Mrs M? 
A 
Yes.  Sorry. 
H
T.A.  REED 
Day 2 -  9
 & CO. 

---

A
THE CHAIRMAN:  Mrs M, we know that this may be distressing for you.  If at any time you 
want to take a break, do let us know. 
A 
Thank you.  Okay. 
MR TYSON:  I do not want to embarrass you any more than I have to, Mrs M, but you have 
shown some emotion just now.  Were you showing any similar kind of emotion when you 
were being asked these questions by Professor Southall? 
B
A 
Yes, I was and I was very angry as well. 
Q 
Were you crying? 
A 
Yes, I was. 
Q 
And were you upset? 
A 
Yes, I was. 
C
Q 
I am sorry to have to go back to the question of the belt.  You say that Professor 
Southall asked you to demonstrate how it was used on the curtain pole? 
A 
Yes, he did. 
Q 
And did you show him? 
A 
I showed him with a pencil and a shoe lace. 
D
Q 
You told the Panel earlier that at one point Professor Southall had said the words, 
“Very clever.” 
A Yes. 
Q 
Was that in relation to the demonstration about the belt, or had it been another 
section? 
E
A 
He said it straight after the demonstration of how he tied the belt  
Q 
And how would you describe the way that he said, or the manner in which Professor 
Southall said, “Very clever”? 
A 
He said it quite sarcastically actually. 
Q 
And in relation generally to the questions that Professor Southall was asking you, how 
F
would you describe his manner of questioning? 
A Very 
aggressive. 
Q 
You said that at one time you had seen another professor, Professor Black.  Was the 
style of questioning the same or different? 
A Completely 
different. 
G
Q 
And by comparing the two medical experts, who would you describe Professor 
Southall’s manner of questioning your? 
A Unprofessional. 
Q 
And why do you say that the questioning was unprofessional? 
A 
He did not believe a word I was saying, and Professor Southall was asking me 
questions one after another.  At one point he did not let me explain.  He just kept questioning 
H
me. 
T.A.  REED 
Day 2 -  10
 & CO. 

---

A
Q 
I need to come back to this note that we were looking at, Mrs M.  Can I take you to 
the bottom paragraph of this first page, where there seems to have a conversation recorded 
about the ambulance.  That was a call by you.  Will you just read that to yourself? 
A 
(Pause for reading)   Yes, okay. 
Q 
And does that set out broadly your recollection of the discussion you had about the 
B
ambulance and the ambulance men? 
A 
Yes, it does. 
Q 
And was it Professor Southall or Ms Salem who is asking you these questions 
A Professor 
Southall. 
Q 
Turn over the page, please.  Just read the first three lines of the next page. 
C
A To 
you? 
Q To 
yourself. 
A 
Okay.  (Pause for reading)
Q 
Was there a discussion about an overdose being taken by your husband? 
A 
Between me and Professor Southall? 
D
Q 
Yes.  Did he ask you about it? 
A 
I am sorry.  I cannot recollect that. 
Q 
You see what is written at the top of the second page – those three lines? 
A 
Yes I do. 
E
Q 
You cannot recollect that? 
A 
I cannot, I am sorry. 
Q 
Just look at the next paragraph, please, about a magazine.  Can you just read those 
words, please. 
A 
(After a pause)  Yes, that is fine. 
F
Q 
Did he ask you about the magazine? 
A 
Yes, he did. 
Q 
And does that show that the nature of the discussion that you had about the magazine? 
A 
Yes.  It does, yes. 
Q 
Then, reading the paragraph about the television program, just read those three lines 
G
to yourself, please.   (Pause for reading)   Does that reflect the discussion you had about the 
television programme? 
A 
That was only a brief conversation when we were discussing the bullying incident, 
yes
Q 
Were you asked whether you had said anything on the television programme? 
A 
Yes.  Professor Southall asked me, and I told him that I had not said a word.
H
Actually, he got involved in the conversation. 
T.A.  REED 
Day 2 -  11
 & CO. 

---

A
Q 
It is going to be the next paragraph.   Would you just read those words about the 
schooling incident, please?  (Pause for reading)  Were you asked about that by Professor 
Southall?
A 
Yes, I was. 
Q 
Does that paragraph more or less record what you said? 
B
A 
Yes, it does. 
Q 
Could you read the next paragraph, please, to yourself. (Pause for reading)  Were you 
asked about the two boys that you had heard about at the inquest? 
A 
Yes, I was. 
Q 
Were you aware before the inquest that these boys had said this to the police? 
C
A 
I think I was.  I cannot recall.  I just remember the conversation I had with somebody 
about one of the boys, yes. 
Q 
Had you spoken to either of the boys yourself? 
A 
Not until after the inquest, no. 
Q 
Did you give to Professor Southall the information about what happened to one of the 
D
boys that is recorded in this note? 
A 
Yes, I did. 
Q 
Can you just read the next two lines to yourself, please?  (Pause for reading)  Was 
there a discussion about your eldest child’s height and weight and matters like that? 
A 
Yes, there was. 
E
Q 
Can you take us through it, as best you recall now, at the time? 
A 
Professor Southall mentioned that because my eldest son was quite tall and his weight 
that the pole should have broken and it did not.  He just kept saying that it should have 
broken due to his height and weight. 
Q 
And what kind of tone was he using when he was saying that? 
A 
Very aggressive and sarcastic. 
F
Q 
Skip the next four lines and then go to the next two lines, please, which talk about the 
curtain rail.  Did Professor Southall discuss the curtain rail with you? 
A 
Yes, he id. 
Q 
What kind of questions was he asking you about the curtain rail? 
A 
He was asking me what type of curtain rail it was and how it was fixed to the wall. 
G
Q 
Were there any questions about where the rail was now? 
A 
Yes, he did.  I explained what had happened to it afterwards and he did not believe 
me. 
Q 
What did you explain that had happened to it afterwards? 
A 
My husband had taken it down off the wall and chopped it up and put it in the bin. 
H
T.A.  REED 
Day 2 -  12
 & CO. 

---

A
Q 
You say that Professor Southall did not believe you.  How did you ascertain that? 
A 
I explained to him that when I found my eldest son I attempted to jump on the rail, 
grab hold of it and pull it down myself and it did not come down and he said, “I don’t believe 
that because you are heavier than your son”. 
Q 
All the questions that I have been asking you to date about this interview, Mrs M, 
relate to your eldest son. Is that your recollection? 
B
A 
Yes, it is. 
Q 
Please have a glass of water, if you want to.  Can you go over the page, please, to the 
top of the next page?  We see that there is mention there about you being absent from work a 
bit prior to your eldest child’s death.  Were you asked about your work record? 
A 
No, not really. 
C
Q 
It is recorded here that you said words to the effect that you must have been fed up 
with your job at the time.  Can you recollect saying that? 
A 
No, I do not recollect saying that because I liked my job at that time. 
Q 
Were you liking your job at the time of your eldest child’s death? 
A 
I was, yes. 
D
Q 
There is reference in that paragraph to Child and Family Service appointments.  Had 
there been made available to you opportunities to go to the Child and Family Service with 
your youngest child? 
A 
Yes, there was.  Yes. 
Q 
Who was the doctor who was running that service? 
A Dr 
Solomon. 
E
Q 
Were those sessions for the benefit of you and your husband or were they for the 
benefit of your youngest child? 
A 
We were all told that we could all attend but my husband did not attend because of his 
job commitments but I took my younger son to them. 
Q 
Could you, in this note, go down to the fourth paragraph where syringes are 
F
mentioned?  Do you see that paragraph? 
A Yes. 
Q 
Could you just read that to yourself?   (Pause for reading)
Were you asked by Professor Southall about your knowledge of syringes and injections? 
A 
Yes, I was. 
G
Q 
Could you take the panel through the kind of questions you were asked about these 
things? 
A 
Professor Southall asked me if I had seen injections being given, if I had access to any 
medications, any drugs, and I explained that I did not because I was not trained to do that;  
I was just trained to clean the operating theatres and I had no contact with patients at all. 
Q 
Did Professor Southall appear to accept what you were saying? 
H
A 
No, not really.  No. 
T.A.  REED 
Day 2 -  13
 & CO. 

---

A
Q 
How did you judge that? 
A 
I judged it that he thought that I had actually killed my son. 
Q 
Was there a discussion about ways in which your son could have died? 
A 
Yes, there was. 
B
Q 
I know this might be painful for you, Mrs M, but perhaps in your own words you can 
take us through that discussion as you recall it. 
A 
After all the questions Professor Southall asked me, he said, “There are only two ways 
that my son could have possibly died, the first one being through experimenting”.  I was not 
quite sure at that time what he meant.  The second one was that he meant to do it and the third 
one was that he was murdered. 
C
Q 
How did the conversation go on? 
A Sorry? 
Q 
Was there a discussion about any of those three and which was the most likely? 
A 
Yes, there was. 
Q 
Perhaps you can tell the panel how that discussion went? 
D
A 
Professor Southall just turned to me and said, “I put it to you that you killed your son 
by injecting him, hanging him up, leaving him there to die and then ringing the ambulance”.  
(Pause)  Can I just have a minute, please? 
THE CHAIRMAN:  We will take a 10-minute break at this time. 
MR TYSON:  Mrs M, we are just going to stop for ten minutes and have a break. 
E
(The Panel adjourned for a short time)
MR TYSON:  Mrs M, can you hear me? 
A 
Yes, I can. 
Q 
Are you comfortable proceeding or do you want further time? 
F
A 
I am fine.  Thank you. 
Q 
I am sorry but I am going to have to come back to distressing matters.  You said that 
Professor Southall said to you, “I put it to you that you killed your son by injection. You hung 
him up, leaving him to die and then called an ambulance”.  Can you please tell the panel in 
what kind of tone Professor Southall was saying this? 
A 
As I said before, it was aggressive, uncaring.  He just came straight out with it and 
G
just said, “This is what I think happened”, and that is when he said that I injected him and 
hung him up and left him. 
Q 
Was it true? 
A 
No, it was not true. 
Q 
What do you consider to be the cause of your eldest son’s death? 
H
A 
I believe that he was bullied and that is the truth. 
T.A.  REED 
Day 2 -  14
 & CO. 

---

A
Q 
Did you give Professor Southall any other people who could help you on the question 
of bullying? 
A 
I mentioned other parents that had children in the same school. 
Q 
If you look at that note that we were looking at on page 2, you see about two-thirds of 
the way down some names that are there mentioned? 
B
A Yes. 
Q 
Are those the names that you gave Professor Southall? 
A Yes. 
Q 
Perhaps you can read the next paragraph to yourself about the gentleman that is 
mentioned.   (Pause for reading)  Is the gentleman there mentioned the head teacher of the 
C
school where your eldest child was? 
A Yes. 
Q 
Did you say words to the effect that we see in that paragraph? 
A 
Correct.  I believe that is correct.  That is what he said. 
Q 
Can you read the last paragraph to yourself, please?   (Pause for reading)
D
A 
Yes, that is correct. 
Q 
Was there a discussion about how the belt was tied around your eldest
child’s --- 
A 
Yes, there was. 
Q 
Were you initially reluctant to talk about that? 
E
A 
I did not want to talk about it and I said that to Professor Southall. 
Q 
How did the conversation go on? 
A 
Professor Southall said to me that if I did not show him how it was tied then I must be 
guilty.
Q 
How did you take that accusation? 
F
A 
I was very angry about it. 
Q 
But did you in fact tell him how it was tied? 
A 
Yes, I did.  I did, yes, but he could not understand how I was explaining it to him, so  
I showed him. 
Q 
You told us earlier that you used a pencil and screen? 
G
A Yes. 
Q 
Can I ask you, please, to keep a hand in the document we are looking at and go over a 
few pages. You will see a section marked (bb).  It follows.  Go forwards and you will see a 
section called (bb).  You will see in this section there is some handwriting. Do you see the 
handwriting? 
A 
I do, yes. 
H
T.A.  REED 
Day 2 -  15
 & CO. 

---

A
THE CHAIRMAN:  Mr Tyson, for the benefit of the panel, could you point out if this is the 
same BB?  Then it is before rather than after. 
MR TYSON:  I am sorry.  (To the witness)  Do you see the handwriting under section (bb)? 
A Yes. 
 
Q 
Can you turn a couple of pages into there at a page which is marked at the bottom 
B
161, which has a diagram of what looks like maybe your house.  There is some page 
numbering at the bottom, Mrs M.  It is 161. 
A 
Yes, I have got it. 
Q 
You see there is a diagram.  Is that the upstairs of the house that you were living in at 
the time? 
A 
Yes, it is. 
C
Q 
Is that your drawing or somebody else’s drawing? 
A 
Somebody else’s drawing. 
Q 
But does it reasonably accurately show the layout of the top floor of your house? 
A 
Yes, it does. 
D
Q 
On the day that your eldest child died, did you first see it when you were sitting on the 
toilet that we see marked there with an arrow? 
A 
Yes, that is right. 
Q 
Was the bathroom door and also your eldest child’s door open? 
A 
The bathroom door was not open fully but I could see directly into my son’s bedroom, 
yes.
E
Q 
Is the bed normally placed where it is on the hard lines, as opposed to the dotted 
lines? 
A 
Yes, that is correct. 
Q 
Is the window the other side of that bed? 
A 
Yes, it is. 
F
Q 
Is that the window with the curtain pole over it? 
A 
Yes, that is right. 
Q 
Is that the window from where you saw your eldest son? 
A 
Yes, it is. 
G
Q 
Would you turn over two pages, please, to page 163?  Is that your drawing or 
somebody else’s drawing? 
A 
Somebody else’s drawing. 
Q 
We see a drawing on the far left-hand side which appears to be of the curtain pole.
We see there is a drawing there of something being looped over itself with two ends hanging 
round.  Is that how you found the belt on the day in question? 
H
A 
Yes, it is. 
T.A.  REED 
Day 2 -  16
 & CO. 

---

A
Q 
Did you on that day in question, Mrs M, put that belt on that pole? 
A 
No, I did not. 
Q 
Could you go back to the document which we have been looking at, please, which is 
in the section before in your bundle.  Do you have that? 
A Yes. 
B
Q 
I was asking you about the bottom paragraph.  It is recorded here, about three lines 
from the bottom that Professor Southall had told you that he felt that this was crucial 
information which was needed.  That is in relation to you talking about how the belt was tied 
around your eldest child’s neck.  Did he use those kind of words? 
A 
Yes, he did. 
C
Q 
We see in the next line down some wording about wanting to prove your innocence.
Were those words which you used or were they words that Professor Southall used? 
A 
Professor Southall said that if I did not show him how it was done, then I must be 
guilty.  So I said I would show him if it proves that I am innocent. 
Q 
Did you go on to show him? 
A 
Yes, I did. 
D
Q 
I think you told us earlier that that eventually led to the remark of him saying, “Very 
clever”, or words to that effect.  Is that right? 
A 
Yes, that is right. 
Q 
In the course of this interview with Professor Southall, how much conversation do 
you recall there being about your youngest son? 
E
A 
There was no conversation about my youngest son at all. 
Q 
How much conversation do you recall there was about your family and family life 
generally? 
A 
There was quite a bit. 
Q 
Was the main thrust of the interview about your youngest son or about your eldest 
F
son? 
A 
My eldest son. 
Q 
The interview eventually came to an end.  Can you tell the Panel, please, the range of 
emotions which were going through you as you walked out of the door? 
A 
I was very upset, I was very angry, I was crying.  I felt sick that I had been accused of 
murdering my own son and that is something I have to live with forever.  I am still quite 
G
angry about it. 
Q 
You came back from that interview and, following that, did you go and see anybody 
about the interview? 
A 
Yes.  I asked the social worker to take me straight to my solicitors to see Beth Parry, 
my solicitor. 
H
Q 
Did you give her an account of what had happened? 
T.A.  REED 
Day 2 -  17
 & CO. 

---

A
A 
Yes, I did. 
Q 
Did you also see another professional with whom you were involved at the time 
around this time? 
A 
Yes.  I recall seeing Dr Soloman. 
Q 
Did you give her any kind of account or description of what had taken place? 
B
A 
I recall giving her a brief description of the interview, yes. 
Q 
If it was suggested to you that Professor Southall was polite and courteous 
throughout, what would you say to that? 
A 
That is not true at all.  He was not polite and he certainly was not courteous. 
Q 
If he felt that you were not answering questions fully, what would be his reaction? 
C
A 
He would just ask me another one, one after another. 
Q 
If you felt unable to answer any particular question, what was his reaction to that? 
A 
He got quite annoyed. 
Q 
Did he make any comments about your reluctance to answer any questions? 
A 
Yes, he did.  He said if I did not answer them, I must be hiding something. 
D
Q 
From your recollection, did he accuse you of murdering your son only once or at any 
other times throughout the interview? 
A 
He accused me of murdering my son once as he went through the scenario.  At the 
end of the scenario, he said, “I put it to you that you killed your son”, and then he went on to 
describe how I had done it. 
E
Q 
Did you gain the impression that you were being believed by Professor Southall? 
A 
No, not at all. 
MR TYSON:  If you would just wait there, please, you will be asked some questions on 
behalf of Professor Southall. 
Cross-examined by MR COONAN
F
Q 
Mrs M, as Mr Tyson has indicated, it is not my intention to cause you any distress by 
asking you these questions.  Do you understand? 
A 
I do, yes. 
Q 
But to assist the Panel, both Mr Tyson and I, doing our respective duties, have to 
delve into these matters.  Do you understand? 
G
A 
Yes, I do. 
Q 
You completed your evidence a few moments ago by in effect telling us that Professor 
Southall had accused you of murdering your son, as I say, in effect, on three occasions.  Is 
that right? 
A Yes. 
H
T.A.  REED 
Day 2 -  18
 & CO. 

---

A
Q 
You are saying to this Panel that he had done so in clear, unmistakeable terms.  Is that 
right?
A 
Yes, that is right. 
Q 
Those clear and unmistakeable terms were said to you by this doctor in the presence 
and hearing of this senior social worker.  Is that right? 
A 
That is right, yes. 
B
Q 
She must have been sitting feet away from Professor Southall. 
A 
Yes, she was. 
Q 
Let me set the scene on Professor Southall’s behalf by suggesting to you that he did 
not at any stage accuse you of murdering your child. 
A He 
did. 
C
Q 
Let me make it clear on his behalf what I am suggesting is that you came away from 
that interview with a perception that you had been accused of murder. 
A 
He did accuse me of murder. 
Q 
Do you see the distinction between the two points I am putting to you? 
A 
Yes, I do. 
D
Q 
Let us start at the beginning.  This may involve going over some earlier ground but it 
may help to put it into context.  Before the interview on 27 April, you knew that the local 
authority, in other words, social services, had obtained an Emergency Protection Order, an 
EPO.  They had obtained that on 29 January. 
A 
I was only aware of it when they knocked on my door that morning with the police 
officers. 
E
Q 
I do not dispute that.  Obviously it follows that you came to know that social services 
had obtained the EPO. 
A Yes. 
Q 
Did you know what the basis of the grant of the EPO was? 
A 
Eventually I did, yes. 
F
Q 
Did you come to know what that basis was before the interview with Professor 
Southall?
A 
Yes, I did. 
Q 
Did you come to know therefore that the basis of the grant of the EPO by the court 
was that your youngest son was at risk of significant harm from you? 
G
A Yes. 
Q 
When you came to know about the EPO, in other words, that your youngest child had 
been taken from you in the circumstances which you have just alluded to, you must have 
been very angry and very upset about those events, must you not? 
A 
Yes, I was. 
H
Q 
And very confused? 
T.A.  REED 
Day 2 -  19
 & CO. 

---

A
A 
I was not confused, no. 
Q 
Perhaps I could put it a different way.  You must have been at a loss to understand 
how this could have come about. 
A Yes. 
Q 
That is the EPO.  Can I move on to the next stage in the events?  Did you become 
B
aware that social services, the local authority, were then applying for what is called an 
interim care order? 
A 
Yes, I was aware of that. 
Q 
That application was arranged to be heard in the County Court, was it not? 
A Yes. 
C
Q 
Did you understand that the reason put forward for the application for the interim care 
order was that it was to be a holding measure until social services could investigate whether 
or not they were dealing with a case of Munchausen’s syndrome by proxy? 
A 
Yes, I was aware. 
Q 
Did you also understand that that application for an interim care order was supported 
by the social services and by what is called the Guardian ad litem, or called then at least the 
D
Guardian ad litem?  Did you understand that? 
A 
Yes, I understood that. 
Q 
The Guardian ad litem was a Mrs Inwood.  Was that right? 
A 
Yes, she was.  That is correct, yes. 
Q 
The Guardian ad litem is appointed to look after the interests of the child; in other 
E
words, is appointed in this case to look after the interests of your youngest child? 
A 
I understood that, yes. 
Q 
Eventually, the application for an interim care order was heard in the county court and 
was heard by a judge called Judge Tonking.  Is that right?  Do you remember that? 
A 
Yes, that is right.  Yes, I do. 
F
Q 
Was the upshot of that care process – and I am summarising this – that the judge 
agreed that your youngest child should be returned to you.  Is that right? 
A 
Yes, that is correct. 
Q 
But that thereafter investigations should be carried out into whether or not 
Munchausen’s syndrome by proxy was present here or not and that such an investigation 
would be carried out by or on behalf of social services? 
G
A 
I am sorry I am not sure I understand.  Can you repeat that please? 
Q 
Yes, of course.  The judge agreed that, first of all, your youngest son should go home? 
A 
Yes, that is right. 
Q 
Because he had been in an approved foster care since the making of the EPO? 
A 
That is right, yes. 
H
T.A.  REED 
Day 2 -  20
 & CO. 

---

A
Q 
But it was recognised by social services and by the Guardian ad litem that there were 
nonetheless still serious concerns as to whether or not there was a case of Munchausen’s.   
A 
Yes, I understand now.  Yes, sorry. 
Q 
That investigation as to whether or not the authorities were dealing with a case of 
Munchausen's syndrome by proxy would therefore be carried out whilst your youngest son 
was at home with you? 
B
A 
That is right, yes. 
Q 
Eventually – and the precise date I am not particularly concerned about – but certainly 
before 27 April you came to understand that that investigation or assessment would be carried 
out, at least in part, by Professor Southall and Dr Dora Black. 
A 
Yes, that is right. 
C
Q 
Were you given to understand that both Dr Black and Dr Southall represented 
different medical disciplines? 
A 
No, I was not led to believe that.  I thought they were both the same. 
Q 
Did you understand – and again, Mrs M, so that I make it clear, this is again before 
27 April – that the question which had been raised by the authorities – I can use that 
expression generally – of Munchausen’s syndrome by proxy involved a suspicion of abuse of 
D
your youngest child by you? 
A 
That is correct. 
Q 
Before the interview took place did you understand that investigation or assessment 
that we have just discussed, which would be carried out, would involve a close look at the 
circumstances surrounding your eldest son’s death? 
A 
No, I was not aware of that at all. 
E
Q 
So you did not understand that there would be any focus on your elder son’s death at 
that stage? 
A No. 
Q 
Therefore, would it be fair to say that your expectation in this regard in terms of the 
investigation and the assessment which was to be carried out would be focused upon whether 
F
or not there was any basis for the suspicion that you were abusing your youngest child? 
A 
I was told that it would be a medical to see if I had Munchausen’s syndrome. 
Q 
Can we look at that in two respects?  That is all you were told, was it, that it was 
simply going to be as you just described it – and I am not disputing what you say.  As you 
have described it, you were told that you were going for a medical to see whether or not you 
were suffering from Munchausen’s.  Is that right? 
G
A 
That is correct.  That is right, yes. 
Q 
Of course, a medical could take many forms.  You can get this out of the way.  Did 
you anticipate that there would be any physical examination of you? 
A 
I was not sure what it entailed. 
H
T.A.  REED 
Day 2 -  21
 & CO. 

---

A
Q 
May I come back to that aspect of it in a moment.  Did you think, nonetheless, that 
there might be questions or discussion by Dr Southall, and for that matter Dr Black, about the 
possibility of you abusing the child, your youngest child? 
A 
Yes, I was expecting that, yes – my youngest child. 
Q 
That is the first bit of background I want to deal with.  Can I now just pause for a 
minute and just ask you about an event of which I am a little ignorant and I wish you to help 
B
me.  Before 27April had you at some stage, in say January, February or March time, been to 
see the police again? 
A 
I went down to the police station with my solicitor at one point, but I cannot 
remember when. 
Q 
Was that immediately following your eldest son’s death, because we know that you 
made a witness statement three days later?  It is not that occasion I am concerned about 
C
because that was back in 1996. 
A 
Yes, yes, I did go on another occasion. 
Q 
Which solicitor did you go with?  Was it Beth Parry? 
A 
No, it was not. 
Q 
It was another firm, was it, or the same firm but a different solicitor? 
D
A 
Yes, Mr Townsend. 
Q 
I interrupted you, I am sorry.  Was it the same firm as Beth Parry’s firm? 
A 
I do not think it was, no, because I had to have separate representation from my 
husband.
Q 
Was it separate representation for the purposes of, for example, the interim care order 
E
proceedings, or was it with a view to possible criminal proceedings?  I am not at the moment 
able to understand the factual circumstances? 
A 
I was told it was for the interim proceedings. 
Q 
So it follows, does it, that since the interim care proceedings only arose as a real 
possibility after the EPO, it must have been some time after 29 January that you went to the 
police station 
F
A 
Yes, it was. 
Q 
When you went to the police station did the police officer, whoever it may have been, 
and the name does not concern me, did he or she attempt to ask you some questions about the 
belt? 
A 
Yes, he did. 
G
Q 
Did you say “no comment” to the police officer’s questions? 
A 
Yes, I did. 
Q 
Was that on the advice of your solicitor? 
A 
Yes, it was. 
Q 
Let us just move on a stage.  Again, this is still before 27April.  Did you go to see 
H
Dora Black? 
T.A.  REED 
Day 2 -  22
 & CO. 

---

A
A 
I cannot remember if it was before Professor Southall or afterwards. 
Q 
Can I suggest to you that it was before and it was certainly round about 15 April? 
A Okay. 
Q 
It may be that, as a result of further questions I am going to ask you, we might be able 
to get a clearer picture, but first of all, where did you see Dr Black? 
B
A In 
London. 
Q 
When you came down to London, did you come down with your youngest child? 
A 
My youngest child and my husband. 
Q 
So Dr Black saw all three of you, did she? 
A 
Yes, she did. 
C
Q 
You came to London – and I am using your expression which is in a statement we 
have from you – and you went to see the sights, did you not? 
A 
Yes, we did. 
Q 
Then you saw Dr Black and you thought she was a really nice lady, did you not? 
A 
Yes, I did. 
D
Q 
She came across to you at the time as being really concerned about your youngest 
child? 
A 
That is correct. 
Q 
She came across to you as being really concerned about your relationship with your 
husband? 
E
A 
I do not agree with that.  She did not seem that concerned about my relationship with 
my husband. 
Q 
It depends in the sense in which one uses the word “concerned.”  Put it this way:  was 
she showing particular interest in your and your husband’s relationship? 
A 
She mentioned it in the past tense, but was pleased that we had sorted things out, 
when we actually went to see her, 18 months prior to seeing her. 
F
Q 
I appreciate this is quite some time ago; it is six years ago now, or more, six-and-a-
half years ago.  Just try and think back.  Do you remember Dr Black expressing concern not 
only about your youngest child but also about you and your husband’s relationship? 
A 
Yes, it was mentioned, yes. 
Q 
It may have been mentioned but did she express real concern? 
G
A 
I cannot remember if she expressed real concern. 
Q 
Mrs M, this is just a purely administrative matter, but do you have in front of you, 
there in Australia, a copy of your witness statement you made this year to Field Fisher 
Waterhouse? 
A 
Yes, I do – not in front of me at the moment though. 
H
Q 
Is it obtainable? 
T.A.  REED 
Day 2 -  23
 & CO. 

---

A
A 
Yes, it is. 
Q 
Can you just help us?  Where would you have to go to get it? 
A 
No, not at the moment, no.  It would take me about half an hour, an hour, to get it. 
Q 
I do not want to break off at the moment but let us see how we can proceed without 
doing that and see how we can go.  Can I just suggest to you that, first of all, you remember 
B
making a witness statement in June of this year? 
A 
Yes, I do. 
Q 
To Field Fisher Waterhouse, for the purposes of these proceedings? 
A 
Yes, that is correct. 
Q 
I am just doing this simply to try and assist your recollection or judgement which was 
C
present at the time you made the statement.  That is all. 
A Okay. 
Q 
Mr Tyson has this as well and I am looking at paragraph 10.  I am just going to quote 
a sentence from a paragraph in that statement and can you tell me whether it jogs your 
memory or not.  You are dealing with seeing Dr Black in London: 
D
“I cannot remember if she asked about how my eldest child died.  She was really 
concerned about my youngest child and about my and my husband’s relationship.” 
All right? 
A 
That is right, yes. 
Q 
I hope you do not think I am being unfair, but that is how you were putting it, you see, 
E
to Field Fisher Waterhouse in June of this year.  Do you accept that that is an accurate recall 
of your experience when you went to see Dr Black? 
A 
Yes, that is correct. 
Q 
Is it also your recollection that there was really very little focus, if any, on the 
circumstances or the fact of your eldest child’s death? 
A 
Yes, that is correct. 
F
Q 
With that in mind – when I say “that” in mind, all those factors that you and I have 
just covered in mind – by the time that you arrived for the meeting with Dr Southall on  
27 April, you thought you would be going for a medical? 
A Yes. 
Q 
And is this right – and I want you, please, to listen very carefully.  Did you think that 
G
this interview with Dr Southall, this medical, was going to be – and I choose my words 
deliberately – did you think it was going to be an emotional examination?  An examination of 
your thoughts and feelings? 
A 
An examination of my thoughts and feelings. 
Q You 
did? 
A 
I did, yes. 
H
T.A.  REED 
Day 2 -  24
 & CO. 

---

A
Q 
In other words, to be emotionally examined? 
A Yes. 
Q 
So in other words, to be emotionally examined, to be asked questions about your 
thoughts and feelings, just as had happened with Dr Black? 
A Yes. 
B
Q 
And Dr Black’s discussions with you were directed towards your thoughts and 
feelings, were they not? 
A 
Yes, they were. 
Q 
And so with that expectation that this interview would be just like Dr Dora Black’s 
interview, when Dr Southall began asking you questions relating to the circumstances 
surrounding your eldest child’s death you must have been seriously jolted? 
C
A 
Could you repeat that?  Sorry.  I never heard that. 
Q 
When Dr Southall began to ask you some questions about the circumstances 
surrounding your eldest son’s death you must have been seriously jolted because --- 
A 
Yes, I was. 
Q 
It was – I hope this is not an exaggeration on my part – but it was wholly unexpected? 
D
A 
Yes, it was. 
Q 
Mrs M, may I just ask you a few questions, please, about yourself, about how you 
were feeling when you arrived for the interview.  In your evidence this morning in England 
but, of course, this evening in Adelaide, you said that your emotions were very high indeed.
That is right, is it not? 
A 
Yes.  That is correct. 
E
Q 
When you say your emotions were very high indeed, it may be obvious but can you 
just help us a little more.  Does that mean, for example, that you were, as it were ---   Were 
you on a knife edge?  Were you upset or tearful before you went into the interview?  You 
help us? 
A 
I was not tearful.  I was not on a knife-edge.  I was upset at the fact that my son had 
been taken away and I just wanted it all sorted out. 
F
Q 
So you were upset even before you went in? 
A 
I was not teary upset, no.  I was just upset that things had just progressed as they did. 
Q 
So emotionally upset, but not teary? 
A Yes. 
 
G
Q 
Of course it is not difficult, perhaps, for us to understand why that may be the case 
because you have had the tragic death of your eldest son in 1996, your youngest son had 
spent some time with foster parents in the earlier part of 1998 until returned to you by the 
judge.  Yes? 
A 
Yes.  Sorry, yes. 
Q 
And of course, was it not the case had left? 
H
A Sorry? 
T.A.  REED 
Day 2 -  25
 & CO. 

---

A
Q 
Had your husband left you at about this time? 
A No. 
Q 
Was he still with you? 
A Yes. 
B
Q 
So if we just try and bring the events of 27 April to life a little more, right at the 
beginning, no doubt when you are going into the hospital premises at Stoke on Trent, you 
were emotionally upset within you, no doubt anxious about what was going to happen? 
A Yes. 
Q 
Thought it would be an interview just like Dora Black’s interview? 
A Yes. 
C
Q 
Just wanted the whole thing sorted out? 
A 
That is right, yes. 
Q 
Because, of course, there was a real possibility that the case would go back to court 
and there might be an application by the social services for a full care order? 
A 
That is correct, yes. 
D
Q 
Because obviously – this may be obvious but I would like your comment on it – if the 
investigation or assessment which you knew social services were going to carry out, if that 
did turn up evidence of Munchausen syndrome by proxy, that would, as it were, tend towards 
an application in due course for a full care order, would it not? 
A 
That is correct, yes. 
E
Q 
And so it is not surprising that you were anxious when you when to see Dr Southall? 
A Yes. 
Q 
Now, nobody had suggested to you that you should take somebody with you? 
A 
No.  Nobody said anything like that. 
Q 
When you refer to “nobody,” can we just examine, please, who you are referring to 
F
there.  Does that carry with it an expectation that if somebody was going to tell you to bring 
somebody, that person would have been somebody in social services? 
A 
I was not given that, no.  No.  I took it to mean I could have taken anybody, but 
nobody told me I could have done before I went to that meeting. 
Q 
I follow.  So you walk into this room in the hospital and you find Dr Southall, 
together with Francine Salem? 
G
A 
That is correct, yes. 
Q 
And this Francine Salem was the social worker who had been instrumental in the 
application for an emergency protection order, had she not? 
A 
Yes.  Yes, she had. 
Q 
And you knew that, did you not? 
H
A 
I knew that, yes. 
T.A.  REED 
Day 2 -  26
 & CO. 

---

A
Q 
And she been involved in the application for an interim care order? 
A 
That is correct. 
Q 
And I think she had given evidence in those proceedings? 
A 
Yes, she did.  Yes. 
B
Q 
So when you walked into that room and saw her, first of all that was wholly 
unexpected, was it not? 
A 
I was very surprised to see her there, yes. 
Q 
But you must have been someone upset and annoyed that she was present? 
A 
No.  I was not annoyed or upset.  I just was not told that she would be there. 
C
Q 
But you were sufficiently concerned at her presence during that interview that you got 
your solicitor subsequently to write a letter of complaint to social services that she was 
present, did you not? 
A 
That is correct.  Yes, I did. 
Q 
Again, “being a little surprised” to find somebody is not something which generates 
letters of complaint, is it? 
D
A 
Yes, because I was not told that she would be there.  I just thought it would be me and 
Professor Southall. 
Q 
But certainly you did not like the idea of her being present.  Is that right? 
A 
Not really, no.  I did not want her there, no. 
Q 
Did you object? 
E
A 
No, I did not object.  No. 
Q 
But this was a woman who you discover for the first time sitting in on this interview;  
this was a woman who, I suggest, as you understood it had suspected you, and still suspected 
you, of suffering from Munchausen’s? 
A 
That is right, yes. 
F
Q 
Did Francine Salem say anything to you at all? 
A 
No, nothing at all. 
Q 
Not even, “Hello”? 
A 
No.  Not even “Hello”. 
Q 
Are you sure about that? 
G
A 
Yes, I am. 
Q 
I can put in this way, and again I hope I do not exaggerate, but she was totally mute 
throughout the interview, was she? 
A 
Yes she was. 
Q 
Could I just suggest a couple of things.  First of all, that she did say, “Hello”.  Yes?  
H
Or not? 
T.A.  REED 
Day 2 -  27
 & CO. 

---

A
A 
If she did, I did not hear her. 
Q 
Oh!  Well, how could you have failed not to hear somebody say, “Hello” when you 
are in --- 
A 
That is why I said in my statement she never said anything, because I never heard her 
speak one word. 
B
Q 
Again, I do not want to be pedantic about this but you are in, I suggest, a small room.  
Professor Southall is there.  Francine Salem is there.  If you did not hear her say, “Hello,” it 
must follow on your evidence that she did not say, “Hello”? 
A 
She did not say, “Hello”. 
Q 
I am going to suggest to you that she did, and she said, “Hello, Mrs M,” and I am 
going to suggest to you that she said something to you along the line of, that she was there 
C
just as a social worker, as she assumed to be the case had been present when you saw Dora 
Black? 
A 
No, she did not say that all. 
Q 
So she did not mention anything to you about her understanding of there being a 
social worker present when you saw Dr Black?  Can I be sure about that, and be clear about 
it?
D
A 
That is right, yes.  Yes, I am. 
Q 
Again, I want to make the position the position clear so that you are not misled and 
nobody else is.  I suggest that not only did she say “Hello”.  There was a brief reference to 
her understanding, that there was a social worker present when you saw Dr Black? 
A 
There was not one at Dr Black. 
E
Q 
No, I appreciate that. 
A 
And I --- 
Q 
I appreciate that.  I am not suggesting there was.  What I am suggesting is that France 
Salem observed or is there a comment which reflected her understanding or belief that there 
had been.  Do you follow? 
A Oh, 
right. 
F
Q 
But you reject my suggestion, do you? 
A 
I do, yes. 
Q 
I also want to suggest to you that Francine Salem occasionally chipped in in this 
interview purely to provide additional pieces of information or to put a gloss on any other 
piece of information that Dr Southall or you were bringing into the discussion.  Did she do 
G
that or not? 
A 
She spoke to Professor Southall.  Sorry.  She did speak to Professor Southall, yes, but 
directly to me. 
Q 
Ah!  What was she saying to Professor Southall? 
A 
She was filling him in – the extra information. 
H
Q Exactly. 
T.A.  REED 
Day 2 -  28
 & CO. 

---

A
A 
But she did not speak to me. 
Q 
I am not suggesting that she, as it were, was part of the interviewing process, but the 
idea that she just sat there totally mute through is wrong, is it not? 
A 
Well, yes, because she spoke to Professor Southall. 
Q 
Did she have any papers with her? 
B
A 
A pad and a pencil, yes. 
Q 
And she was taking notes, was she not? 
A 
She was, yes. 
Q 
And did you see Dr Southall making any notes? 
A 
Yes, I did. 
C
Q 
Before we look at the content of the interview, Mrs M, could I just ask you about two 
matters in relation to the way in which both those two people dealt with you.  Frequently, 
during the interview Francine Salem smiled at you in a sympathetic way, did she not? 
A No. 
Q 
Did she not smile at all? 
D
A 
No, she did not smile at me. 
Q 
So just tell us:  did she just sit there – this is my expression – but did she just sit there 
with a stony face, or what? 
A 
Yes.  Yes, she did. 
Q 
When you saw your solicitor later on, and we are going to hear evidence from your 
E
solicitor, you accused Francine Salem of sitting there smirking, did you not? 
A 
Possibly, yes, but she was not smiling at me. 
Q 
Who was she smiling at? 
A 
I do not know. 
Q 
I suggest to you that you had a pretty dim view of Francine Salem’s presence there 
F
because, I suggest, you were somewhat fearful of this woman’s motives in being there, 
bearing in mind the risk to you of a further application for a full hearing? 
A 
No, I was not fearful of Francine Salem at all. 
Q 
Why did you describe Francine Salem as smirking? 
A 
Because she was grinning as she was writing. 
G
Q 
You perceived that as smirking, did you? 
A 
Yes, I did. 
Q 
Dr David Southall:  I want to suggest to you on his behalf, first of all two things.  First 
of all, that throughout this interview he was indeed polite? 
A 
No, he was not. 
H
Q 
That he was indeed courteous? 
T.A.  REED 
Day 2 -  29
 & CO. 

---

A
A 
No, he was not. 
Q 
And that he was indeed calm? 
A 
No, he was not. 
Q 
Next, I want to suggest to you that during the whole of this interview he conducted it 
in such a way as to allow you to answer in your own time. 
B
A 
No, he did not. 
Q 
You deny that, do you? 
A 
Yes, I do. 
Q 
In your evidence this morning you said that “Dr Southall was asking questions one 
after the other.  He did not let me explain.  He just kept on questioning me”. 
C
A 
That is correct. 
Q 
That, if I may say so, gives or may give the impression of somebody who is just 
steamrollering his way through this interview, asking questions, not listening to what you 
have to say, not allowing you to answer in your own time, and just simply not listening at all.  
Is that right? 
A That 
is 
right. 
D
Q 
That is the picture you want this panel to have, is it? 
A 
That is the picture that it was that day of the interview. 
Q 
There is just one aspect of this, and it is one that you have specifically denied a few 
minutes ago when you denied the specific suggestion I put to you that he allowed you to 
answer in your own time, and you say that is not true. 
E
A 
He let me answer about the way that the belt was tied in my own time, but that was 
all.
Q 
That was all? 
A 
He was intrigued on how my son had done it. 
Q 
You see, the interview itself, as we can tell from the note that you have been shown 
F
by Francine Salem, covered quite a number of aspects of the case, did it not? 
A Yes. 
Q 
I just need to know from you whether you are saying that throughout this interview he 
did not allow you to answer in your own time? 
A 
He kept interrupting me when I was explaining.  When he asked me the question,  
I tried to answer but before I answered, he asked me another question. 
G
Q 
I am going to suggest to you that the picture you are painting is simply incorrect, and  
I want to put to you what I suggest was the picture.  First of all, that he allowed you to answer 
the questions he put in your own time? 
A 
No, that is not correct. 
Q 
You say that is not correct. 
H
A Yes. 
T.A.  REED 
Day 2 -  30
 & CO. 

---

A
Q 
But I suggest on occasion he was persistent in the sense that he kept returning to 
aspects of the first question that he had put because he wanted further information about a 
particular aspect of the main question.  Now, that is the picture, is it not? 
A 
No.  No. 
Q 
Then I am driven now to ask you, please, and I know you have not physically got it 
B
but I am going to read to you what you said in your witness statement in June of this year on 
this topic.  It is paragraph 42.  “I would not agree with the suggestion that Professor Southall 
was polite and courteous throughout.”  Then this:  “I can agree that he allowed me to answer 
in my own time.  He was very persistent and kept returning to questions if I did not answer 
particular questions to which he wanted answers.”  Now that is very different, is it not? 
A 
He kept returning to one specific question after each of the questions he asked me, 
and that is when he allowed me to answer that specific question. 
C
Q 
As you will appreciate, I am not disputing the fact that he may have asked you on 
more than one occasion the same question perhaps in a different guise but directed to the 
same topic.  That I do not dispute, but the idea you are putting across is that this is a man, this 
doctor, this professor, did not allow you to answer questions in your own time.  I suggest to 
you that is false. 
A 
No, that is true. 
D
Q 
And Francine Salem therefore would have witnessed, would she not, the manner in 
which Dr Southall was conducting this interview? 
A 
Yes, she would. 
Q 
Do you accept that the questions that he put were clear and straightforward? 
A 
Yes, they were. 
E
Q 
Rather than just for the moment at least following the structure of the content of the 
evidence that you gave this morning, or indeed this evening in your case, you have, in effect, 
accused this doctor of being aggressive, of being accusatory in his manner to you, or 
threatening you, of hectoring you, of being sarcastic, of saying he did not believe you.  I do 
not suggest that is an exclusive list of the descriptions that could be applied if your evidence 
is accurate, but in respect of any one of those descriptions, I am going to suggest to you that 
F
the picture you are painting is not correct. 
A It 
is 
correct. 
Q 
But I, on his behalf, allow you this, that you did not like the questions that he was 
putting; you did not like the pointedness of the questions; and you have treated them as if he 
was accusing you, threatening you, hectoring you, and actually saying he did not believe 
you? 
G
A 
That is right, yes. 
Q 
There is a difference, is there not? 
A 
I do not think there is. 
Q 
Again, so that we are clear about this, this picture of a doctor behaving in the ways in 
which I have just described, would all have been witnessed by Francine Salem, the senior 
H
social worker sitting in that room feet away.  Is that right? 
T.A.  REED 
Day 2 -  31
 & CO. 

---

A
A 
That is right, yes. 
Q 
Mrs M, can you indicate at any stage if you would like a break?  I appreciate we have 
been going now for nearly three hours, although you have had a short break. 
A 
No, I am fine. 
Q 
Are you sure? 
B
A 
I am fine, thanks, yes. 
THE CHAIRMAN:  Perhaps we can go on for another 15 minutes, if Mrs M is all right, and 
then we will take another break. 
MR COONAN:  This document which you were taken to and you have gone through with
Mr Tyson, Mrs M, earlier in the course of your evidence, do you still have it there? 
C
A 
That is Francine Salem’s note? 
Q That 
is 
right. 
A 
Yes, I do have it. 
Q 
You have agreed that she was making notes of the conversation? 
A Yes. 
D
Q 
Mr Tyson did not actually ask you to look at every single one of these paragraphs, 
although the majority he did, but certainly in relation to the paragraphs that you were asked to 
look at, apart from three instances where you say to the panel that you cannot recall saying 
something during the course of the interview, you in effect do not challenge the content of 
this document at all, do you? 
A No. 
E
Q 
So Francine Salem has captured the content of the interview pretty well? 
A 
As far as I believe, yes. 
Q 
And, leaving aside the three instances where you cannot recall saying it, it is pretty 
well – and again I do not want to labour the point – or 100 per cent accurate, is it not? 
A 
I would not say 100 per cent. 
F
Q 
I am going to give you all the opportunity you wish to say what you challenge as 
being wrong or not said by you in this document. 
A 
OK.  It is pretty accurate, yes. 
Q 
You say “pretty accurate”.  I am going to suggest to you it is 100 per cent accurate, is 
it not? 
G
A Yes. 
Q 
Again, as I understand it, what therefore you are saying is that Francine Salem, sitting 
there in that room, capturing everything that is said by Dr Southall and yourself, in terms of 
the content here 100 per cent accurate, has simply sanitised the account, deliberately sanitised 
the account, by excluding from it the fact that you were accused of murdering your child 
three times.  Is that right, because it does not appear here, does it? 
H
A 
No, it does not.  No. 
T.A.  REED 
Day 2 -  32
 & CO. 

---

A
Q 
In particular, the way you put it just before the short break, the last of the three 
allegations of murder:  “He turned to me and said ‘I put it to you that you injected your child, 
stringing him up’ ” – that is the phrase you used, ‘stringing him up’ – “left him to die and 
rang the ambulance”.  There is not a word of that in this document, is there? 
A 
There is not, no. 
B
Q 
It may be self-evident but there is no reference in the document to Dr Southall putting 
positively assertions to you and saying he rejected your answer – not a word of that either, is 
there? 
A 
No, there is not. 
Q 
And there is not a word, is there, of the evidence you have given to the effect that
Dr Southall accused you of being guilty of murder simply because you would not or were 
C
reluctant to answer questions about the belt? 
A 
There is nothing in there at all, no. 
Q 
I am going to suggest to you that in particular, if you look at the bottom of the third 
page of the note, right at the bottom ---   Do you see the reference to the belt? 
A Yes. 
D
Q 
If you look at it again, forgive me if I just read part of this out and I do not want to 
upset you but I think it ought to be read into the transcript.
“Mrs M initially declined to talk to Professor Southall about how the belt was tied 
around your eldest child’s neck.  Mrs M said that she would be pleased to talk about it 
if it cleared her name, but she had been advised not to by her solicitor.”
E
Pausing there, we have just dealt with that earlier.  All right? 
A 
That is right, yes. 
Q 
So that is right.  
“Professor Southall told Mrs M that he felt that this was a crucial piece of information 
that was needed.  Mrs M did tell Professor Southall as she felt she wanted to prove her 
F
innocence and that she could do this through explaining how the belt was tied”.
That account by Francine Salem, Mrs M, is exactly as it is written. 
A 
I do not agree with that. 
Q 
There was no browbeating; there was no threat; and there was no imputation that 
unless you talked, you must be guilty, was there? 
G
A 
That is what was said to me by Professor Southall. 
Q 
What I think is quite clear from the content of your evidence is that you accept that 
Professor Southall mentioned that there were in effect three scenarios that would be the 
subject of consideration at part of this investigation and assessment, did he not?   
A 
I am sorry, could you say that again, please? 
H
T.A.  REED 
Day 2 -  33
 & CO. 

---

A
Q 
Yes.  What Professor Southall was saying, I suggest, was that as part of this 
investigation and assessment – in other words the investigation and assessment that you have 
given evidence about and knew was going to take place by social services – as part of that 
investigation, three scenarios would have to be considered? 
A Yes. 
Q 
(1) accident; (2) suicide and (3) murder.   
B
A Yes. 
Q 
When he mentioned the third such scenario, in other words, that this investigation 
would have to consider the question of murder, you must have been extremely upset. 
A 
I was upset, yes. 
Q 
Simply because he had told you that this assessment and investigation would have to 
C
consider it as one of the three options. 
A 
Yes, that is right. 
Q 
The questions that he went on to ask: about the belt, about your knowledge of 
injections, about the circumstances generally, about your eldest son’s death, all those factors, 
coupled with the fact that he had even mentioned the question of murder, led you to think – to 
think – that he was accusing you of murder of your eldest child.  Is that not right? 
D
A 
No.  He did accuse me of murder of my eldest child. 
Q 
Do you accept that the first time the question therefore of murder generally was raised 
was in fact in the course of this interview by Dr Southall? 
A Yes. 
Q 
So nobody had ever said that to you before? 
E
A No. 
Q 
Did you not understand that questions about your eldest son were being asked in the 
interests of your youngest son? 
A 
Not at the time, no. 
Q 
I just want to have a brief word about the question of drugs and medication.  I do not 
F
dispute for a moment that the topic was raised by Dr Southall and he asked you about your 
knowledge or experience of drugs.  I suggest he raised that in the context that the question of 
whether or not your eldest son had been drugged may be an issue which would have to be 
looked at.  Those were not his exact words; it is my summary of his position.  Do you 
understand?
A 
Yes, I do. 
G
Q 
Do you also understand that there is a distinction to be drawn between that suggestion 
which I put to you and an outright accusation by Dr Southall that you had in fact drugged and 
then hung your eldest son?  Do you see the difference? 
A 
Well, no, not really, because he was asking me the questions and then he told me what 
I had done. 
Q 
Lest there be any doubt about it, I have to put this to you.  At no stage during the 
H
course of this interview did Dr Southall say, assert, accuse you of having done anything. 
T.A.  REED 
Day 2 -  34
 & CO. 

---

A
A 
Yes, he did. 
Q 
What you did by putting two and two and two together is of course a different matter.  
It may be – I know not – that you walked out thinking that this man had accused you of 
murder, but he had not. 
A 
He did accuse me of murder. 
B
Q 
At the time when you left the interview, you have told us --- 
THE CHAIRMAN:  If you are moving on to a separate topic, Mr Coonan, would this be a 
good time to break? 
MR COONAN:  Certainly, madam. 
C
THE CHAIRMAN:  We will take a 15-minute break now, Mrs M.  I need to remind you that 
you are on oath and should not discuss the case or your evidence with anyone.
(The Panel adjourned for a short time)
MR TYSON:  Madam, I note that on the screen, the witness is not here, but what I have to 
say does not in fact at the moment require her.  I have asked the Panel to be recalled simply 
D
on a human basis that it is as I understand it 10.30 at night in Adelaide and this witness 
started giving evidence at about six o’clock.  The plan is that she goes on until about 
midnight, which will be 1.30 our time.  It appeared to me that it was only human that she 
should be entitled at some time during the course of that to have a meal of some sort, to have 
her supper.
It is entirely my fault; I should have raised the issue before we adjourned for 15 minutes.   
E
I would invite you to ask the witness when she returns when she would appreciate the 
opportunity of having a slightly longer break so that she could have her evening meal. 
THE CHAIRMAN:  Mr Tyson, I was unaware that this might be an issue with the witness.  
Obviously, as you have raised it, it would be entirely appropriate for us to at least give her 
that opportunity.  When she returns, I will ask her if she would like a longer break. 
F
MR TYSON:  My learned friend as I understand it agrees with my sentiments. 
MR COONAN:  Madam, both Mr Tyson and I have discussed it, both on a human level, 
bearing in mind the amount of time she is having to deal with, certainly the invitation should 
be given to her.  Very often in my experience, witnesses decline offers of comfort breaks, but 
it is important, because quite clearly one does not want any suggestion that proper facilities 
were not accorded to her and thus the quality of her evidence was in any way affected.  That 
G
is I think an important point. 
(The video link was re-established)
THE CHAIRMAN:  Mrs M, can you hear us? 
A 
Yes, I can. 
H
T.A.  REED 
Day 2 -  35
 & CO. 

---

A
THE CHAIRMAN:  Before we carry on, I have something important I would like to ask you.  
That is, for your own comfort and well being, do you in fact need a longer break in order to 
get a proper meal?  Do not hesitate to say so if you do need a longer break. 
A 
No, I am fine, thank you. 
THE CHAIRMAN:  We are very clear that you should feel comfortable and able to continue 
giving evidence totally happily and we are prepared to break for longer if you wish. 
B
A 
No, it is okay.  There is nowhere open, anyway!  I am fine, honestly.  Thank you. 
THE CHAIRMAN:  In that case, we will accept your reassurance, but if you need a break to 
get a drink or anything before you have finished, please feel free to say so. 
A 
Thank you very much. 
THE CHAIRMAN:  Mr Coonan will now continue. 
C
MR COONAN:  Mrs M, when you gave evidence this morning, you said that at the end of the 
interview you were upset, angry, crying and sick. 
A Yes. 
Q 
Were you hysterical at any stage? 
A 
No, I was not hysterical. 
D
Q 
At no stage were you hysterical.  Is that right? 
A 
Sorry, can you say that again, please? 
Q 
At no stage were you hysterical. 
A 
Not when I left the meeting, no. 
E
Q 
But during the meeting, were you hysterical? 
A 
I would not say hysterical.  I was getting very upset. 
Q 
Let us take this slowly.  During the course of the interview, were you crying? 
A 
Yes, I was. 
Q 
Were you sitting down? 
F
A 
Yes, I was. 
Q 
Were you sitting down with Professor Southall in front of you? 
A 
Yes, I was. 
Q 
Was Francine Salem in front of you too? 
A 
No, she was not.  She was at the back, to my side.  She was at the side of me, but 
G
slightly back from me. 
Q 
When you were crying, how were you crying? 
A 
How was I crying? 
Q 
Yes.  Was it just a single tear, was it a good cry?  I hope what I am saying makes 
sense.
H
A 
A good cry. 
T.A.  REED 
Day 2 -  36
 & CO. 

---

A
Q 
Did you need tissues? 
A 
Yes, I had tissues. 
Q 
Did you fish those out and use them? 
A 
Yes, I did. 
B
Q 
How long did the good cry last for? 
A 
I am sorry, I do not follow. 
Q 
I agree it is a long time ago, but can you attempt to give the Panel some idea – and  
I am not being facetious – was it five minutes, a minute, two minutes, three minutes?  You 
tell us. 
A 
Two or three minutes. 
C
Q 
When you were crying for two or three minutes, was there a pause in the interview 
once you were crying? 
A Yes. 
Q 
By that, do we understand that no further questions were being put to you? 
A 
No, I do not think so.  Sorry, I cannot remember. 
D
Q 
Your impression is that there was a pause.  At what stage did you start having this 
proper cry? 
A 
I do not remember.  I am sorry. 
Q 
You have told us that you had a proper cry lasting for two or three minutes. Were you 
at that stage, or indeed at any stage during the course of the interview, hysterical? 
E
A 
Not that I can recall, no. 
Q 
Mrs M, I have to suggest to you that your evidence in part has been infected –
whether deliberately or otherwise is not for me to say – with a degree of exaggeration and 
over-sensitivity about these matters.  I want to suggest to you that you alleged earlier that you 
were hysterical during the course of this interview.  Do you remember making that 
allegation? 
F
A 
No, I cannot remember. 
Q 
Again, Mr Tyson has this.  In your witness statement made this year, in June, after 
Professor Southall had accused you of murdering your youngest child, you said this: 
“By this stage I was hysterical.  I was crying and I felt sick.  I had just been accused 
of murdering my son.”   
G
I ask you again: were you hysterical? 
A 
I was not hysterical, not in the interview, no, but I was crying. 
Q 
Why did you tell Field Fisher Waterhouse that you were hysterical? 
A 
I was hysterical when I got to the solicitors. 
H
T.A.  REED 
Day 2 -  37
 & CO. 

---

A
Q 
Let us just pause there for a minute.  I think the evidence is going to be that you did 
not go to the solicitors until two days later. 
A 
I went straight to the solicitors.  The social worker took me round there straight from 
the hospital. 
Q 
We will examine that later, but I want to stay with this point please.  You alleged,  
I suggest, in your statement to Field Fisher Waterhouse in June of this year that immediately 
B
following the allegation that you murdered your child you were hysterical and were crying 
and sick at that stage.  Are you saying that is not true? 
A 
I would not say I was hysterical, no. 
Q 
Why did you say it? 
A 
Maybe I got my times wrong.  I was hysterical in the solicitors. 
C
Q 
Again, it is absolutely clear, I suggest, that when you made your statement to Field 
Fisher Waterhouse you were saying in terms that immediately following the allegation by 
Professor Southall that you had murdered your child you said “by this stage I was hysterical.”
It is nothing to do with going to see a solicitor.  That was false, was it not? 
A 
I cannot remember being hysterical in the interview. 
Q 
So that the record is clear, I have given you that quotation from a statement which  
D
I appreciate you do not have in front of you, but is signed by you and dated 28 June of this 
year, made for the purposes of these proceedings.  Let us just leave hysteria on one side and 
let us just deal with the question of the good cry for two or three minutes.  We have a picture, 
therefore, do we, of you having this good cry and these two, Professor Southall and Francine 
Salem, sitting there watching you cry.  Is that right? 
A 
That is right, yes. 
E
Q 
Again, it may be self-evident, but there is no suggestion in Francine Salem’s note of 
any distress at all, is there? 
A 
No, it does say that, no. 
Q 
I do not want my position to be misunderstood unintentionally, but nonetheless I do 
not want it to be misunderstood.  I grant you that you may well have been, to a degree, upset 
because Dr Southall even mentioned the possibility that this assessment and investigation was 
F
going or would have to consider at least the question of murder.  Do you follow my position? 
A 
Yes, I do. 
Q 
But that such degree of upset was not demonstrated in any way at all.  There was no 
sustained crying for two or three minutes.  That is my suggestion to you.  Can I solicit an 
answer from you for the transcript? 
A 
Sorry, I am having trouble hearing. 
G
Q 
I want to put a suggestion to you and I want to be sure that you have heard the earlier 
part of what I put, so my I retrace my steps. 
A 
Certainly, yes please. 
Q 
I do not want the position to be misunderstood.  I entirely accept on Dr Southall’s 
behalf that you may have been, to a degree, upset simply because of the topics that were 
H
touched upon, which included, as one of the three scenarios, a reference to murder.   
T.A.  REED 
Day 2 -  38
 & CO. 

---

A
A I 
agree. 
Q 
But that any upset that you may have had was not demonstrated.  In other words, there 
was no sustained crying for two or three minutes or anything like that. 
A 
I agree, yes. 
Q 
Do you say that there was crying or not crying? 
B
A 
There was crying. 
Q 
And that when you left the interview you were upset because Dr Southall had simply 
referred to the topic of murder, but no more than that at stage? 
A 
I do not agree with that, no.  He called me a murderer. 
Q 
When you left the room was it your state of mind, just putting this in broad terms, that 
C
you found the interview offensive because you took the view that Dr Southall had gone 
beyond his remit? 
A 
I believe so. 
Q 
Did you know at that stage what his remit was? 
A 
I did at that stage, yes. 
D
Q 
What was it? 
A 
Sorry, I cannot hear you. 
Q 
When you left the room did you think that Dr Southall had gone beyond his remit? 
A 
Yes, I did. 
Q 
Did you know at that stage what his remit was? 
E
A Yes. 
Q 
What was it? 
A 
I took it to be that he wanted to find out how my son had died, and he obviously 
thought I had done it. 
Q 
I do not want to get into a semantic dispute, but you have agreed that you thought he 
F
had gone beyond his remit. 
A 
Yes, in the way he questioned me, yes. 
Q 
What did you think was his remit in the first place? 
A 
I just thought he was going to be me and him, just a general talk about my emotions, 
how I was feeling, and he was very aggressive in the way that he spoke to me, the way that he 
asked me the questions, and it was just one after another.  I thought it would be a bit more 
G
relaxed, and it seemed to be all about my son and not about my second son, which is what  
I thought it was going to be as well; but my second son was not mentioned. 
Q At 
all? 
A 
At all.  Not at all, no. 
Q 
Mrs M, that, with respect, is simply not right because even in Francine Salem’s note 
H
there are references to your youngest son.  That is right, is it not? 
T.A.  REED 
Day 2 -  39
 & CO. 

---

A
A 
Professor Southall never asked me directly anything about my youngest son. 
Q 
Let us just move on please to the events after leaving that interview room.  When you 
left, your understanding is that you went to see your solicitor, the same day? 
A 
That is right, yes. 
Q 
So there is no doubt about it, you are referring here to Beth Parry, are you? 
B
A 
Yes, I am. 
Q 
Did you actually see her face to face 
A 
I did, yes. 
Q 
Are you saying that the same day you gave her a full account of what had happened? 
A 
Yes, I feel I did. 
C
Q 
Are you saying that you gave her the sort of full account that you had given to this 
Panel today? 
A 
Yes, I do. 
Q 
We will hear, as you may or may not know, Mrs M, from your solicitor when she 
comes to give evidence, but is it not the case that you confined yourself to a telephone call to 
D
the solicitor but did not see her until two days later? 
A 
No, the social worker that picked me up to take me to Stoke took me round to see 
Beth.
Q 
Do you remember seeing Dr Solomon, who we understand is now called Dr Corfield, 
the next day? 
A 
On the what?  sorry. 
E
Q 
The next day? 
A 
I cannot recall it, no. 
Q 
I am sorry to interrupt. 
A 
It is okay. 
F
Q 
Do you remember going to see Dr Corfield at any stage after the interview? 
A 
Yes, I do remember that.  I do not know what day it was though. 
Q 
When you saw Dr Corfield did you give her the account that you have given to the 
Panel today? 
A 
I think I mentioned it, yes.  I do not know in how much detail.  I did mention it.   
I cannot remember. 
G
Q 
Did you tell Dr Corfield that Dr Southall had accused you in stark terms of murdering 
your eldest child? 
A 
Yes, I am sure I did. 
Q 
Because this is a doctor, Dr Solomon, somebody that you trusted, was it not? 
A 
That is right, yes. 
H
T.A.  REED 
Day 2 -  40
 & CO. 

---

A
Q 
There would have been no reason for you not to unburden yourself completely of the 
experiences that you had in the interview, would there? 
A That 
is 
right. 
Q 
Mrs M, I am going now just to turn to one last matter.  I should just cover this, 
however, although we touched on it earlier.  During the time that you saw your solicitor – 
you say it was the same day, we will hear the evidence about that – whenever it was, you 
B
complained through your solicitor about the presence of Francine Salem at that interview and 
complaint was made to social services by letter? 
A 
That is right, yes. 
Q 
Again, it is self-evident but there was no complaint by your solicitor about the 
conduct of Professor Southall, was there? 
A 
No, not that I am aware of.   
C
Q 
These events took place in April 1998.  Did you become aware of a woman called 
Mrs Mellor? 
A 
Yes.  I am, yes. 
Q 
And did you make contact with Ms Mellor? 
A 
Ms Mellor, no.  She got in touch with me 
D
Q 
She got in touch with you.  So that we identify the correct person, she is called Penny 
Mellor, is she not? 
A 
That is right, yes. 
Q 
And I just want to establish one or two simple facts.  Did she come to act as an 
advocate for you in relation to complaints relating to Dr Southall? 
E
A 
She wanted to, yes. 
Q 
Well, she did become an advocate for you, did she not? 
A 
I did not ask her to write any complaint.  She just said that she would act for me. 
Q 
And however it came about – I am frankly not interested in that but I am just 
interested in the fact that she did adopt that mantle as advocate – she had done that at the 
F
latest by about 1999? 
A 
I am not sure.  I had no further contact with her after she got in touch with me.  I had 
very little contact with her. 
Q 
But if I suggested that date to you, you are not in a position to comment either way.
Is that right? 
A 
Yes.  That is right, yes. 
G
Q 
And just this.  This woman is the coordinator of a campaign group, is she not? 
A 
So I believe, yes. 
Q 
And she campaigns against the very notion that there should be a diagnosis of 
Munchausen’s? 
A 
I am sorry.   Can you say that again, please. 
H
T.A.  REED 
Day 2 -  41
 & CO. 

---

A
Q 
She campaigns – her group, led by her – campaigns against the very notion of the 
existence of a diagnosis of Munchausen’s? 
A 
Yes, I believe so. 
Q 
And again, I do not want to be overly generalist about this, but perhaps I suggest this 
would do:  that in that guise she has mounted campaigns against paediatricians who have 
been involved in diagnoses of Munchausen’s? 
B
A 
I cannot comment on that.  I do not know the woman or what she does really.  I have 
had one conversation with her, and that was it. 
Q Any 
correspondence? 
A 
I cannot remember if I did or not. 
Q 
But she introduced herself to you as, presumably, somebody and what her role was? 
C
A 
She introduced me to herself, yes, but she was not clear on her role. 
Q 
But at least you knew at that stage when she offered her services as an advocate for 
you, that she headed up an activist group.  Is that right? 
A 
I was not aware of it being an activist group.  I am not sure what I thought, to be 
honest.  I really do not.  I cannot comment on that, I am sorry. 
D
Q 
Finally this, Mrs M.  It is a question I have to put to you, as I will probably put to 
others.  Have you in recent times been interviewed by the press? 
A Yes. 
Q 
When was that? 
A 
Oh, I cannot remember when it was. 
E
Q 
My question was, “in recent times”.  Was it last week, last month, last year or what? 
A 
It was not last year.  It was a while ago, yes. 
Q 
Again, I am sorry to press you, but when you say “a while ago,” that could mean 
many things.  It is rather like a piece of string. 
A 1999. 
F
Q 
Have you not been interviewed by the press since? 
A No. 
Q Sure 
about 
that? 
A I 
cannot 
remember. 
Q 
Mrs M, you went to Australia, so we are told, in was it August or September of this 
G
year?
A September. 
Q 
Whilst you have been in Australia, have the press interviewed you either by telephone 
or video link at all? 
A No, 
nothing. 
H
Q Right. 
T.A.  REED 
Day 2 -  42
 & CO. 

---

A
A 
No, none at all. 
Q 
Before you went when you were in this country, since 1999 have the press or any 
member of the press in whatever guise interviewed you about these events? 
A 
No.  They tried to, but they have not. 
MR COONAN:  Mrs M, those are all the questions I have for you.  Thank you very much. 
B
MR TYSON:  With respect, my learned friend, if he is suggesting to my client that she has 
talked to the press, he should put the publication or whatever to her, rather than dance around 
the question. 
MR COONAN:  This is not a question of dancing.  It was an inquiry.  If the answer is given 
in that way, I accept it.  There is no suggestion in the light of that answer.  The question was 
C
prompted by the intervention from the press gallery on the first day. 
MR TYSON:  I am glad my learned friend makes that clear, because my clear understanding 
of the line of questioning was that you were doubting this witness’s account and had, fact, 
your proverbial back copy, some document that you were going to put to her. 
MR COONAN:  I am not sure that now is the time for Mr Tyson to comment.  You have 
D
heard the way I made the inquiry of the witness.  I do not retract the inquiry.  I have received 
the answers and as far as I am concerned, that is it. 
MR TYSON:  I am grateful for the way my learned friend now puts it. 
Re-examined by MR TYSON
E
Q 
Mrs M, I need to ask you some questions arising out of the question that you have just 
been asked by Dr Southall’s barrister, and you were asked just now about a lady called
Ms Mellor.  Do you recall writing to the General Medical Council with a letter of complaint 
dated 15 March 2002? 
A 
Yes, I do. 
Q 
And do you recall making mention of that woman in your letter of complaint to the 
F
General Medical Council? 
A 
Yes, I do. 
Q 
And did you say these words: 
“I am writing further to our telephone conversation regarding the possibility of a  
Ms Penny Mellor writing to you on my behalf i.e. a complaint against 
G
Professor David Southall, North Staffordshire Hospital.   
I wish to inform you that I DO NOT want Ms Mellor to have anything to do with my 
complaint with which I will explain to you now.” 
Is that what you told the General Medical Council? 
A 
Yes, I remember. 
H
T.A.  REED 
Day 2 -  43
 & CO. 

---

A
Q 
And was that your position in 2002 and was it your position earlier than 2002? 
A 
Sorry.  Can you say that again, please. 
Q 
You said that that was your position in 2002, and my question is, was it your position 
earlier than 2002 that you did not want this lady involved in your matters? 
A 
That is correct. 
B
Q 
And you told the Panel that your involvement with her was some time, I think you 
said, in 1998.  I do not want to misquote you on that, but your contact with her amounted to 
one conversation which you took no further.  Is that right? 
A 
That is right, yes. 
Q 
Turning to other matters, you were asked about the matter coming to the court in front 
of a judge called Judge Tonking.  Do you remember that? 
C
A 
Yes.  I do, yes. 
Q 
Did the case last a number of days? 
A 
Yes, it did. 
Q 
And did the local authority want to keep your youngest child with foster parents? 
A 
Yes, they did. 
D
Q 
And was the result of the hearing that, in fact, your youngest child was restored to 
you? 
A 
Yes, he was. 
Q 
Were you present when the judge gave his judgment? 
A 
Yes, I was. 
E
Q 
Have you at any time seen a copy of the judge’s judgment? 
A 
Yes, I have. 
Q 
So it is clear for the sake of the transcript, I am going to put to this witness a transcript 
of the copy of the judgment of His Honour Judge Tonking on Tuesday 10 March 1998.  Do 
you recall, Mrs M, that the judge listed some ten reasons why the local authority wanted your 
F
youngest to remain in foster care? 
A 
I can remember a long list, but I cannot remember exactly what they were. 
Q 
And for the sake of the transcript, I am putting page 3H down to and including 4H of 
the transcript.  Also, did the judge recall that were three reasons why the guardian,
Mrs Inwood, felt that the youngest child should remain in foster care? 
A 
Yes.  I believe that is correct. 
G
Q 
And did the judge say these words? 
MR COONAN:  I am sorry to interrupt.  Can you make it clear there is the reference to the 
threshold criteria? 
MR TYSON:  Yes.  Did the judge say, and you can be shown the document if necessary 
H
somehow, at page 5F: 
T.A.  REED 
Day 2 -  44
 & CO. 

---

A
“Notable for its absence in those lists of grounds on which it is said that the threshold 
is crossed is the suggestion, which was a significant part of the local authority’s case 
when the Emergency Protection Order was obtained, is a suggestion that it was 
suspected that the mother suffers from Munchausen’s Syndrome or Syndrome by 
Proxy.”
B
Do you recall --- 
A Yes. 
Q 
--- that the local authority abandoned Munchausen’s symptom syndrome by proxy as 
a ground for seeking your youngest child to remain in care by March 1998? 
A 
Yes.  I remember that. 
C
Q 
And you recall the judge saying – this is at 6G: 
“As to this point it, should be borne in mind it does not follow that, because the local 
authority have at this stage abandoned that particular argument that there are 
reasonable grounds for believing that [your child] is at significant risk because of 
Munchausen’s on the part of mother…”. 
D
That there was a significant risk for your child. 
A 
Yes, I remember that also. 
Q 
You were asked also about seeing Dr Black? 
A Yes. 
Q 
And you were asked to compare the question of the style of interviewing of Dr Black 
E
with Professor Southall.  Do you remember those questions? 
A 
Yes, I do. 
Q 
You indicated that the way she was asking questions was different from the way that 
Professor Southall was asking questions? 
A 
That is right, yes. 
F
Q 
Are you aware that one of the questions that she was asked to look at is to whether 
there was Munchausen’s syndrome by proxy in this case? 
A 
Yes, I was. 
Q 
In the course of the proceedings, did you see that lady’s report? 
A 
Yes, I did. 
G
Q 
And do you record that she dealt with it in her report the issue of whether 
Munchausen’s was present or not in your case? 
A 
Yes, that is right. 
Q 
And do you record – and for the benefit of the transcript this is paragraph 38 of her 
report –she said that: 
H
T.A.  REED 
Day 2 -  45
 & CO. 

---

A
“However, in my experience, the features of this case do not match those of 
Munchausen Syndrome by Proxy” 
A 
Yes, I remember that. 
Q 
Do you remember her saying that she had not seen the case of Munchausen Syndrome 
by Proxy – 
B
“… where the mother induced accidents and I cannot find one in the literature.” 
A 
Yes, I remember that too. 
Q 
And do you remember her saying it would be almost impossible for children of the 
age of your oldest child and your youngest child to be injured by a parent without 
C
discrepancies in the accounts arising? 
A 
Yes.  I remember that. 
Q 
You also record that she said that it would be not possible for a parent to induce a 
child to hang himself? 
A 
I remember that too. 
D
Q 
And you recall that she said: 
“I do not believe she could hang himself unless he was rendered unconscious first and 
the time scale makes that unlikely.” 
A 
Yes.  I remember. 
E
Q 
And did she go on to say: 
“In any case, this would be homicide and not MSBP? 
A Yes. 
Q 
And did she go on from your recollection to say: 
F
“Mother herself has attended her GP an unusual number of times and has been 
presented by her own parents frequently.  However the conditions for which she has 
been treated are common ones, and her pattern is not necessarily abnormal.” 
A Yes. 
G
Q 
And do you record that Dr Black concluded: 
“In my opinion this is not a case of MSBP or factitious illness.”
A 
Yes.  I remember that one too. 
H
T.A.  REED 
Day 2 -  46
 & CO. 

---

A
Q 
You were asked about the presence of Francine Salem at the interview and whether 
you objected or not.  Did you know whether you had a right to object to the social worker 
being present? 
A 
No, I was not aware that I could object. 
Q 
If it is suggested to you that she said to you words to the effect, “I’m here just as you 
had a social worker at Dr Black’s interview” --- 
B
A 
She did not say that. 
Q 
If she had said that, can I ask this, would you have told her that there was no social 
worker at Dr Black’s? 
A 
I would have said that, yes. 
Q 
You were asked about the question of smirking, which is a word that you are recorded 
C
to have used in relation to Ms Salem.  How would you use the word smirking?  Is it a good 
thing to smirk or a bad thing to smirk? 
A 
I would say in those circumstances it as a bad thing to smirk. 
Q 
Was she smirking in the course of your interview with Professor Southall? 
A Yes. 
D
Q 
You were asked about the notes of Francine Salem that were put to you.  You 
indicated that the words may be accurate. Do these notes reflect the tone or the manner in 
which this interview was put or was carried out? 
A 
No, certainly not. 
Q 
You were asked about scenarios.  Perhaps listen to this question carefully.  Did 
Professor Southall give you an open opportunity to answer the question about murder or did 
E
he suggest the question about murder and the manner to you? 
A 
He suggested it to me, that that was how I killed my eldest son. 
Q 
Do you have in front of you the Francine Salem notes of this meeting? 
A 
I do, yes. 
Q 
Do you remember being asked about the third page, the bottom paragraph, by  
F
Mr Coonan, who is Dr Southall’s barrister? 
A 
Sorry, which paragraph? 
Q 
It is the bottom paragraph on the third page, which starts that you
“…initially declined to talk to Professor Southall about how the belt was tied around 
[his] neck.” 
G
A Yes. 
Q 
Can I ask you this?  Were you taken through this statement at any time by your 
solicitor? 
A 
Not that I can remember, no. 
H
Q 
Were you asked at any time by your solicitor to make notes about this statement? 
T.A.  REED 
Day 2 -  47
 & CO. 

---

A
A 
Yes, I was. 
Q 
Did you make any notes about this statement shortly after you received it? 
A 
Yes, I did.  I made some alterations. 
Q 
Did you write those notes and alterations on the document itself? 
A 
Yes, I did. 
B
Q 
Is the document that you are looking at at the moment one which has got handwriting 
written all over it? 
A No. 
Q 
Could you look at this?  I am not asking the panel to look at it for the moment.  It is 
an adjustment.  Could you look at your aa tab? 
C
A Yes. 
Q 
Does that have handwriting written on it? 
A 
Yes, it does. 
Q 
Whose handwriting is that? 
A 
It is mine. 
D
Q 
How soon after you got this document did you put that handwriting on it? 
A 
Shortly after I received it. 
Q 
Were the comments that you wrote on true to the best of your knowledge and belief? 
A 
Yes, they are. 
E
Q 
Could I ask the panel, please, to insert in their panel bundles the section (aa) under 2, 
as another section in their bundles?  It may be that you should possibly place it by where you 
have got the existing one that you are looking at, at tab (gg) at page 23.
(Document circulated)  Could we look, please, at the third page, which has rather a lot of 
handwriting at the bottom of it?  Do you see that? 
A 
Yes, I do. 
F
Q 
I think you told us earlier that this is in your handwriting? 
A 
Yes, it is. 
Q 
You see the section that says, three lines of the typescript,
“Professor Southall told [you] that he felt that this was a crucial piece of information 
that was needed.  [You] did tell Professor Southall as [you] felt [you] wanted to prove 
G
your innocence that [you] could do this through explaining how the belt was tied.” 
Did you write:
“Forced to tell them.  Proff Southall said that a child protection case took preference 
over a criminal one, and if I was not prepared to tell him then it must be I had 
something to hide!” 
H
T.A.  REED 
Day 2 -  48
 & CO. 

---

A
Is that how the conversation went? 
A 
Yes, it was. 
Q 
“…and because there was no toxicology report done on [my eldest son] and that [my 
eldest son] had been cremated, it was a vital piece of evidence that could prove that
I did not murder [my eldest son].” 
B
Is that what it said? 
A 
Yes, that is correct. 
Q 
Did you say: 
“…that I was given the wrong advice by my solicitor to stay quiet.” 
C
Is that what he suggested to you? 
A 
That is what he suggested, yes. 
Q 
You go on to say:   
“He accused me of murdering [my eldest son].  Proff Southall said it was a crucial 
piece of evidence.” 
D
Is that what you wrote? 
A 
Yes, that is what I wrote. 
Q 
Is that right? 
A Yes. 
E
Q 
That you were accused by him of murdering your eldest child? 
A Yes. 
Q 
Do you remember now the context in which toxicology came up? 
A 
Yes, I do. 
Q 
Can you help the panel as to that? 
F
A 
Yes.  When Professor Southall was asking about my job description and if I had 
access to medication and if I had seen any injections, he put it to me that I actually stole the 
drugs from my work, injected some medication into my eldest son and waited until he went 
unconscious, hung him up and then left him until he was dead and then I rang the ambulance. 
Q 
How, in that context, did the question of a toxicology report come in? 
A 
Because there was a needle mark on my son’s arm.  It came out in the inquest. 
G
Q 
How did Professor Southall bring it up? 
A 
He asked me if I had any access to injections or medications. 
Q 
Was it you or he who mentioned the words about no toxicology report? 
A 
He did.  I did not know there was not one.  
H
T.A.  REED 
Day 2 -  49
 & CO. 

---

A
Q 
It has been suggested to you that you have exaggerated your account to the panel 
about how Professor Southall conducted this interview.  What do you say about that? 
A 
I know exactly the way he conducted himself; it is exactly the way I said it. 
Q 
It was suggested to you that he did not accuse you of murdering your eldest child.  
What do you say about that? 
A 
He did accuse me of murdering my eldest child. 
B
MR TYSON:  Thank you.  Just wait there a moment.  Those are the questions from me.  You 
may be asked some questions from the panel, or you may be asked by somebody else. 
MR COONAN:  Madam, may I just be permitted to raise one matter in relation to a document 
which I have just been supplied with?  It arises out of the first question put by Mr Tyson in 
re-examination.  I can show Mr Tyson the document. 
C
MR TYSON:  There is an issue about this. 
THE CHAIRMAN:  Are you content to resolve this matter? 
MR TYSON:  I am content to look at the document to see what he wants to put. 
(Pause for the document shown to Mr Tyson)
D
Subject to the advice of your Legal Assessor, in my submission it is impermissible for my 
learned friend to put this document now to this witness, though I accept that he could have 
put it to the witness during cross-examination.  We all regret things when we sit down and 
think, “Gosh, I should have asked that question or that question”.  In my submission, my 
learned friend should have put it in his cross-examination and he did not and it is too late 
now.  I am quite happy that the document be shown to the learned Legal Assessor.  I hope 
E
that he will agree with me on my analysis.  (Document shown to the Legal Assessor)
THE CHAIRMAN:  I will ask the Legal Assessor for his view. 
MR COONAN:  Could I reply?  A number of questions were asked of the witness.  Perhaps 
she should in effect leave the court while this issue is discussed? 
F
THE CHAIRMAN:  Mrs M, would you be kind enough to wait there for a moment while this 
legal matter is resolved?  We hope it will very short but what we are going to do effectively is 
make it so that you cannot hear what is being said.  If you were here in person, we would ask 
you to leave while this is discussed.  We are going to make it so that you cannot hear but 
please do not go away.  There will be a few more questions yet.  I am sorry about this. 
A 
OK, thank you. 
G
(The witness’s microphone was turned off)
MR COONAN:  Madam, you may remember that I asked a number of simple questions about 
the witness’ contact with a woman called Penny Mellor.  She told you that the contact had 
been minimal but that she accepted that there had been contact.  At that stage, I was content 
to leave the matter because I had established, for my purposes, that there had been contact.  
The relevance of that may be seen later. 
H
T.A.  REED 
Day 2 -  50
 & CO. 

---

A
My learned friend took the matter a stage further in re-examination and he elicited from this 
witness that, in a letter to the GMC of 15 March 2002, she was saying she wanted nothing to 
do with Penny Mellor.  I do not want to prejudice the situation in any way but I have been 
supplied with a document from files held by the other side which my learned friend is aware 
of for which --- 
MR TYSON:  Not by FFW; I have never seen it before. 
B
MR COONAN:  From the Trust.  It is a document which deals directly, in our submission, 
with the piece of evidence elicited in re-examination for the first time that this witness 
wanted nothing to do with Penny Mellor.  I said that in the interests of you carrying out due 
inquiry, as you are obliged to do, you should receive this document, which I anticipate this 
witness will identify as being signed by her and dated in the year 2000, which goes to the 
precise piece of evidence which she gave in answer to Mr Tyson’s questions.  I could not 
C
anticipate that Mr Tyson was going to ask that question.  It has emerged, so it is right that you 
should receive the best possible evidence in order to deal with matters not merely of 
credibility, but also of looking at the complete horizon of the evidence in this case. 
Madam, I say that this is firstly relevant.  It would have been relevant if it had been 
introduced earlier and it is relevant now.  It is a matter which in my submission I should be 
entitled to ask about.  Mr Tyson can re-examine further – this is a common approach adopted 
D
in these cases – and indeed you can ask about it.  I do not mind who does it, but it ought to be 
in evidence.  That is the way I put it. 
MR TYSON:  Madam, my learned friend directly asked questions of this witness about
Ms Mellor and asked direct questions of this witness about her contact with Ms Mellor.  He 
could at that point, had he so chosen, in order to make good his claims, put in the document 
which my learned friend now wishes to put in.  He chose not to.  I, properly in my 
E
submission, asked questions arising out of this witness’s involvement with Penny Mellor.  It 
appears that my learned friend is unhappy with the answer which I elicited and now wants to 
have a second go at cross-examining this witness.   
In my respectful submission, the rules, unless bent in an unusual way, under rule 50 do not 
permit a second bout of cross-examination after re-examination.  My learned friend had 
ample opportunity to put this document to the witness.  He chose – and he is an experienced 
F
advocate – not to put the document to the witness.  He now wishes to have a second and,  
I would say, wholly impermissible bite at the cherry by having another go at cross-examining 
this witness.  To say that it is a wholly new matter arising out of my re-examination is not 
correct in my submission.  It cannot be a wholly new matter, because he was the one who 
raised the involvement of this witness with Penny Mellor and I dealt with it by producing the 
document showing my client’s views in 2002 about this woman.  That is the beginning, the 
end and the middle of it.  He cannot have another bash. 
G
MR COONAN:  My learned friend highly overstates the position in terms of the procedure 
which is adopted in these proceedings and indeed in criminal courts up and down the land.  
There are many, many cases where an advocate will even say – I do not say that is the case in 
this case – “I forgot to put something in cross-examination” and the general view of the judge 
is that that is allowed, provided the opposition has an opportunity to deal with it.  I am not 
suggesting Mr Tyson should not have an opportunity to deal with it.  Of course he should. 
H
T.A.  REED 
Day 2 -  51
 & CO. 

---

A
Secondly, I am not proposing to repeat my cross-examination.  I simply wish him to adduce 
the document and get the witness to identify it.  The document speaks for itself.  I will ask 
two questions and sit down. 
THE CHAIRMAN:  Thank you.  I think the Panel should now take some advice from the 
Legal Assessor about this matter. 
B
MR TYSON:  I have to say, although I do not want to say it, that in your dual role as both 
judge and jury in order to rule on this matter properly, you have to see the document.  It is 
unfortunate, but those are the rules.  It is not a matter where the Legal Assessor can keep it to 
himself.  It is because of your particular role as a sort of hybrid judge and jury, even though 
you are heavily reliant on the advice of your Legal Assessor, it is you who have to make the 
legal determination on this and you have to see the document in order to make that 
determination. 
C
THE CHAIRMAN:  It is normal, if the Panel is being asked to receive evidence which is 
disputed in some way, for legal advice to be given before that document is received.  If the 
legal advice is that we should see the document before we make a decision on whether to 
admit it, then so be it.  I think at this stage it would be helpful to the Panel to get the Legal 
Assessor’s input on this matter. 
D
MR TYSON:  Of course, I abide by your ruling. 
THE LEGAL ASSESSOR:  Madam, as has been said, the rules under which you operate for 
the purpose of this hearing prescribe the order of questioning of witnesses.  However, you 
will be aware of course of the provisions of your rule 50: 
“The …Committee may receive oral, documentary or other evidence of any fact or 
E
matter which appears to them relevant to the inquiry into the case before them.” 
That section of the rule really points to the underlying task of this Panel, which is to ensure 
that justice is done and that relevant evidence is before it.  Of course, at any stage it is open to 
the Panel to call for evidence of its own motion. 
Mr Tyson has perfectly fairly said that had this document been adduced perhaps at an earlier 
F
stage, in other words, during the course of Mr Coonan’s cross-examination, he could not 
possibly have objected to its production, but he takes the point that the rules are the rules and 
he cannot have two bites of the cherry, as he has put it. 
So far as the document is concerned, you probably have gleaned from the observations which 
have been made the thrust of the document, albeit not the detail. It is urged upon you by
Mr Coonan that the document itself is relevant to the topic concerning Ms Mellor and the 
G
witness’ involvement.  I have had the opportunity of seeing the document and, as to the 
qualifying observation by Mr Tyson that you should see it first, in the light of the fact that 
you have had an indication of its overall nature, I would advise you that in the circumstances 
it is unnecessary for you to see it before considering the advice which I give you and also of 
course the submissions made by counsel. 
My advice to you is that you should look to rule 50, you should have well in mind the 
H
underlying need to ensure that justice is done and that the relevant evidence is before you.  In 
T.A.  REED 
Day 2 -  52
 & CO. 

---

A
that regard, my advice to you, bearing these matters in mind, is that you would find this 
document would indeed, subject of course to comment and your own interpretation of it, be 
helpful as a piece of evidence which may appear to you to be relevant to the inquiry. 
THE CHAIRMAN:  Thank you.  In view of the Legal Assessor’s advice to the Panel, do you 
wish to make any further comments, Mr Tyson? 
B
MR TYSON:  I have heard the advice.  I do not agree with it, but that is not my role at this 
stage.  You are bound by the Legal Assessor’s advice, not my observations on it. 
THE CHAIRMAN:  Mr Coonan? 
MR COONAN:  Thank you for the invitation, madam.  For what it is worth, I agree with the 
advice.
C
THE CHAIRMAN:  If there is still no agreement on this matter, then the Panel has no option 
but to go into camera and determine how it should proceed.  I am acutely aware of the time in 
Adelaide and the position of the witness.
MR TYSON:  Madam, I am caught between making an issue of this.  If the Panel has to retire 
and have a written determination and whatever, we are talking about in my submission even 
D
on the simplest point 45 minutes.  I am conscious of the fact that it is 11.30 p.m. in Adelaide.  
The issue is not so important in my respectful submission that I need to pursue it in light of 
the time in Adelaide and in light of the welfare of my client.  I am content that the document 
can be put to the witness. 
THE CHAIRMAN:  That matter is therefore resolved.  Thank you.  We need to bring Mrs M 
back now and the document can be put to her. 
E
(The video link was re-established)
THE CHAIRMAN:  (To the witness)  Perhaps I could explain what is now going to happen, 
Mrs M.  We apologise for having had to ask you to leave the room, as it were, but the matter 
of legal dispute has now been resolved.  The outcome of that is that a document which was 
not put to you during Mr Coonan’s cross-examination is now going to be raised.  Mr Coonan 
F
is going to ask you another couple of questions and then after that, Mr Tyson will have the 
opportunity to ask you questions arising from that.  Mr Coonan? 
Further cross-examined by MR COONAN
Q 
Mrs M, could you just help me, please, about one matter which was touched upon 
both by myself towards the end of my questions of you?  It was also touched on again by  
G
Mr Tyson when he began to ask you some further questions.  It concerns Ms Mellor.  You 
told the Panel I think when I was asking you some questions that your contact with
Ms Mellor was correct.  You said that it was limited to a telephone conversation.  Mr Tyson 
asked you some questions and your attention was drawn to the fact that in a letter written to 
the General Medical Council on 15 March 2002, you – and I paraphrase – had indicated that 
you did not wish Penny Mellor to have anything to do with your complaint. 
A 
Yes, that is right. 
H
T.A.  REED 
Day 2 -  53
 & CO. 

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A
Q 
The matter I want to draw your attention to is this.  It may be somebody will have to 
put this in front of the screen so that you can see it.  I wonder if that can be done?  (Document 
held in front of screen)  Can you see that document, Mrs M? 
A 
I cannot see it, no.  It is all fuzzy.  (After a pause)  Yes, I can now. 
Q 
Can you look at the document and see at the bottom there is a signature? 
A 
Yes, I can see that. 
B
Q 
Is that your signature? 
A 
It is, yes. 
Q 
You can of course look at the document through the assistance of the person holding 
it, but just to save your eyesight, can I just read to you what the document says?  It has your 
home address on it, it is dated 10 January 2000, it is addressed “To whom it may concern” 
C
and says, “I …” and then your name: 
“ … give permission for Penny Mellor to advocate for myself and my son.” 
That is your youngest son – 
“ … I also give permission for Penny Mellor to have access to any medical files or 
D
any other files relating to myself or my son.” 
And you sign that letter.  Is that right? 
A 
Yes, I did. 
Q 
Did you send that letter to the hospital Trust? 
A 
Yes, I did. 
E
MR COONAN:  Thank you very much.  That is all I wish to ask you.  Madam, there are of 
course copies of that and I invite you to receive it.  (Same distributed and marked as D1)
Further re-examined by MR TYSON
Q 
Mrs M, as a result of this letter, did anything happen as far as you are aware? 
F
A 
No, not that I am aware. 
THE CHAIRMAN:  Mrs M, that matter is now dealt with, so we can now revert to where we 
were before, which is the time when the Panel can ask questions. 
Questioned by THE PANEL
G
MRS LLOYD:  Good evening, Mrs M.  I just want to ask you a few questions for 
clarification purposes of evidence we have already heard or seen.  Firstly, you said that your 
meeting or interview with Dr Black was very different from your experiences of your 
interview with Professor Southall. 
A Yes. 
Q 
Could you just clarify for the Panel the kind of questions and the kind of discussion 
H
that you had with Dr Black? 
T.A.  REED 
Day 2 -  54
 & CO. 

---

A
A 
She started off by interviewing my son, my youngest son, and then me and my 
youngest son, and then all of the family.  She kept her tone very quiet.  She was not 
aggressive in her questioning at all.  She was actually very sympathetic and she gave us the 
opportunity to answer her questions. 
Q 
That is very helpful.  You did say at one point in your evidence, Mrs M, that there 
was very little focus during your interview with Dr Black about your son, M1’s, death.  Is 
B
that correct? 
A 
I am sorry, could you say that again please? 
Q 
You did say during the course of your evidence that there was very little focus during 
your interview with Dr Black about your son, M1’s, death? 
A 
Sorry, yes.  She did mention it and she did ask me a few questions, but it was mainly 
about my youngest son and his feelings and what he had been saying to myself and how he 
C
had actually been in himself physically – just generally about my youngest son more than my 
eldest son.  But she did ask me questions about him. 
Q 
Is it possible just to clarify the kind of questions she asked you about your eldest son? 
A 
She asked me how he died, if he had had any problems in school, was I aware of any 
problems in school, how he was at home, just general stuff about him really. 
D
Q 
That is fine, thank you.   Now, moving on I am just clarifying.  Your eldest son died 
in 1996.  Is that correct? 
A 
Yes, that is correct. 
Q 
Your interview with Professor Southall was in 1998? 
A 
That is right, yes. 
E
Q 
So two years have lapsed then between the death of your son and your interview with 
Professor Southall? 
A 
Yes, that was correct. 
Q 
Can I ask you, during the time between your son’s death and your interview with 
Professor Southall was there a police investigation about your son’s death? 
A 
No, none at all. 
F
Q 
Was there a post mortem? 
A 
Yes, there was. 
Q 
Was there an inquest? 
A 
Yes, there was.  
G
Q 
Can I also ask you whether you were ever charged with any offence in relation to your 
son’s death? 
A 
Yes, nothing at all. 
Q 
The other thing I just want to clarify with you, Mrs M, is that again during the course 
of your evidence you said that during the interview with Professor Southall and Francine 
Salem there was no focus on your youngest son, who we are calling M2. 
H
T.A.  REED 
Day 2 -  55
 & CO. 

---

A
A 
I think Professor Southall may have asked me one question about one incident, but 
nothing else.  There was no other mention of my son. 
Q 
Could we just turn to the page please in your bundle, where that report is? 
A 
Sorry, which report? 
Q 
Francine Salem’s report. 
B
A 
Right, sorry.  Okay. 
Q 
Both in the version we have got in our bundle and the amended bundle that we have 
just received as (aa) there is a paragraph on our page 24 about your youngest son and it talks 
about your youngest son’s stools.  Can you see where I mean, near the bottom of the page? 
A Yes. 
C
Q 
The third paragraph up from the bottom of the page. 
A 
I have got it. 
Q 
Just looking at that paragraph, Mrs M, it does infer that you were asked questions 
about your youngest son? 
A 
Yes, there were questions about my youngest son but I can only remember the one 
about him … I was being asked about any accidents that he had actually had and that was 
D
only one incident.  I cannot remember any of the others I am afraid. 
MRS LLOYD:  Thank you very much, Mrs M.  I have no further questions for you. 
THE WITNESS:  Thank you. 
THE CHAIRMAN:  Mr MacFarlane is a medical member of the Panel. 
E
MR MACFARLANE:  Good evening, Mrs M. 
A Good 
evening. 
Q 
I want to ask a couple of questions.  The first one is on the same page of Francine 
Salem’s report and I would like you to look at the fourth paragraph down from the top which 
starts. “Regarding the scalding incident to …”.   
F
A 
Yes, I have got it. 
Q 
Within that paragraph are two references to a Mrs Stone. 
A Yes. 
Q 
Is that the same Mrs Stone who was M1’s teacher? 
A 
No, it is not. 
G
Q 
I thought so.  It is just I thought that perhaps it was a coincidence. 
A No. 
Q 
During the evidence you told us that Dr Southall was sitting in front of you. 
A 
Yes, and slightly to the side as well, not directly in front of me. 
H
Q 
You said that Francine Salem, the social worker, sat behind you? 
T.A.  REED 
Day 2 -  56
 & CO. 

---

A
A 
She was to the side of me but slightly back from me, and I was at an angle.  I was not 
square but I was at an angle looking across the room diagonally to Professor Southall, and 
Francine Salem was sort to the side of me but I could still see her. 
Q 
So when you were talking about her facial expressions – and I have heard “smirk” 
being used once or twice – was she directly observable or did you have to turn to see her to 
see her facial expression? 
B
A 
No, I could see her, yes. 
Q 
My final question is this, and to explain, I do work as a general practitioner part-time.  
During the time that you had the interviews with Dr Black and Dr Southall and what-have-
you I can fully understand that this was a difficult time in your life and we have heard that 
you have been to see your own family doctor on a number of occasions.  Was your family 
doctor treating you for any illnesses or problems at that time? 
C
A 
After my eldest son died I was taking antidepressants, but I did not take them for very 
long because I did not feel they were working; but I cannot remember being treated for 
anything else. 
Q 
So at the time when you had the interview with Dr Southall you were not being 
treated with antidepressants or anything else? 
A No, 
nothing. 
D
MR MACFARLANE:  Thank you very much indeed. 
THE WITNESS:  Thank you. 
THE CHAIRMAN:  Dr Sarkar is another medical member of the Panel. 
E
DR SARKAR:  Good evening, Mrs M. 
A Good 
evening. 
Q 
I have got a few questions which I will ask very slowly.  If you need me to repeat 
please feel free to do so, and I apologise in advance if those questions have been asked.  I just 
wanted clarification.  When you went to see Professor Southall, did Professor Southall 
explain to you why he was asked to see you? 
F
A 
No, he did not at all, no.  He did not explain at all. 
Q 
Did anybody else explain to you why Professor Southall might be interested in seeing 
you? 
A 
I was told that I had to go and attend a medical with Professor Southall at Stoke at a 
certain time on a certain day and that I would be picked up by a social worker that was not 
connected to the case, and that is exactly what had happened. 
G
Q 
Am I correct in assuming that nobody actually, including your solicitor, explained 
what Professor Southall’s remit might be? 
A 
No, that is right.  Yes, you are right. 
Q 
The next question:  When you went into Professor Southall visiting rooms you found 
the social worker, Ms Salem.  Did Professor Southall introduce you to Ms Salem? 
H
A 
No, he did not. 
T.A.  REED 
Day 2 -  57
 & CO. 

---

A
Q 
Did Professor Southall explain why the social worker was there? 
A 
No, he did not at all. 
Q 
Did he ask your permission for Ms Salem to be present during the interview? 
A 
No, he did not. 
B
Q 
I now move on to a different kind of question.  Do you know what kind of medical 
doctor Professor Southall is? 
A 
I believe he is a paediatrician. 
Q 
What kind of doctor did you think Dora Black was? 
A 
I actually thought she was a psychologist. 
C
Q 
At that point – and it is no fault on you if you did not realise at that time – did you 
realise that there is a difference between these two specialties? 
A 
Yes.  I did not at the time but I do now, yes. 
Q 
Did you have any idea in your head – mind you, this investigation/care proceedings 
had been going on for a while – that Professor Southall and Dr Dora Black may have been 
asked to answer different questions in their instructions? 
D
A 
Yes, I can understand that.  
Q 
But you are telling us, the Panel, that Professor Southall did not explicitly make it 
clear what he was seeing you for, or what would be the basis of his report, or the 
confidentiality implications? 
A 
Yes, that is right.  Yes. 
E
DR SARKAR:  Thank you very much. 
THE WITNESS:  Thank you. 
THE CHAIRMAN:  Mr Simanowitz is a lay member of the Panel. 
MR SIMANOWITZ:  Good evening, Mrs M. 
F
A Good 
evening. 
Q 
I have got a few questions but seemingly I am the last member of the Panel to ask you 
questions.  I think you said in evidence that if you had known that Francine Salem would be 
at the interview you would have taken your solicitor along? 
A 
I would have done, yes. 
G
Q 
Why would you have wanted to do that? 
A 
Francine was around from the very beginning of the case, being very persistent, which 
I can understand with the questioning and the reasoning.  To sort this case out she needed a 
lot of background, but it was also the way that she asked the questions.  She was very 
persuasive, persistent, a bit like Professor Southall’s manner, and I felt very uncomfortable in 
her presence.  If I knew that she would actually be there then I would have taken somebody 
with me to also take notes or just be there to reassure me, and a spokesperson maybe; but  
H
I was not given the opportunity to do that. 
T.A.  REED 
Day 2 -  58
 & CO. 

---

A
Q 
As far as my questions are concerned they will be on different topics because I am 
just moving through the evidence that you gave.  The next thing I wanted to ask you was 
about the belt and you told the Panel that you demonstrated how it had been tied.  I think at 
one point you said a shoelace and then at another point you said a string, and in fact in 
Francine Salem’s report she refers to a wire.  First of all, can I clarify which it was? 
A 
It was a piece of string. 
B
Q 
A piece of string and a pencil? 
A 
That is correct, yes. 
Q 
Who gave you those items to demonstrate? 
A 
Professor Southall gave me them. 
C
Q 
He asked you to demonstrate with those items? 
A 
Yes, he did.  I could not explain to him, I could not explain to him how it was, so  
I said I could show him. 
Q 
Bear with me one moment.  When Dr Southall said very bluntly to you, he put it to 
you that you had murdered your son, how did you react? 
A 
I was stunned.  I felt physically sick.  I was not sick.  I could not believe that 
D
somebody was calling me a murderer to my face. 
Q 
Did you say anything? 
A 
No, I cannot remember – I cannot recall that I did, no.  I was that stunned when he 
actually said to me … I cannot remember that I said anything back to him, no. 
Q 
Was that a time when you cried? 
E
A 
No, that was not the time when I cried.  I cried afterwards, when I finally realised 
what he had said to me, on the way out. 
Q 
We have heard a lot about Munchausen’s by proxy. 
A Yes. 
Q 
At what stage did you understand what that meant? 
F
A 
My solicitor told me later on, after I was taken to the police station from my home and 
I was advised to seek separate legal advice from my husband, and I went round and I 
explained what I was being accused of and she explained it to me, nobody else. 
Q 
When was that? 
A 
That was on the morning my youngest son was taken and the police and the social 
worker came to the house, the police took me down the police station and advised me to seek 
G
legal advice separate from my husband.  I then went to a solicitor who explained to me what 
MSP was. 
Q 
Turning now back to the interview, we have heard there was a time when you cried 
for some two or three minutes.  Did either Dr Southall or Francine Salem try to comfort you 
in any way? 
A 
No, they did not, not at all. 
H
T.A.  REED 
Day 2 -  59
 & CO. 

---

A
Q 
They did not offer you a tissue or anything like that? 
A 
No, nothing.  No. 
Q 
My final question is really by clarification.  I may have missed something.  I think 
you said that you did not make a complaint to your solicitor about the conduct of Dr Southall 
at the interview.  Is that right? 
A 
Yes, that is correct, yes.  I did go back and tell her what happened at the interview.   
B
I suppose it was my fault because I automatically thought she would put a complaint in, so 
maybe that was a misunderstanding on my behalf. 
Q 
I am sorry, I think I am misunderstanding.  You actually did, you told your solicitor 
about the way he had ---? 
A Yes. 
C
Q 
And you told your solicitor that you were not happy about that? 
A 
Yes, she knew I was not happy about it, yes. 
MR SIMANOWITZ:  Thank you. 
THE WITNESS:  Thank you. 
D
THE CHAIRMAN:  I am the last person to go as Chairman, Mrs M, so I do still have a 
couple of outstanding questions, if I may.  I am returning to the notes of the meeting that 
were made by Francine Salem.  In your evidence, when challenged about that you agreed that 
the notes were accurate insofar as they went.  When asked about the tone you said that it did 
not reflect the tone of the meeting.  What would you say about how complete these notes are?  
Does it record everything that happened? 
A 
No, it does not.  I do not feel that it does.  I think some things have been omitted, but 
E
I was not able to say that.  That is what I feel. 
Q 
You feel that some things were omitted? 
A 
I do not feel the way that they are written, I do not feel that that is an accurate picture 
of actually what happened in the interview. 
Q 
So are you saying that if you go through it fact by fact, as written, each sentence or 
F
paragraph is not wrong, but it is when you take it all together? 
A 
Yes.  It is not wrong.  Yes, I am sorry.  It is not wrong.  It is just the way….   Yes.  As 
you have said it, that is how I agree with it. 
Q 
I do not really want to put words in your mouth but I am just trying to understand ---? 
A No. 
 
G
Q ---what 
you 
mean? 
A 
Yes.    
Q 
So when challenged you would say, “I cannot pick on something that is wrong,” but 
when you take it altogether you feel it is not a complete account.  Is that ---? 
A 
That is right, yes. 
H
T.A.  REED 
Day 2 -  60
 & CO. 

---

A
Q 
How long was the interview altogether?  Do you remember how long you were in the 
room? 
A 
It has to be around two hours. 
Q 
Two hours?  Right. 
A Yes. 
B
Q 
And somebody was talking throughout that time, was there? 
A Yes. 
Q 
Were there any long gaps of silence? 
A 
There were no breaks, no gaps or nothing. 
Q 
So a verbatim record would have been quite long? 
C
A 
Yes, it would have been. 
Q 
Thank you very much on that one.  One last question.  That is on that document, at the 
bottom of page 25, a paragraph which you have been asked about quite a bit and I think on 
your own annotated copy we saw that you had quite a bit to say about this paragraph.  The bit 
I would like you to clarify is ---   Have you found it again? 
A 
I have found it, yes.  Sorry. 
D
Q
“Mrs M said that she would be pleased to talk about it if it cleared her name…”. 
How did that actually arise, because what made you need to think about it?  What suggestion 
was there that made you need to clear your name? 
A 
All the way through the interview with Professor Southall, he kept saying, after he 
E
accused me of murdering my son, he said, “You’ve got to be guilty.”  All the evidence started 
off with, I would not tell him how the belt was tied.  That is when I got all upset and he said, 
“You’ve got to tell me.  It is an important piece.  I need to know.”  And that is when he kept 
asking me and asking me and asking me, and in the end said, “I’ll show you.”  That is when 
in fact it all came out. 
Q 
Had anything happened before this interview with Dr Southall that might have 
F
suggested that your name needed clearing of something? 
A 
No, not that I am aware of.  No.  I did not even know Professor Southall before this 
case.
Q 
So I think what I am getting at was how this expression to clear your name had 
cropped up, but there was nothing --- 
A Sorry? 
G
Q 
There was nothing you knew about before you went into this interview that might 
have suggested to somebody that you needed to clear your name? 
A 
There was a mention of my eldest son’s death being an open verdict, and also I am not 
sure when it was, whether it was before the interview or shortly after, I cannot remember, but 
Professor Southall asked the police to open the open verdict.  That is when I had to go down 
to the police station.  I am presuming that is how it came about because it was an open 
H
verdict.  He did ask me if it was an open verdict, and I said, “Yes it was.”  He just looked 
T.A.  REED 
Day 2 -  61
 & CO. 

---

A
quite surprised, really, when I told him.  I suppose that is when I said, “I’ve got to clear my 
name,” and then that is when that cropped up.  I am almost certain of that. 
Q 
I think this is a bit of new information then;  that Dr Southall --- 
A 
I am sorry. 
Q 
Are you saying that there was a question mark put over the coroner’s verdict at some 
B
point? 
A 
The coroner recorded an open verdict and Professor Southall said that needed 
investigating.
Q 
He said that to you in this interview? 
A Yes. 
C
Q In 
this 
interview? 
A Yes. 
Q 
So was that the point at which the question that might be something you needed to 
clear your name? 
A Yes. 
D
Q 
It happened during the interview, not before? 
A 
Yes, it did. 
Q 
I think I have got that clear now, thank you. 
A Sorry. 
THE CHAIRMAN:  That seems to have provoked another question from Mr Simanowitz.  
E
Those were all my questions.  
MR SIMANOWITZ:  It is that very thing that has provoked the question. I was looking at the 
version of that note, that report that you have annotated, where it says, “Mrs M said that she 
would be pleased to talk about it if it cleared her name,” you have written:  “No, I did not.  
He said that.”    “He said that.”  Is that referring to that statement? 
A 
Yes, it is.  I did not say I would be pleased to talk about it because I found it very 
F
difficult to talk about, so Professor Southall said that, not myself. 
Q 
So it is that bit about being pleased to talk about it that you mean, when you say, “No, 
I did not say that.” 
A Yes. 
MR SIMANOWITZ:  Thank you. 
G
THE CHAIRMAN:  Mrs Lloyd now has another question. 
MRS LLOYD:  Mrs M, as a result of the Chair’s question I wonder if I could ask you a 
further question? 
A Yes, 
certainly. 
H
T.A.  REED 
Day 2 -  62
 & CO. 

---

A
Q 
You have just said in response to a question that was put to you that “Professor 
Southall asked the police to open the open verdict”.  Is that correct? 
A 
That is what the police told me when I went down the police station, yes. 
Q 
How did that occur?  How did you get to go to the police station?  I just need to 
understand the events that have taken place here.  You had the interview with 
Professor Southall? 
B
A Yes. 
Q 
Did he ask the police prior to the interview with you or after the interview with you, 
for the police to open ---? 
A 
I cannot remember.  I honestly do not know if it was before or after.  I was just asked 
to attend the police station with my solicitor to answer some more questions about my son’s 
death, the belt in particular. 
C
Q 
So that was after you had seen Professor Southall? 
A 
I cannot remember if it was before or after.  I think it was after because…   I cannot 
remember, to be honest with you, whether it was before or after.  Sorry. 
Q 
Who asked you to attend the police station?  Was it by letter from the police, or 
telephone call? 
D
A 
My solicitor informed me that I was asked to go to the police station to answer some 
more questions. 
Q 
Could you just help the Panel by advising us the sort of questions you were asked by 
the police? 
A 
They specifically asked me about the belt and I did not answer them all.  I did not 
speak to them.  I did not say nothing, but that is all they asked me was questions about the 
E
belt.  I think they might have only asked me one question. 
Q 
As a result of that interview with the police were you asked to see the police again? 
A No. 
Q 
Were you told whether any further action would be taken? 
A 
No, there was no further action to be taken.  No. 
F
MRS LLOYD:  Thank you very much, Mrs M. 
THE CHAIRMAN:  Those are all the questions from the Panel and we are very near the end, 
but it sometimes happens that either counsel may have questions that arise from the Panel’s 
questions, and they are entitled to ask them in the final round.  Does either counsel have 
further questions for Mrs M?   Mr Tyson has risen. 
G
Further examined by MR TYSON
Q 
In relation to the questions you were asked just now by Mrs Lloyd there may be a 
document in your bundle – and I underline that.  Would you look at (jj) in your bundle, 
please.
H
THE CHAIRMAN:  I do not think we have it. 
T.A.  REED 
Day 2 -  63
 & CO. 

---

A
MR TYSON:  I am not saying that you had it.  I am asking this witness whether it is in her 
bundle, (jj).  Is there a section (jj) in your bundle? 
A 
Yes, I have the letter. 
Q 
Is that a letter from the West Mercia Constabulary? 
A 
Yes, it is. 
B
Q 
And is it a letter addressed to your solicitors dated 3 December 1998? 
A Yes. 
Q 
And does it indicate that the police have re-investigated the matter? 
A 
That is correct, yes. 
C
Q 
Does it says: 
“The review has only recently been completed and has not revealed anything to 
suggest the original verdict at the coroner’s court was not correct.” 
A That 
is 
right. 
D
MR TYSON:  And if you want to see that letter I can have it available for the Panel.  I have 
no further questions for my client. 
THE CHAIRMAN:  Mr Coonan? 
Further cross-examined by MR COONAN
E
Q 
Madam, I have two very, very short matters.  Mrs M, as you heard me say, two short 
matters.   You were being asked some questions by Mrs Lloyd about the sequence of events 
in relation to police investigations.  Can I just attempt to clarify, subject to further evidence, 
these matters.  Do you agree that you went to see the police, and you were asked questions 
about the belt before you saw Dr Southall? 
A 
Sorry.  Can you say that again, please? 
F
Q 
Do you agree that you went to see the police who asked you some questions about the 
belt and that that was before you saw Dr Southall? 
A 
As I said before, I cannot remember if I went before or after the meeting with 
Professor Southall. 
Q 
What is the basis for you asserting, as you did, that it was Dr Southall who asked the 
police to reopen the investigation? 
G
A 
The police said so. 
Q 
The police said that.  Right.  I just want to clarify.  That was not Dr Southall who said 
it?
A 
No, no.  The police told me that. 
Q 
And after you had seen Dr Southall, so we again have it absolutely clear, you did not 
H
see the police again? 
T.A.  REED 
Day 2 -  64
 & CO. 

---

A
A No. 
Q 
The answer is no.  The second matter is this.  You said that the whole of this interview 
took two hours? 
A 
Yes.  Sorry, yes. 
Q 
Just stand back and have a think about it.  Is it really two hours?  Or was it more like 
B
one hour, plus or minus a bit either side? 
A 
No, it was longer than an hour. 
Q 
I am not tying myself to an hour exactly, you understand, but there is a difference 
between one hour and two hours? 
A 
I understand that, yes.  I believe it was two hours. 
C
MR COONAN:  All right.  Thank you.  Thank you, madam. 
THE CHAIRMAN:  Mrs M, that finally completes all the questions we have from your.  I am 
able to release you from your oath.  Thank you very much for giving your evidence. 
THE WITNESS:  Thank you. 
D
THE CHAIRMAN:  Good night. 
THE WITNESS:  Thank you, goodnight. 
(The witness withdrew)
(The video link was terminated)
E
MR TYSON:  Madam, we are in a slightly bizarre situation about my opening, but I ask your 
indulgence for one other matter.  I have a very short witness who is a medical witness, who is 
the psychiatrist who saw this lady immediately after the interview that we just heard 
described.  She has enormous clinical difficulties being here at any time other than this 
afternoon.  She would just be a short witness because all she can do, as it were, is read her 
note, in effect, of this matter.  I would ask that you hear her when we resume after lunch for 
F
about an hour, and then we discuss at that time whether I carry on with my opening or 
whether, because we have all had a long day, we start again tomorrow morning. 
THE CHAIRMAN:  On that last matter, it had already been my view that if it was possible, 
we should finish earlier rather than later today, given the late sitting last night and the long 
morning.  I take it generally there is agreement that this witness should be --- 
G
MR TYSON:  I am looking at my learned friend.   
MR COONAN:  Mr Tyson was kind enough to indicate that he had difficulties with his next 
witness in terms of her availability.  I do not want to cause any difficulties.  Strictly speaking, 
we would have to wait until he has finished his opening, but I do not want to cause problems.   
The Panel clearly wants to get on with this, and so do we.  I am prepared to consent that we 
take this irregularly out of order.  It seems sometimes that irregularity is built into the system, 
H
but there it is.  So I am content.  Equally by that stage I, for one, might be flagging.  I confess 
T.A.  REED 
Day 2 -  65
 & CO. 

---

A
that straight away.  So my learned friend’s latter suggestion about rising after that, I would 
embrace his idea. 
THE CHAIRMAN:  Will it be satisfactory if we do take a proper break now, and have your 
witness in about one hour’s time – say quarter to three. 
MR TYSON:  Or three o’clock.  Whatever you want. 
B
MR COONAN:  I would prefer three o’clock. 
THE CHAIRMAN:  Three o’clock it is.  We will break now until then. 
(Luncheon adjournment)
C
ALISON CORFIELD, Affirmed
Examined by MR TYSON
THE CHAIRMAN:  Thank you for coming to give evidence, Dr Corfield. 
(Introduction)
MR TYSON:  Could you give the panel your full name? 
D
A 
Dr Alison Corfield. 
Q 
What is your professional address? 
A 
Cams, Bourne House, Radbrook College Complex, Radbrook College Road, 
Shrewsbury.
Q 
Are you a consultant in child and adolescent psychiatry? 
E
A I 
am. 
Q 
Do you work for a PCT in or near the town that you have just mentioned? 
A 
I am employed by Telford and Wrekin PCT but I work entirely within Shropshire. 
Q 
Madam, perhaps I could mention this to you and the panel and to the witness. I have 
had permission from my learned friend to lead on a lot of the introductory evidence of this 
F
witness.  (To the witness)   Prior to November 2000, were you registered with the GMC as  
Dr Alison Solomon? 
A I 
was. 
Q 
Have you since re-married and changed your name and registration to Dr Corfield. 
A I 
have. 
G
Q 
In preparing the statement that you did for these proceedings, did you have an 
opportunity of looking at your files in respect of the M family? 
A Yes. 
Q 
Was the youngest child, who we know as M1 or the youngest child, with his parents 
and did they attend the Child and Family Service where you saw them on a number of 
occasions? 
H
A They 
did. 
T.A.  REED 
Day 2 -  66
 & CO. 

---

A
Q 
Were you first referred the youngest child by his head teacher following the death of 
his older brother? 
A Yes. 
Q 
Did you first meet with the youngest child and his mother in August 1996?  We have 
heard that the death of the eldest child was in June 1996.  Did they remain seeing you and 
B
your colleagues until March 1997 when they were discharged? 
A Yes. 
Q 
Were they told that they could come back to you at any time if they wanted? 
A They 
were. 
Q 
So the discharge was in March 1997.  Was your next contact with the family in May 
C
1997? 
A 
Yes, that was my colleague Brian Turner, who was the clinical social worker and he 
had contact with them at that point. 
Q 
Was it the mother who made contact with your colleague Mr Turner on that occasion? 
A Yes. 
D
Q 
Was a history given by the mother that the youngest child had become withdrawn and 
that there were further problems at school? 
A 
Yes, it was. 
Q 
Did he offer to see the mother and the youngest child in that May but on the day of 
the appointment was that appointment cancelled? 
A Yes. 
E
Q 
Was that due to the fact that the youngest child did not want to attend? 
A 
Yes, that was the case, and his mother was encouraged to come on her own if she 
wished to, but she did not take that up. 
Q 
Was there a re-referral in October 1997 made by the GP? 
A There 
was. 
F
Q 
Was the history given in October of 1997 that the youngest child was very withdrawn 
and there had been increasing tensions at school? 
A It 
was. 
Q 
Following that October 1997 referral, did you see the youngest child on two occasions 
with his mother? 
G
A I 
did. 
Q 
I believe that was on 9 and 23 December? 
A Yes. 
Q 
In the middle of January 1998, were you informed that social services were making 
inquiries under a section of the Children Act in relation to this child? 
H
A Yes. 
T.A.  REED 
Day 2 -  67
 & CO. 

---

A
Q 
Did you become involved in those inquires to the extent that you attended two 
strategy meetings? 
A I 
did. 
Q 
I want to point those to you.  Bundle 1 is in front of you.  I ask you to look under 
section 1, at a tab marked “o”. 
B
A 
I have that. 
Q 
The panel has seen this document already but it is a strategy meeting held by the local 
authority, as we see on Monday 26 January.  We look amongst the attenders and we see you 
in your former name three up from the bottom? 
A Yes. 
C
Q 
As I understand it, that was a sort of pooling of information session, if I can put it this 
way? 
A It 
was. 
Q 
If you go to page 8 within that document, do we see in the first paragraph that you had 
learned at that meeting that Dr Southall had suggested that there were concerns for the 
youngest child and the panel question was:  if the child was removed, would his situation 
D
improve or worsen.  Do you see that? 
A Yes. 
Q 
We see on the next line that you offered to speak to Professor Southall about the case? 
A 
Obviously that was recorded.  I did not do so. 
Q 
That is the question I was going to ask.  We note in the recommendation that 
E
Professor Southall’s views about the matter were going to be, as it were, formally sought? 
A Yes. 
Q 
Then a few days later was there another strategy meeting, which we see under tab “r”.  
We can see that you attended that.  Your name is four up from the bottom. 
A Yes. 
F
Q 
The panel has been taken to this document.  It is clear that in the course of it certain 
advice had been obtained from Professor Southall, amongst others, and I think you were 
informed at that strategy meeting that an emergency protection order had been obtained for 
the child, the youngest child? 
A Yes. 
Q 
Then we have heard that the EPO was made and that subsequently the local authority 
G
applied for an interim care order? 
A 
Yes, they did. 
Q 
Did you produce a number of reports that were considered at the hearing for the 
interim care order? 
A I 
did. 
H
T.A.  REED 
Day 2 -  68
 & CO. 

---

A
Q 
Did you, in March 1998, attend the hearing and give evidence at the interim care 
order application? 
A I 
did. 
MR TYSON:  I have shown my learned friend the passages out of the judgment which in due 
course will come in front of the panel concerning your attendance at that.  For the benefit if 
the transcript, I am going to take the witness to page 8F.  You do not have that. 
B
MR COONAN:  I do not mind the witness seeing that.  We have copied it.  It may be that not 
all the pages have been photocopied on the back. 
MR TYSON:  It might be helpful if everybody were to have that.  I only need the judgment. 
(C4 marked and circulated)
C
MR TYSON:  I am grateful to my learned friend’s legal team for providing the copies. 
(To the witness)   Dr Corfield, could you look at page 8.  We can see how you were rather 
dramatically introduced into the proceedings.  Two lines about 8F the judge says:   
“I realised from the start of this hearing that there was to be no oral evidence from any 
medically, and in particular any psychiatrically, qualified person.  It was in these 
D
circumstances that I suggested that Dr Solomon should be called.  Dr Solomon is a 
consultant child psychiatrist to whom [the youngest child] was referred by his GP 
within a month of the [eldest child’s] death and with whom he has had contact on and 
off since that time.  Her report, written jointly with Mr Brian Turner, they both being 
of the Child and Family Service, appears at the end of the bundle at page 632.
Dr Solomon is the only psychiatrically-qualified expert who has seen [the youngest 
child] and I felt that she could assist the court in this application. 
E
When the parties were faced with my strong view that she should be called it was 
suggested that I should call her.  I did so.  I am grateful to her for having attended 
court at shot notice and some inconvenience and I will draw on her evidence in the 
course of this judgment.” 
Does that remind you? 
F
A 
I do remember that 
Q 
Going on to page 21F, may I read this part of the judgment and see if you recall this.
“Here I return to the evidence of Dr Solomon.  Her view is that the case does need 
further investigation.  In her words, it has reached a stage where it is important to look 
at a number of issues.  She has balanced on one hand the need for that investigation to 
G
take place with, on the other, [the youngest child’s] interest while it does so.  She is, 
in my judgment, in the best position of anyone who has participated in this case to do 
so, having both the knowledge of the parties involved and the psychiatric qualification 
to do so.  Her firm view is that [the youngest child] should be at home with his family 
while investigations take place.” 
Was that your firm view at the time? 
H
A 
Yes, it was. 
T.A.  REED 
Day 2 -  69
 & CO. 

---

A
Q 
Was that not the view of the local authority? 
A 
I believe it was not. 
Q 
Was it not the view of the guardian? 
A 
I have looked through the notes and I understand also it was not the view of the 
guardian.
B
Q 
The learned judge went on to say:
“She says that he looks to his parents as his main support and that in any event living 
away from them will not make a difference to what he will say about them.  She feels 
that he will better be able to cope with enquiries in the family environment and has 
found it quite difficult to cope with it in the foster setting.  She has actually seen [the 
C
youngest child] since he has been in the foster home, the only qualified psychiatrist, 
so far as I know, to do so, and she reports him telling her that he feels confused and is 
commenting about people asking him lots of questions.  I say in passing that people 
have now had five weeks in which to do this.” 
The judge made a finding of your view:
D
“I find that evidence compelling.  I do not agree with the criticisms which have been 
levelled at Dr Solomon and about the basis on which she holds her view. I accept her 
evidence about this.” 
A 
Yes, I remember that. 
Q 
Just go on to page 23G, and I think we have been told from an earlier witness that  
E
Mrs Inwood was the guardian.  Do you recall that? 
A I 
recall 
that. 
Q 
Picking it up at 23G:   
“I have to say that on the basis of their respective qualifications and knowledge of 
[the youngest child] I prefer the opinion of Dr Solomon on this point.  I mean no 
F
disrespect at all to Mrs Inwood by that but I cannot accept both their opinions, I have 
to choose between them, and for the reasons that I have given I prefer the opinion of 
Dr Solomon.  If I may say so, she was an impressive and thoroughly balanced witness 
with whom I would find it very difficult, particularly in the absence of other 
psychiatric oral evidence, to disagree on this point.” 
A Yes. 
G
Q 
Do you recall that tribute being given by the learned judge?  At the end of the day, 
just to see what the judge in fact found for the sake of the record, could you pick it up at 26F.
You will see that the learned judge says:
“I have considered the range of powers which the court has, and there has been 
discussion about both residence and supervision orders.  Neither is felt necessary by 
H
any party if I do not make a care order.  It must be plain to everyone concerned by 
T.A.  REED 
Day 2 -  70
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---

A
now that I do not feel that [the youngest child’s] interests will be served by the 
making of an interim care order.  His best interests, in my judgment, with all respect 
to those who disagree, to whose opinions I have given the closest scrutiny, are for him 
to return to live with his parents and accordingly this application is refused.” 
A Yes. 
B
Q 
After that evidence in March, did you see the child or his parents again? 
A 
I did see them in the April. 
Q 
Would you have made notes of any contact you had with the child? 
A 
I would have made notes at the time, yes. 
Q 
Again, could you look at bundle 1 which is in front of you, please, and go to section 
C
EE?  I wonder if you could clear up one tiny point.  We see in the contact record on the front 
page, the date of 28 April and we see over the page on your clinical note of that consultation, 
27 April.  The Panel has heard evidence that the mother saw Professor Southall on 27 April.
With that information in mind, do you have any view as to what the date was that you saw the 
mother?  Was it on the day she saw Professor Southall or the day after? 
A 
I am certain it was the day after, on 28 April. 
D
Q 
We see again on the contact record that the duration of the meeting was 60 minutes. 
A Yes. 
Q 
And that you saw both parents and the youngest child. 
A I 
did. 
Q 
Before we go into the notes of this meeting, do you have an independent recollection 
E
of this family at all? 
A 
I do, because it was a very exceptional case and, even without the involvement in 
these proceedings and my knowledge of those over the past year, I have always remembered 
the case, because it was complex and obviously quite exceptional in its content and also in 
the process of what happened during it. 
Q 
The manuscript note which we see in EE, is this in your handwriting? 
F
A It 
is. 
Q 
Again, following up questions I have just asked you, you have had an opportunity, 
have you, of looking at this note fairly recently? 
A I 
have. 
Q 
Apart from this note, do you have much independent recollection of this particular 
G
consultation? 
A 
I do have a picture in my mind of Mrs M talking to me about it. 
Q 
We will see – and thank you for having reasonable clinical handwriting – that you 
first deal with how the youngest child was and that he had been telling his mother about 
drawing.
A 
Yes.  I had seen him I think previously in April and at work at that time we had a 
H
workbook about bereavement and so I had been doing some work with him. 
T.A.  REED 
Day 2 -  71
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---

A
Q 
You indicated that he was sleeping okay in his own bedroom, that he had a good 
appetite and there had been no further remarks about going to kill himself.  
A Yes. 
Q 
Had he made any remarks to you about that at any time that you can recall? 
A 
I think whenever I had asked him directly, he had said that was something he would 
B
not do.  I think from looking at my notes, that when he spoke, he had had some individual 
sessions with Mr Turner when he spoke to him and he would acknowledge that was what he 
had said.  He did not spontaneously say it to us. 
Q 
You record that he had been going out to play and the parents thought that he had 
been a lot more cheerful since he saw Dave Gillett.  Can you help us as to who Dave Gillett 
was? 
C
A 
He was an educational psychologist working with the local authority who had done an 
assessment on him earlier that term.  He had found that, although of average ability, he did 
have some very definite, specific learning difficulties of a dyslexic type. 
Q 
It appears that Dave Gillett had told him that he was clever.  Is my reading of that 
correct?
A 
Yes.  I think what his parents had observed about that was that it had given him a very 
D
positive boost; that he had been discouraged about his work at school. 
Q 
But had been encouraged, it appears, by Mr Gillett.  Is that right? 
A Yes. 
Q 
Do I see a line which says, “Parents” – something? 
A 
Yes.  “Parents positive about that.” 
E
Q Then: 
“[Youngest child] much happier at school.  Said he enjoyed it yesterday.” 
Then there is a discussion about arguments between the parents in the past.  Is this something 
you would have brought up, Dr Corfield? 
F
A 
Yes, I would have done, because I wanted to explore the effect on the boy of knowing 
the difficulties there had been between his parents over the years.  So that was really a 
recurring theme in the ongoing appointments and discussions. 
Q 
When it says, “Said this should never have happened”, is that the advice which you 
were giving? 
A 
No.  I would interpret that as what his parents said. 
G
Q 
Similarly, “Didn’t argue in front of the children”? 
A 
That is what they said on that occasion. 
Q 
Do you go on to record, “[M2] said he hadn’t head things that upset him.” 
A 
Yes, I recorded that. 
H
Q 
And, “He and [M1] went outside or upstairs.” 
T.A.  REED 
Day 2 -  72
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---

A
A Yes. 
Q 
Then there is a reference to a booklet.  I do not need that we need to go into that in 
any great detail.  “All joined in.  See sheets.”  Is that some work you were doing with the 
family? 
A 
I think that was the same workbook I mentioned before. 
B
Q 
Is that “F” for father? 
A Yes. 
Q 
“not sort counselling”. 
A 
Yes.  Sorry I spelled it wrong! 
Q 
“Fear of losing job.”  Then we have a reference to a person by the name of Dora 
C
Black.  Can you assist the Panel as to how that reference and the discussion in the next two 
lines came up? 
A 
Yes.  Dora Black was a child and adolescent psychiatrist.  One of her areas of 
specialism was around traumatic bereavement and also Munchausen’s by proxy and she was 
preparing a report as an expert in the same proceedings.  I think she was instructed by all 
parties in the end to do that. 
D
Q 
By the time they saw you in April, had the family been to see Dr Black? 
A They 
had. 
Q 
Do you there record, as it were, the family view of how that had gone? 
A 
I think they felt – well, they said they had felt it was a reasonable experience. 
Q 
Then there is a mention of Professor Southall.  Can you assist the Panel as to how that 
E
name came to be discussed at that consultation? 
A 
I am not certain whether I introduced it or perhaps Mrs M introduced it, but I think it 
was in the context of discussion about the reports which were being prepared for the 
proceedings. 
Q 
You have recorded that Mrs M went to see him yesterday. 
A Yes. 
F
Q 
That Mr M was not there because of his job. 
A Yes. 
Q 
And that Mrs M had been seen on her own. 
A Yes. 
G
Q 
Could you carry on, please, in your own words as to how the note goes? 
A 
There was a social worker present during the interview called Francine Salem, who 
was the social worker who was involved in the case in Shropshire.  Mrs M told me that she 
found the interview very upsetting and I think I put it in her own words, “offensive”.  She 
elaborated on that by giving me an idea of some of the questions that she told me Professor 
Southall had asked her, things that he had talked about.  I put in quotation marks, because  
I believed that this is what she said and why I recorded it like that, that “they had not done 
H
toxicology”, meaning on her eldest son’s body, and that it was “quite possible that [she] had 
T.A.  REED 
Day 2 -  73
 & CO. 

---

A
drugged him first”.  She told me that she felt accused of killing the older boy and that she had 
been expecting the interview to focus on the youngest son and the issues around 
Munchausen’s by proxy, but that was not how she saw the interview proceeding. 
Q 
Can you recall her manner when she was describing her experience with
Professor Southall? 
A 
I do recall her.  I can imagine her there.  I think she was upset and she was also quite 
B
shocked and taken aback. 
Q 
Can you recall whether she said anything about the nature of the questioning or 
anything like that? 
A 
I recall that she said that a lot of the questions centred around the death of the oldest 
boy and they seemed to imply that she might have killed him herself, that the questions were 
perhaps testing that hypothesis.  I recall she also told me that Professor Southall had 
C
suggested there needed to be further police investigations. 
Q 
You used the words “testing the hypothesis”.  Are those your words or your 
recollection of her words? 
A 
That is my interpretation. 
Q 
Is there anything else about that consultation in relation to what Mrs M told you about 
D
Professor Southall which you can now recall? 
A 
I think that is the limit really of what I can say about that interview. 
Q 
When you have recorded the words that she found it “offensive and upsetting”, were 
those her words or your words? 
A 
I would say that those were my words. 
E
Q 
Subsequently, did you do a further report for the court which we have under the next 
section, which is tab (ff)? 
A I 
did. 
Q 
That is a report dated, I think, 1 May? 
A Yes. 
F
Q 
It records that since your initial report in February you had seen the youngest child on 
17 February, which we see in the third paragraph? 
A Yes. 
Q 
Then you add in the penultimate paragraph on that page that your next contact was 
when you were called to court and you have written the date about that? 
A Yes. 
 
G
Q 
Then you saw the father and the child, as we see in the next paragraph, on 7 April.
Then going over the page, in the middle of the fourth paragraph down, the third line, do you 
record: 
 “My most recent appointment was on 28.04.98”? 
H
A Yes. 
T.A.  REED 
Day 2 -  74
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---

A
Q 
That is the one that you have been telling the Panel about? 
A Yes. 
Q 
Do you record in the penultimate paragraph that: 
“They told me that they had already met Dr Black”, 
B
and that Dr Black had seen the youngest child for an individual discussion and Mrs M told 
you that she had seen Professor Southall and she found this interview difficult and 
disturbing? 
A Yes. 
Cross-examined by MR COONAN
C
Q 
Dr Corfield, good afternoon.  As you know, I represent Dr Southall.  There are just 
two preliminary background matters.  You were asked by Mr Tyson about the case 
conferences. 
A Yes. 
Q 
The Panel have looked at the documentation in relation to that.  I am not going to take 
D
you to them in detail.  We know the first one is on 26 January and the second one was on
29 January. 
A Yes. 
Q 
You were present at both and we see from the order of personnel who else was 
present?
A Yes. 
E
Q 
Can I just ask you this:  Was Mrs M present at either or both of those two case 
conferences? 
A No. 
Q 
The second preliminary matter is this.  Could I take you to the report that you 
prepared, which is at tab 1(ff) in our bundle?  Do you see that? 
F
A Yes 
Q 
It is your report dated 1 May 1998.  This was provided to the court, was it? 
A 
It was, yes. 
Q 
We see at the bottom paragraph on the first page a reference to you seeing the 
youngest with his father on 7 April 1998. 
G
A Yes. 
Q 
At that time his mother, Mrs M, was in hospital following a miscarriage? 
A 
That is what I was told. 
Q 
Do you know how long she was in hospital for? 
A 
I do not, I am afraid. 
H
T.A.  REED 
Day 2 -  75
 & CO. 

---

A
Q 
Do you know when the miscarriage was? 
A 
I think from reviewing the notes it was just prior to that date. 
Q 
I would like your assistance, please, about a number of matters arising out of the 
meetings you had with Mr and Mrs M and the youngest on 28 April. 
A Right. 
B
Q 
We have the benefit of your notes.  The notes that you have written do not purport, do 
they, to be a verbatim account of what each one or other person said during the course of the 
interview? 
A 
No, they are not a verbatim account. 
Q 
In effect, they go through the filter of yourself and you write down an impression.  Is 
that fair? 
C
A 
Can I look at it again? 
Q Yes, 
please 
do. 
A 
Where is it? 
Q 
I am so sorry, you will find it at tab 1(ee). 
A 
(After a pause)  Yes, I would say that it is probably a mixture of obviously my 
D
interpretation of things that I have quoted them as saying and a few things when I have 
written it in quotation marks, which I would believe to be verbatim. 
Q 
The content of the note.  First of all, if I can take it in this sequence, a reference to the 
presence of Francine Salem being present which Mrs M did not like? 
A Yes. 
E
Q 
Do you recall any other aspect of that point that you recorded? 
A 
I did not record anything further.  I feel that at that time they were angry with social 
services.
Q Angry? 
A 
Because he had been removed. 
F
Q 
Would it be right to say that Mrs M in effect told you or gave you the strong 
impression that she was very unhappy that Francine Salem was there? 
A 
I think she said that she was unhappy about it.  I am not sure that she said very 
unhappy.
Q 
I use that expression, Dr Corfield.  Forgive me, I am not being mischievous, but it is 
the phrase you used in the statement you made on 1 September 2005, which I have in front of 
G
me.  Would you like to see it?  I do not want you to feel as though I am being unfair. 
A 
Okay, sure.  Yes, I would like to see it.  (Same handed to the witness)
Q 
Dr Corfield, if you would just go to the last page of the statement, is that your 
signature? 
A It 
is. 
H
Q 
And the date 2005? 
T.A.  REED 
Day 2 -  76
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---

A
A Yes. 
Q 
If you would just go to paragraph 9 you will just see where I got the quotation from.  
Just look at the last few lines? 
A Yes 
Q 
Again, you used the expression, did you not: 
B
“I recall Mrs M being very unhappy about Ms Salem.” 
A 
I did, yes. 
Q 
Again, that was 2005? 
A Yes 
C
Q 
We are now in 2006? 
A Yes. 
Q 
Do you think that was an accurate description in 2005 as to how she felt? 
A 
I think it is a reasonable description.  I think the notes record that she did not like the 
fact that she was there, and so I think it would be another way to put it, that she was very 
D
unhappy with it. 
Q 
It may, you see, have a particular forensic significance in the context of these 
proceedings that I ask you about that? 
A 
Sure, of course. 
Q 
The next matter is that, as we see and the Panel see, you have recorded that she found 
E
the interview with Professor Southall offensive and upsetting.  You told us very fairly that 
those were your words? 
A Yes. 
Q 
What you have done is, in effect, to translate that which she was saying to you so that 
you get to that description, “offensive and upsetting”? 
A Yes. 
F
Q 
So the picture is this, is it, that as you have recorded at the bottom of your note that 
Mrs M “felt”, and I emphasise that word, “felt” that she had been accused of killing the eldest 
child? 
A Yes. 
Q 
You said again a few minutes ago in answer to questions from Mr Tyson that she had 
G
been asked a lot of questions centred around the eldest boy that seemed to imply that she was 
responsible.  Do you see? 
A 
I see, yes. 
Q 
That was your strong impression, was it, that she was saying to you that the 
implication of what Professor Southall was saying was, in effect, that she was responsible for 
his death? 
H
A 
I think that was the implication as she saw it, yes. 
T.A.  REED 
Day 2 -  77
 & CO. 

---

A
Q 
You remember, do you not, she in effect saying to you, or at least this was your 
impression, that Professor Southall had been in effect testing or putting forward a number of 
hypotheses.
A 
I think that was my way of putting it. 
Q 
Yes, but of course your way of putting it must have been based upon what she was 
B
saying to you? 
A 
Yes, I recall that she gave more detail issues around the curtain rail and whether it 
would have held the boy’s weight and issues like that. 
Q 
The important point is, Dr Corfield, that the way it was being put to you by her led 
you to think that what was being spoken about between Professor Southall and her was a 
series of hypotheses? 
C
A 
That I thought that? 
Q 
Yes, based upon what she was saying and how she was saying it? 
A 
I thought she interpreted it as him saying to her “You could have killed him”, perhaps 
not that “You did kill him” but that “You could have killed him”, and these are other 
subsidiary questions around that. 
D
Q 
So we have, on the one hand, your impression that she was saying to you that 
Dr Southall had said that there was a possibility of she being responsible.  Yes? 
A Yes. 
Q 
But at no stage did she say that Dr Southall had in fact accused her of murdering this 
child? 
A 
I would have to say that she did not say those words. 
E
Q 
If Mrs M had said to you in terms that Dr Southall had in fact accused her of 
murdering her eldest son, you would have been startled, would you not? 
A 
I would have been. 
Q 
You would have made a note about it? 
A 
She may well have felt that that was said to her.  I was looking at it that he was testing 
F
hypotheses --- 
Q 
That may be. 
A 
-- in a forceful manner. 
Q 
That may be, but just so that we are clear about it, if she had come to you and said, 
“Dr Corfield, Dr Southall has accused me of drugging the boy, stringing him up, letting him 
G
die, calling the ambulance” and that she was responsible for murdering the child, you would 
have noted it, would you not? 
A 
I think I would. 
Q 
But she did not say that, did she? 
A 
No, I recorded she felt accused of killing him. 
H
MR COONAN:  Thank you very much, Dr Corfield. 
T.A.  REED 
Day 2 -  78
 & CO. 

---

A
Re-examined by MR TYSON
Q 
The evidence that we have heard from Mrs M this morning was as my learned friend 
put it to you, that she said that in this interview with Professor Southall, Professor Southall 
had in fact said those things to her, that he had accused her of drugging the boy, stringing him 
up, letting him die and calling the ambulance.  Was there any discussion with you about those 
B
aspects of the death of the eldest boy? 
A 
As I said just now, she did talk about Professor Southall discussing the curtain rail and 
whether it would have taken the weight of him.  So some of those details were there in terms 
of the questions that she was asked, or the things that he might have said, as she related to 
me, anyway. 
Q 
I think you recorded the words that she “felt accused of killing”? 
C
A Yes. 
Q 
And that was it.  She did feel that she had been accused of killing? 
A She 
did. 
THE CHAIRMAN:  Dr Corfield, at this time it is possible that members of the Panel may 
have some questions for you.  Mr McFarlane is a medical member. 
D
Questioned by THE PANEL
MR McFARLANE:  Good afternoon.  Thank you for coming.  I do sometimes work part time 
as a general practitioner.  When you noted that Mrs M felt accused of the suggestion that she 
had killed her eldest child, and you noted it as such, did you take the trouble to explore these 
issues further?   This is quite a surprising thing to come out if you are taking a history from 
E
the patient. 
A 
Yes.  I did ask around that, and she told me the information that topics that had been 
brought up about, maybe, the only way she could have done it would have been to drug him 
first, and the need for the police to investigate this further. 
Q 
Your note is obviously short.  
A Yes. 
F
Q 
I do not particularly want to criticise the brevity of your notes, but would it normally 
have been something that you perhaps would want to expand further? 
A 
I think that that is perhaps true, yes.  As I said, my feeling at that time was that I was 
not certain of what the instructions were to Professor Southall in providing his report, 
because normally there would be certain questions that an expert would be asked to answer.  
So I was not sure how that fitted in with his report, because I had not seen that at that time.  
G
So I think that I was kind of waiting to see what happened through the reports that were 
written.
Q 
I see.  Because in your subsequent report you do not seem to have discussed this 
aspect at all. 
A 
No.  I think I was, I suppose, respecting the position that he was writing the court 
report, and the court report would be produced.  Other experts who had been instructed too, 
H
and I was waiting to see what they would be saying. 
T.A.  REED 
Day 2 -  79
 & CO. 

---

A
Q 
Did you feel that this comment, that Mrs M had come out with perhaps was over-
exaggerated by her and that the brevity of your note and the fact that it has not been put in 
your subsequent report, you were feeling that it was not of such great importance and 
therefore you did not want to unnecessarily draw attention to it? 
A 
I do not think I was thinking like that, no. 
B
MR McFARLANE:  Thank you very much indeed. 
THE CHAIRMAN:  Mr Simanowitz is a lay member. 
MR SIMANOWITZ:  Good afternoon, Dr Corfield.  I just want to clarify a matter of 
ambiguity.  Could you look at the strategy meeting report.  It is at tab O? 
A Yes. 
C
Q 
It is the last page.  There is a statement there. 
“Dr Solomon offered to speak to Professor Southall about the case.” 
And you said, “I didn’t”. 
A Yes. 
D
Q 
Is it that you did not offer or you did not speak to him? 
A 
I cannot recall.  I perhaps myself remember it more that of course as I was the 
clinician involved with the child, I would normally say if any of the experts want to discuss 
with me – that is the way round I remember it, saying that if he wanted to be in touch with 
me. 
E
Q 
But in fact you did not speak to him? 
A 
I did not, no. 
MR SIMANOWITZ:  Thank you. 
THE CHAIRMAN:  Dr Sarkar is a medical member. 
F
DR SARKAR:  Did you know at that time Professor Southall personally? 
A 
No.  I knew of his work but I never met him. 
Q 
And you knew that he was working on this same case? 
A 
I knew that he was instructed to provide an opinion, yes. 
Q 
I know I am repeating what the other doctor asked you already, but in the course of 
G
interviewing a family, when a mother comes up with such a serious matter only the day 
before she has been interview by Professor Southall which caused her great distress, and she 
came out feeling, as you recall it, that she was accused of murdering her son, drugging him, 
etc. etc., and not repeating the point about the brevity of the note, did you at any point 
contemplate asking others involved in the case, like a social worker or the court, permission 
to speak to Professor Southall to clarify if this was the case? 
A 
No, I did not. 
H
T.A.  REED 
Day 2 -  80
 & CO. 

---

A
Q 
It did not cross your mind --- 
A No. 
Q 
--- that this is indeed a very serious matter and perhaps it is fair to say it is not what 
doctors usually do in their work, even if they are instructed by the court? 
A 
Yes, indeed.  Yes.  I did not take it any further at the time, no. 
B
Q 
But it struck you as something unusual? 
A 
It did strike me as something unusual, yes. 
Q 
But you did not pursue the matter any more vigorously than you have told us already? 
A 
I did not. 
THE CHAIRMAN:  Mrs Lloyd is a lay member. 
C
MRS LLOYD:  Good afternoon, Dr Corfield.  Dr Corfield, just for clarification, your notes 
under (ee) seem to be clinical notes you were keeping on the family that you were having 
contact with.  My understanding is that these are confidential notes which form part of the 
family medical or clinical records? 
A Yes. 
D
Q 
And the report that you have prepared, where you are giving your professional 
opinion for another purpose, you have on page 2 actually made reference to the interview that 
Mrs M had with Professor Southall, in that you stated in the paragraph before last that she 
found the interview difficult and disturbing.  I just want some clarification in terms of 
confidentiality.  The kind of detail that you might record in the clinical notes --- 
A Yes. 
E
Q 
--- would necessarily differ from the kind of information you would then be showing 
on a broader basis? 
A 
Yes.  I think one might put it differently.  I think the clinical interviews in this case at 
that time, the family were aware that the information was being shared, and also might be 
used in the preparation of court reports.  But it is true that I think you would still be 
circumspect about what you would put in that report. 
F
THE CHAIRMAN:  I have a question, if I may.  It is going back to this note which is under 
(ee) on page 2 – your handwritten notes there at the end.  It is where you have written, “… 
felt accused of killing [child M1]”. 
A Yes. 
Q 
I am just trying to explore what this might have meant.  I think you said that you 
perhaps cannot recall exactly what was said, but in the way that you write up notes as a 
G
psychiatrist, in doing this would you try and summarise, or put a gloss on the words that the 
patient was using to you?  You have listened to what the patient has said? 
A Yes. 
Q 
Would you be thinking what sort of thing happens in an interview given perhaps by a 
psychiatrist, although Dr Southall is not a psychiatrist, but that kind of interview, would you 
then be transferring those thoughts into how you write up the notes? 
H
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Day 2 -  81
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A
A 
Yes.  I think if something particularly significant is said, you would try to record that 
verbatim.  Also, it is encapsulated the point that you wanted to make overall, so I think that 
the quotes that I put down there encapsulated the idea of Mrs M’s view that she had been 
accused of killing the boy.  So I would say those quotations really, verbatim quotations, fed 
into that conclusion, which was her own conclusion too. 
Q 
Perhaps you will appreciate we are trying to explore the difference --- 
B
A Yes. 
Q 
--- whether there was anything said about actual words. 
A Yes. 
Q 
And how the use of words then makes a person feel.  I just wondered if you could 
remember any more about how she had expressed those feelings? 
C
A 
I think her words would have been, “He accused me of killing the boy,” and I would 
have written, “She felt accused of killing him.” 
Q 
Because you were translating her words into how you would see it as a psychiatrist? 
A 
Yes.  I could have written down her actual words, but I did not on that particular 
point.
D
Q 
Does that boil down to the fact that  you cannot now say exactly what words she 
would have used? 
A 
I think beyond what I put in the quotation marks, I cannot say exactly what words she 
used.
THE CHAIRMAN:  Thank you.  That explanation is very helpful.  It is possible either 
counsel might have further questions arising from the panel’s questions. 
E
Further cross-examined by MR COONAN
Q 
Madam, would you permit me two questions?  (To the witness)  Dr Corfield, a few 
minutes ago, in answer to questions by the Chair of the panel, you said, can I suggest for the 
first time, that her, Mrs M’s, words would have been that Dr Southall accused her of killing 
him? 
F
A Yes. 
Q 
Would have been? 
A Yes. 
Q 
We have to be very careful, do we not, about a witness such as you who is called 
primarily to give evidence as to what was recorded at the time, as you have done, and then 
G
overlaying it, eight years later, with the patina of reconstruction, have we not? 
A Indeed. 
Q 
So to say, as you said a few minutes ago, that Mrs M would have said that is 
speculative at best, is it not? 
A 
I cannot say that she definitely said that, no. 
H
Q 
In other words, you cannot be sure that she said that? 
T.A.  REED 
Day 2 -  82
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A
A 
I cannot be sure she said that. 
Q 
Thank you.  Now, the second matter concerns a couple of matters raised by  
Mrs Lloyd, which I think followed up a line of questions developed by Mr McFarlane by 
reference to the second page of your report, which I think is at 1 ff, to help you.  It is correct, 
as Mr Tyson has drawn our attention to it when he was first questioning you, that on the 
second page in the penultimate paragraph you recorded that Mrs M told you that she had seen 
B
Professor Southall and she had found this interview difficult and disturbing? 
A Yes. 
Q 
There was then some discussion between Mrs Lloyd and yourself about 
confidentiality.  Let me say at once I do not understand the position that you take here.  You 
were being asked to provide a report to give to the judge, were you not? 
A Yes. 
C
Q 
Anything which passes between a party to the proceedings and yourself as an expert is 
potentially relevant to the issue which would be before the court? 
A 
I did not see myself as an expert in providing these reports.  I saw myself as the 
treating clinician providing a professional report on my contact with the family. 
Q 
The point is that you had a dual role here, I think.  You may have been providing 
D
therapeutic care and treatment but you had been instructed by all parties to provide a report 
wearing your expert’s hat? 
A 
It was an update on the work that we were doing because it does not really give an 
opinion as you would do in an expert’s report. 
Q 
Were you being asked at all to deal with the question of Munchausen’s or not? 
A 
I was not. 
E
Q 
But you knew that that was an issue in the case? 
A Yes. 
Q 
And was still a live issue? 
A Well, 
yes. 
F
Q 
Because, if evidence had emerged of Munchausen’s, that would be a highly relevant 
factor to place before the court again? 
A Yes. 
Q 
In other words, the proceedings as a whole were not over, were they? 
A 
No.  I think it was in May when people’s reports were prepared for me. 
G
Q 
The point being that even though the interim care order application was refused at that 
time, that did not mean that the court process was finished, did it? 
A 
It did not. 
Q 
The point I want to explore with you is that if there had been a stark allegation made 
by Mrs M about one of the experts in the case and she had denied it, then you would have 
recorded that, surely? 
H
A 
I agree I could have expanded on it on page 2, but I made a brief comment about it. 
T.A.  REED 
Day 2 -  83
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A
Q You 
did? 
A 
I did make a brief comment about it but obviously Professor Southall’s report was 
being prepared within that timescale and would illustrate his interview with her and his views 
on the case. 
Q 
But there would have been no damage to confidentiality if you had put into this report 
B
for example that Mrs M was accused by Dr Southall of murdering her child “but she has told 
me that this is complete rubbish”, or words to that effect, because that would have assisted 
the forensic process, would it not? 
A 
You said that Mrs M had said that Professor Southall had accused her of killing the 
boy and I think we had agreed that the interpretation was that she had felt accused. 
Q 
The fact that the impression she was giving was that she felt accused was not 
C
something you would feel like putting in the report.  You did not see the need? 
A 
I did not put it in the report. 
Q 
But if she had said in terms that Dr Southall had accused her of killing the child, is 
that something that you would have put into the report? 
A 
I think that would be something that I would have discussed more widely. 
D
Q 
Yes, you would have discussed it more widely with those involved in this forensic 
process, would you not? 
A 
I think I would. 
Q 
And you would have drawn it to the attention of His Honour Judge Tonking in your 
report, would you not? 
A 
I might well have done that 
E
Further re-examined by MR TYSON
Q 
There is a problem here arising out of something that you have told the Chairman, 
which I recorded, and I think everybody else in the room recorded.  You told the Chairman of 
this panel:  “Her words to me would have been he accused me of killing the boy”. 
A Yes. 
F
Q 
My simple question is this.  To the best of your recollection, were those the words that 
she used to you? 
A 
I said they would have been and I think that must imply that no, I cannot say that for 
sure.
Q 
But why do you say they would have been? 
G
A 
Because I wrote down that she felt accused of that, and I was trying to interpret why I 
would have written that down.  My own ideas about that are that it would have been because 
that is what she would have said to me, but I cannot say it absolutely for sure because I 
cannot remember that it was. 
MR TYSON:  Are you saying that as that is what she felt and that would have been because 
she told me that there was an actual accusation? 
H
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Day 2 -  84
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A
MR COONAN:  That is leading. 
MR TYSON:  I am going through your thought processes. 
A 
Yes, it is very difficult.  I wrote down that she felt accused by him. I do believe that to 
be the case.  By that I mean I think, if asked, she would say that is how it came across to her, 
but I cannot remember her saying those words. 
B
MR TYSON:  I do not think I can take it any further.  Thank you very much. 
THE CHAIRMAN:  Thank you very much, Dr Corfield.  That completes your evidence.  You 
can stand down now.  You are no longer on oath.  Thank you for helping us. 
(The witness withdrew)
C
MR TYSON:  There is one bit of housekeeping before I would ask you to adjourn until 9.30 
tomorrow for part two, a small lecture on medical records.  The first witness was shown a 
document arising out of questions by the panel of the police investigation.  I took you to a 
document from the West Mercia Police.  I said I would introduce it and I do now introduce 
that document.  It was brought in from Mrs Lloyd’s questions.  It goes into the bundle under 
C1.  I just ask you to insert it under C1 in the existing tab jj. 
D
THE CHAIRMAN:  Under the circumstances, it does not need an additional number. 
MR TYSON:  Please insert it at the back of C1 just before the figure 2. 
(Document marked and circulated for C2)
THE CHAIRMAN:  Are you able to tell us if you will continue with your opening or will you 
E
be calling witnesses tomorrow? 
MR TYSON:  I will go back to the proper order and continue with my opening, which will be 
on the second part of the heads of charge relating to the SC5s and medical records, and then, 
just to assist the panel, I will be calling the solicitor involved in the end aspect of the case.  
You will be hearing from the solicitor in the afternoon.  Then I will be calling Professor 
David who will be giving wide-ranging expert evidence.  Before you actually hear him, I will 
F
be inviting the panel to take some reading time to read the evidence that he will give, because 
the more pre-reading you can do, the less time that we will actually have to spend in open 
session going through it.  You have his reports in C3, but some time after my opening and 
before I call him, I will ask the panel to absorb such bits of C3 that they want, 
THE CHAIRMAN:  Thank you.  That helps us with what is likely to happen in the next day 
or so. 
G
(The Panel adjourned until 9.30 a.m. on Wednesday, 15 November 2006)
H
T.A.  REED 
Day 2 -  85
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GENERAL MEDICAL COUNCIL
FITNESS TO PRACTISE PANEL (PROFESSIONAL CONDUCT)
Wednesday 15 November 2006
44 Hallam Street, London, W1W 6JJ
Chairman:   
  
Dr Jacqueline Mitton 
Panel Members:
Mrs Leora Lloyd 
Mr Alexander McFarlane 
Dr Sameer Sarkar 
Mr Arnold Simanowitz 
Legal Assessor:   
Mr Robin Hay 
CASE OF: 
SOUTHALL, David Patrick 
(DAY THREE)
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 JOLLIFE 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
MR TYSON opening (continued) 
 
 
  
1 

---

A
MR TYSON:  There are two matters of housekeeping before I begin, Madam. 
First, the gentleman the back is my expert, Professor David.  I have spoken to my learned 
friend and he has no objection to his being here at the moment.  I need to ask the panel’s 
agreement for that. 
B
THE CHAIRMAN:  No member of the panel objects. 
MR TYSON:  Secondly, I am going to burden you now with three more lever arch files, 
which are the special cases files relating to the children, the subject of the heads of charge, 
rather than doing it piecemeal in the course of my opening.  The first one relates to Patients A 
and B.  That will be C5.  (File C5 marked and circulated)
C
The next one relates to Patient D.  That will be C6.  (File C6 marked and circulated)
The last one relates to Patient H, and that will be C7. (File C7 marked and circulated)
THE CHAIRMAN:  If the panel has difficulties seeing the witnesses, when you have 
concluded your opening, we will deal with that. 
D
MR TYSON:  Madam, I now come to the second main section of the heads of charge.  These 
relate to the inappropriate retention by Dr Southall or at his instigation of certain original – 
and that is the point that is key – medical records of patients that should have been in the 
hospital’s medical records but were not.  This happened both at the Royal Brompton Hospital 
where Dr Southall, as he then was, worked until 1992 and then again at the North 
Staffordshire Hospital where he worked after his appointment as a professor of paediatrics at 
the local university first from 1992. 
E
It is the complainant’s case that for many of Dr Southall’s patients, both at the Royal 
Brompton and at the North Staffordshire, Professor Southall created a parallel series of 
medical records.  These were for patients he saw in his capacity as a clinician and in his 
capacity as a clinician and expert witness because there were a number of cases here where 
he saw the child concerned initially as a patient, and then went on to produce reports for 
subsequent child protection issues when those reached the court system. 
F
Madam, these files were called special cases files or S/C files.  Recent investigation by the 
claimants’ solicitors have revealed that it appears that Dr Southall and his team have several 
thousand of these parallel files stretching back to the 1980s.  Not only were these files 
parallel to the hospital filing system but also, we submit, inaccessible to others involved in 
the medical care of the child, especially in the future.  As we will seek to show, the existence 
of these files was not known about by other clinicians, to the administration at the Royal 
G
Brompton Hospital and also not known about by patients. 
You will be relieved to hear that we will not be dealing with the thousands of S/C files in 
existence that have been created but only the four that were created in respect of the 
complainants’ case here, namely Child A, Child B, Child D and Child H. 
The heads of charge deal with two separate aspect of these S/C files.  The first aspect is dealt 
H
with in heads of charge 10 to 12.  These deal with the situation whereby original medical 
T.A.  REED 
Day 3 -  1
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A
records, which should have been in the children’s hospital medical records, were found in the 
S/C files but not elsewhere.  The only way that you could find an original medical record was 
to find it in the S/C file, the existence of which, the file itself, was not known outside the 
department.  Non-exclusive examples of original medical records being found in the relevant 
S/C file are to be found in Appendix 1 of the heads of charge, which I will come to in more 
detail in a minute. 
B
The second category of heads of charge under this head, deals with heads of charge 13 and 
14, which, as you see, state that:
“You treated both Child A and Child H at the Royal Brompton Hospital, and there 
created an ‘S/C’ file for each child 
(b) Each such ‘S/C’ file contained original Royal Brompton Hospital medical 
C
records.
(c)  You took, or caused to be taken, the ‘S/C’ files relating to both Child A and 
Child H away from the Royal Brompton Hospital and to the North Staffordshire 
Hospital.” 
We assert that that was not in the best interests of the child concerned, inappropriate and an 
D
abuse of professional position. 
The gravamen of these heads is that access to these parallel records by subsequent Royal 
Brompton clinicians was made, we submit, even more difficult, if not impossible, as the S/C 
files relating to these children and containing original medical records not available 
elsewhere were physically taken by or on behalf of Professor Southall away from the Royal 
Brompton Hospital to North Staffs on his appointment there.  The basis upon which they 
E
were so taken and why they were so taken is a matter which we will have to ask about and 
deal with in the course of the evidence in this case. 
I will come back to the detail of Appendix 1 in due course, but at the moment now I need to 
give you a short lecture on medical records in general and the creation of special cases files in 
particular.  Here the panel will have the assistance of Professor David, the gentleman sitting 
at the back, who is the distinguished Professor of Child Health and Paediatrics at the 
F
University of Manchester.  He has relied on his long experience of paediatric records and his 
labours for the benefit of his report in this case to be able to give some guidance on the issue. 
He does not purport to be an expert on the subject of medical records per se but he will be 
speaking to you on the basis of his experience and the diligence that has done in researching 
the matter of medical records for your benefit, which has enabled him, we submit, to make 
important points on the subject of medical records in general and of paediatric medical 
records in particular. 
G
Madam, he has produced two relevant reports.  The first deals with medical reports in general 
and that you will find in your C3 at section 7 under the first tab at (a).  Before I go into this in 
any detail I would like you first to note, first, that on page 1 you will see the date of this 
report, which is July 2005, at the bottom, and second, three pages in you will see a heading 
saying:
H
“Matters relating to medical records”,  
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A
which appears to start at page 221 and paragraph 342.  You will see that is about two pages 
in.  I need thus to explain the provenance, insofar as I can, of this report. 
In July 2005 Professor David produced a number of reports for the complainant mothers that 
had virtually identical sections dealing with the issues common to all the cases, and then a 
section at the end dealing with the particular issues raised by a particular complainant.  Those 
B
reports that he prepared in July 2005 concerned matters with which this Panel is not at all 
concerned, but it is here concerned with medical records and the section dealing with medical 
records and common to all of his reports has been abstracted from one of the reports (here it 
happened to be the report on Child A) and it is used for the Panel’s guidance and assistance 
as a generic guide to medical records.  Hence, the odd page and paragraph numbering that 
you will see. 
C
Madam, at this point can I say I am grateful to my learned friend for his permitting me to 
introduce this report at this stage because it will help cut matters down in the course of these 
hearings.
Can I take you, please, to the report, and can I take you to paragraph 344, because the 
Professor starts by asking and then answering ten questions relating to the kind of medical 
records raised in the cases of these complainants.  He sets out the ten questions at paragraph 
D
344 at page 222, and you can see that the questions he has asked are: 
“344.1  What is the important of a patient’s hospital medical records? 
344.2 When a paediatrician, uninvolved in the clinical care of the child, is acting as 
an expert, how and where should documents relating to the case be filed and 
stored? 
E
344.3 When a paediatrician, involved in the clinical care of the child, is acting as a 
expert, how and where should documents relating to the case be filed and 
stored? 
344.4 Is it acceptable for certain original medical records to be kept apart from the 
main hospital clinical records file for a patient? 
F
344.5 It appears that in some case, Professor Southall set up and kept special files of 
his own, files which contained extensive documentation relating to a particular 
case.  These files have been referred to as ‘SC’ files.  I understand that ‘SC’ is 
an abbreviation for ‘Special Case’.  The ultimate question is whether or not it is 
appropriate for a paediatrician to create and store a separate file of documents 
relating to a case. 
G
344.6 Is it appropriate for a paediatrician to receive an original document concerning 
a child but cause it to be retained anywhere other than the child’s medical 
records.
344.7 Is it appropriate for a paediatrician to make (or cause to be made) or obtain 
photocopies of a child’s medical records? 
H
T.A.  REED 
Day 3 -  3
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A
344.8 Is it appropriate for a paediatrician to make (or cause to be made) or obtain 
photocopies of a child’s medical records when the document is specifically 
marked with the instruction that it should not be copied? 
344.9 Is it appropriate for a paediatrician to remove (or cause to be removed) an 
original document from a child’s medical records and replace (or cause to be 
replaced) that document with a photocopy of the original?  Further, is it 
B
appropriate for a paediatrician to place (or cause to be placed) elsewhere an 
original document which should be in the child’s medical records and provide 
(or cause to be provided) a photocopy in such medical records.” 
Then we come to question 10, which is the key question upon which appendix 1 is based: 
344.10 Is it appropriate for a paediatrician to remove (or cause to be removed) an 
C
original document from a child’s medical records and placed it (or cause it to 
be placed) instead in an alternative file that is kept and stored separately from 
the child’s medical records?  Further, is it appropriate to place (or cause to be 
placed) in such alternative file an original document that should be in the 
child’s medical records?” 
Question 9 deals with the issue of having an original document but replacing it with a 
D
photocopy.  Question 10 is having an original document and merely placing it in, for 
instance, the SC file and nowhere else.  It is Question 10 which is the gravamen of the heads 
of charge, or in relation to the answers to Question 10 are the appendix 1 charges in this case. 
Madam, the Professor goes on to answer his own questions and he answers question 1 about 
the important of medical records at page 227 at paragraph 355.  He says: 
E
“What is the importance of hospital medical records? 
In the context of this report, a record is anything which contains information (in any 
media) …”, 
and pausing there, at the moment that includes computer data, 
F
“which has been created or gathered in connection with a child’s illness or referral to 
hospital.” 
You are going to have the opportunity to look at this report in more detail later.  I just merely 
point out that paragraph 356 sets out all the kind of documents that are included in the words 
“medical records.”  At paragraph 357 he says that part of the essential purposes of hospital 
medical records is that: 
G
“357.1  they contain a factual record of information pertaining to the medical     
problems and medical treatment of a patient. 
357.2 they serve as a means of communication between all health professionals 
involved in the care of a patient while that patient is in hospital.” 
H
Here is the important sentence: 
T.A.  REED 
Day 3 -  4
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A
“They may contain information of vital importance to those caring for the patient in 
the future eg information about an operation, an investigation, or a drug allergy.” 
Then over the page at 357.3: 
“they provide information about past illness, investigations and treatment, information 
B
that may have an important bearing on subsequent illness episodes or follow-up.” 
Again, we would say that point 3 is an important point.  Then it is pointed out that they are 
legal documents which are an essential resource should the patient and/or her medical care be 
the subject to any subsequent complaint or litigation.  At point 5 he says they are required for 
questions of audit and at point 6 they may be needed for medical reports. 
C
Then he sets out a Department of Health Circular which summarises the importance of 
medical records and I need to quote to you a bit from this Circular.   
“Medical records are a valuable resource because of the information they contain.  
That information is only usable if it is correctly recorded in the first place, is regularly 
up-dated, and is easily accessible when it is needed.” 
D
Those are the magic words in that paragraph. 
“Information is essential to the delivery of high quality evidence-based health care on 
a day-to-day basis and an effective records management service ensures that such 
information is properly managed and is available.” 
Then it sets out why they are important in various bullet points and you may think the first 
E
bullet point is important: 
“to support patient care and continuity of care” 
Over the page the second bullet point is: 
“to support evidence based clinical practice.” 
F
You need the records in order to provide the evidence.  The fourth bullet point: 
“to meet legal requirements, including requests from patients under access to health 
records legislation.” 
The question of access by patients is important, in our submission, for two reasons, madam.  
G
Firstly, parents may well want the medical records to which they are entitled as parents in 
order to obtain a second opinion from another clinician.  Secondly, parents may seek access 
to their children’s medical records because they are unhappy with the quality of care that they 
have received and need advice from their lawyers as to whether there is a potential case 
against the institution.  Both those patients’ rights are important. 
I need not take you to the next two subparagraphs.  Then there is a quote at paragraph 361 
H
from one of the appendices to the Health Circular.  Paragraph 4.1 quoted there I have read out 
T.A.  REED 
Day 3 -  5
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A
to you, because that has already been quoted in paragraph 358 earlier.  At the fourth line 
down you will see the word “accessible.”  Paragraph 4.2 sets out that: 
“Good record keeping ensures that …”, 
and can I take you to the third bullet point under that: 
B
“those coming after you can see what has been done, or not done, and why.” 
The next bullet point: 
“any decisions made can be justified or reconsidered at a later date.” 
Then over the page, under paragraph 4.4 of this appendix to the Circular, it is said: 
C
“It is therefore vital that you always …”, 
and the first bullet point: 
“record any important and relevant information, making sure that it is complete.” 
D
Then the third bullet point is again, we submit, important in this case: 
“put it where it can be found when needed.” 
Then over the page, at the end of Professor David answering his first question, he makes what 
we say is an important point at paragraph 363, in summary, where he says: 
E
“A patient’s hospital medical records are regarded as sacrosanct and inviolable ie 
must always be kept intact as a very high priority.” 
Then question 2 is how should an expert store the documents?  That is an intriguing section, 
but it is not one that we have to deal with in terms of the heads of charge in this case. 
So we go over to page 233, which is “How should an expert/treating paediatrician store 
F
documents?”  You may wish to add this as a note, that this relates to A, B, D and H.  He sets 
out the question at 368: 
 
“When a paediatrician, involved in the clinical care of the child, is acting as an expert, 
how and where should documents relating to the case be filed and stored?” 
At 370 the Professor says: 
G
 
“It seems to me that the answer to the question depends in part upon whether the 
document is regarded as part of the patient’s medical records or is regarded as part of 
the material that is generated between the expert and instructing solicitor.” 
If I can take you over to paragraph 374, about medical and clinical records.  It says: 
H
T.A.  REED 
Day 3 -  6
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A
 
“Any clinical medical or nursing records (whether handwritten or typed), 
investigation results/reports, charts [et cetera] or clinical correspondence” – and 
I would ask you to note that reference to clinical correspondence – “([i.e] letters to 
and from [the] GP or other consultants, discharge summaries) would universally be 
regarded as being part of the patient medical records, and ….. should be kept in the 
patient’s medical …... file.” 
B
Then he goes on to the next question, which is question 4 at page 239, paragraph 389.  So he 
repeats his fourth question that he asked himself: 
 
“Is it acceptable for certain medical records to be kept apart from the main hospital 
clinical records ….. for a patient?” 
He says: 
C
 
“In general this is not an issue, because in many if not most hospital units the medical 
records for in-patients are kept in a relatively inaccessible (to parents) area such as the 
ward manager’s office.  But in some units, in-patient medical records are left by the 
bedside, or at the end of the bed, freely accessible [to] parents.  This might be done in 
a spirit of partnership with parents, and is somewhat akin to the general use of the 
parent-held ‘red book’ containing all basic information about a young infant.  It 
D
requires little imagination to appreciate that this open system does not lend itself to 
clinical situations when a full sharing of clinical thinking with parents could be 
counter productive.  Such a situation could be emerging concerns about child abuse.” 
So what the Professor is there saying is that when the child is an in-patient – and can 
I underline that – when the child is an in-patient there may well be grounds for saying that 
there should be a slight separation of the files where there are emerging concerns about child 
E
abuse, but thereafter, i.e. if the child is dealt with as an out-patient, or afterwards these 
concerns about having a temporary separation of the files no longer apply, and you may wish 
to make a note there that Professor David deals with this aspect at paragraphs 93-96 on his 
second report, which I will come to in a moment. 
Then he makes the point that I have just been over-making over the page at paragraph 391, 
where he says: 
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“Thus it is that in certain child protection cases, and in certain hospital units, while a 
patient is in hospital, a separate set of records is created, records that are accessible 
only to health professionals and not to the parents or carers.  I have visited units 
where such a policy has been in operation.  The key point is that in such cases 
members of staff ([i.e.] doctors and nurses) would always know that separate records 
were being kept…” 
G
Madam, I simply do not know whether in either the Royal Brompton or in North 
Staffordshire Hospital they had such a policy of, as it were, bedside notes, if I can put it that 
way, but all Professor David is saying here is that if there is such a policy of having bedside 
notes available to parents, there are certain circumstances where there are emerging concerns 
of child protection where it is permissible in those circumstances to have separate notes, but 
thereafter of course they should be merged back in when the child ceases to be an in-patient, 
H
because thereafter the parents do not have access to the bedside notes. 
T.A.  REED 
Day 3 -  7
 & CO. 

---

A
Then we come to question 5, which is dealt with at paragraph 397, page 243, “Separate case 
files”.  He asks the question: 
 
“It appears that in some of the cases under present consideration, Professor Southall 
set up and kept special [case] files of his own, files which contained extensive 
documentation relating to a particular case.  These files have been referred to as ‘SC’ 
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files.  I understand that ‘SC’ is an abbreviation of ‘Special Case’.  If it is true that 
special separate files were set up, the ultimate question is whether or not it is 
appropriate for a paediatrician to create and store a separate file of documents relating 
to a case.” 
At 398 Professor David says: 
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“The exact origin and purpose of these SC files is unclear”. 
Pausing there, at the time that Professor David wrote this first report we had not heard what 
Professor Southall had to say about them, but in his subsequent report, which I will come to, 
Dr Southall had provided an explanation, which is dealt with in the subsequent report.  It 
says:
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“The exact origin and purpose of these SC files is unclear, but I note that the North 
Staffordshire Hospital cardiorespiratory monitoring activity charts has a space for the 
‘Special Case number’ at the top of each page, immediately below the hospital 
number.” 
Madam, just so that you can understand what Professor David is talking about there, if one 
looks, for instance, at the special case file relating to Child H, which is at C7 -pausing there 
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for a moment, one can see the simple size of these parallel files; this is the parallel file on one 
patient (Indicated), Patient H – and at page 21 one can see a cardiorespiratory monitoring 
activity chart, and one can see on the top there is a hospital number and then there is a special 
case number relating to that particular child, and this is, as it were, the special case file 
relating to that child.  I will come to this in more detail in a moment, but part of Dr Southall’s 
research was to have a child sleeping overnight in a hospital in some sort of special jacket to 
which numerous probes and monitors were attached, which recorded a number of matters 
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relating to the child, and at the same time someone in parallel was writing down what was 
happening to the child itself, and that is what a cardiorespiratory monitoring activity chart is.  
I will explain those in more detail, but I just wanted you to see what one was. 
Now perhaps we can re-read together paragraph 398 of Professor David’s report, where he 
says:
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“The exact origin and purpose of these SC files is unclear, but I note that the North 
Staffordshire Hospital cardiorespiratory monitoring activity charts has a space for the 
‘Special Case number’ at the top of each page, immediately below the hospital 
number.” 
He goes on: 
H
T.A.  REED 
Day 3 -  8
 & CO. 

---

A
 
“Plainly the extent of the materials retained in the cases presently under 
[consideration is] quite significant (….. more than one or two items), but I doubt that 
the extent of the papers affects the principle. 
 
Much hinges on the purpose of keeping these ‘SC’ files.  If they were to provide a fail 
safe, in case the main hospital medical records became lost (unsatisfactory as it is, this 
can and does happen), then whilst I have some sympathy with the frustration that 
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results from the loss of records, it is plainly quite impractical (and a misuse of 
resources) for a paediatrician to make and keep a full back up copy set of every 
patient’s medical records just in case one file goes [away]. 
If the special case files were for the purposes of research, then other considerations 
come into play, such as whether research ethics approval had been obtained and 
whether or not informed consent for the research had been obtained. 
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If the special case files were kept purely for administrative convenience, for example 
to assist with the preparation of reports when working in one’s office or at home, then 
subject to two provisions in the next paragraph, it is hard to see what criticisms could 
be made. 
 
To conclude, I am not aware of any regulation prior to 2000 that disallowed 
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paediatricians [from] keeping separate photocopies of selected medical records.  
Whilst I can fully sympathise with families who may have felt that ‘secret’ records 
were being kept ‘behind their back’, in the time period under consideration it is 
unclear to me on what basis one could seriously criticise the practise, provided: 
that the files contained only carbon copies or photocopies and did not ever 
contain any original medical records for a patient; 
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that the purpose of creating these S/C files was not in any way connected with 
research (unless there was consent in each case combined with research ethics 
approval)”.
Madam, Professor David slightly modified those views when he was able to see what 
Professor Southall’s explanation for them was, because Professor Southall’s explanation did 
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not wholly cover the three factors set out which Professor David considered: firstly, are they 
kept as a failsafe?  Are they kept for research?  Are they kept for administrative convenience? 
Question 6 was dealt with under “retaining a document that is not placed in the records”: 
“Is it appropriate for a paediatrician to receive an original document concerning a 
child but to cause it to be retained anywhere other than the child’s medical records?” 
G
This is an important answer: 
“It follows from what has been said thus far that if the document is an item that 
should be filed in a child’s medical records |(such as, for example, a laboratory report, 
or clinical correspondence) then it would be wrong to do anything that would prevent 
that item from being filed in the child’s medical records.  Exceptions to this would 
H
T.A.  REED 
Day 3 -  9
 & CO. 

---

A
include correspondence concerning legal matters and child protection case conference 
minutes”. 
At question 7 he asks the question: 
“Is it appropriate for a paediatrician to make (or cause to be made) or obtain 
photocopies of a child’s medical records?” 
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Professor David says, 
“The answer is that it depends upon the purpose and whether or not that purpose is 
legitimate and justifiable”. 
Then he deals with question 8, which I need not trouble you with as it is not a matter that 
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impacts directly on these heads of charge.  Then he deals with question 9: 
“Is it appropriate for a paediatrician to remove (or cause to be removed) an original 
document from a child’s medical records and replace (or cause to be replaced) that 
document with a photocopy of the original?  Further, is it appropriate for a 
paediatrician to place (or cause to be placed) elsewhere an original document that 
should be in a child’s medical records and provide (or cause to be provided) a 
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photocopy in such medical records?” 
At this point Professor David starts getting stern about the integrity of medical records.  At 
412 he says, 
“I cannot envisage a legitimate reason for doing such a thing.  I am uncertain about 
the ownership of medical records, and whether they are the property of the hospital or 
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the Secretary of State, but a patient’s clinical records are certainly not the property of 
any of the healthcare professionals even if they have contributed to the records; e.g. 
by writing handwritten entries or dictating letters of summaries. 
Although I cannot think of any formal guidance or regulations that concern this 
matter, one would regard removal of one or more original items from a patient’s 
medical records as a form of tampering with the records, and this would plainly be 
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quite unacceptable.  The same comments would apply to failing to place an original 
item into a child’s medical records”. 
He is saying that in the context of being asked, “Can you take an original out and replace it 
with a photocopy?”
Question 10, which is the key issue with which we are concerned in Appendix 1, is taking out 
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an original or failing to place an original in the medical records with no question of any 
photocopy being placed elsewhere: 
“Is it appropriate for a paediatrician to remove (or cause to be removed) an original 
document from a child’s medical records and place it (or cause it to be placed) instead 
in an alternative file that is kept and stored separately from the child’s medical 
records?” 
H
T.A.  REED 
Day 3 -  10
 & CO. 

---

A
By “alternative file” in the context of this case we are referring to the SC file.  The question 
continues,
“Further, is it appropriate to place (or cause to be placed) in such alternative file an 
original document that should be in a child’s medical records?” 
You can see two situations envisaged there.  One is that the original is removed and placed in 
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the SC file; secondly, an original never gets into the SC file in the first place; it is merely 
placed in the SC file and never gets into the original medical records.  What Professor David 
says about that is this, at paragraph 415: 
“It is hard to see how one could justify removing an original item from a child’s 
medical records unless that item had been placed there incorrectly, for example a 
laboratory report that had been misfiled and related to another patient.  Removal of 
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original items from a child’s medical records would be regarded as a form of 
tampering with the medical records and would be quite unacceptable.  Once an item 
had been removed, it would cease to be accessible to others involved in the care of a 
child.  Failing to place (or causing such a failure) an original item in the medical 
records would be no different in its inappropriateness, its seriousness, and its effects 
from removing (or causing the removal of) an original item from the medical records. 
D
The issue that causes the problem is the removal of the item from (or the failure to 
place it in) the medical records.  The fact that the item may be located safely 
elsewhere would not excuse the tampering with a child’s medical records unless there 
was a note to that effect in the medical records or unless the staff (e.g. doctors and 
nurses) looking after the child were aware of the existence and location of a separate 
section of records”. 
E
Again, that largely applies to the in-patient situation.  Professor David will give evidence 
about the potential risks that occur if an individual item is not contained in the appropriate 
medical records.  I anticipate that he may well point out that, whilst it may appear an 
innocuous document that is only to be found in an SC file and not elsewhere -- for instance, 
in this case we have an MRI scan for one of the patients that is not there -- the consequences 
of that when subsequent clinicians or indeed legal people look at the disclosed medical 
records which do not include the SC files, can provide an entirely unacceptable risk to 
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patients or, indeed, to patients’ parents. 
There is a common knowledge – it is particularly acute to some of the people in this room – 
that in the case of Sally Clark, the lady solicitor who was convicted of murdering her two 
children, the main ground upon which she was ultimately released after two years in prison 
was that a medical investigation report was subsequently found which was not in the child’s 
original medical records.  That is the element of risk and the importance in this case of having 
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original medical records, not elsewhere in this parallel and inaccessible series of documents 
called the “SC” files. 
Professor Southall has given two brief and one major explanation as to why he holds these 
parallel files.  These explanations of Professor Southall are at C2, Section 6.  Before we go 
into the wording of those, can I ask you to replace a page which you have in Section 6, under 
Tab 5, which is the first page under 6?  It starts with a document headed, “Hempsons”, page 8 
H
at the top.  Can I ask you all to remove that page 8 and it will be replaced with another page 
T.A.  REED 
Day 3 -  11
 & CO. 

---

A
8?  Perhaps all the old page 8s can be picked up at the same time and destroyed.  (Document 
handed)
It has been a considerable mystery to the complainants, and indeed to the complainants’ 
advisers, as to precisely what are these SC files and what the purpose of them is.  In the 
course of the extensive material, original material if I can put it that way, in this case, there 
have been two documents for which Professor Southall has provided or sought to provide an 
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explanation and then there has been a major document which I will come to in a minute.  Can 
I ask you to go to Section 6 at Tab a?  First, can I ask you to delete in pencil the words “LC” 
which should be replaced by “A”.  So we are dealing with child A in Section 6.  The letter at 
C6 is a letter dated 15 August 1995, and it relates to a child who we know as Child A.  It is a 
letter from Professor Southall when at North Staffordshire to the Director of Administration 
at his old hospital.  You will hear evidence from that gentleman himself, Mr Chapman, who 
is going to give evidence, that he, the Director of Administration, knew nothing about S/C 
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files until this series of correspondence arose.  Professor Southall says, under paragraph 1,
“We always kept our own medical records for all the special cases that we dealt with 
at the Brompton Hospital.  I have arranged for these to be photocopied and enclosed 
with this letter.  However, as far as hospital notes are concerned, I quite agree with 
you that there are no hospital notes missing between ---  ” 
D
– those dates.  I need not worry about that.  This is the first admission, as far as the Brompton 
is concerned, and I hope I am not wrong about this, when the Brompton Hospital heard about 
these special cases records. 
MR COONAN:  I am sorry to interrupt my learned friend.  It may be the first intimation 
Mr Chapman had rather than the Brompton Hospital.  One has to be accurate about that. 
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MR TYSON:  I readily accept that.  This is the first indication that the Director of 
Administration and thus the person ultimately responsible for the medical records was aware 
of that there were separate parallel medical records being held on the children at the 
Brompton. 
Pausing there a moment, of course – and I make the point and it is part of the heads of charge 
– these parallel medical records, these S/C files, relating to Brompton children were taken by 
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Professor Southall up to North Staffordshire where they were never patients. 
Then there is a subsequent letter under tab (b) of section 6 where a further explanation was 
given by Professor Southall to the Deputy Business Manager at his own hospital. This is a 
letter of 16 April 1999.  It is re Patient D.  It says:
“In no way was [Patient D] subject to any form of research in my department.  
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I enclose his special case file so that you can look through it and decide how you 
describe the various contents of this.  My view is that they are part of social services 
and other hospital records rather than being directly related to his admission to the 
North Staffordshire Hospital under my care as a consultant paediatrician.” 
Again, this is an explanation of what these S/C files are and what they are for, but I have to 
say it is not an explanation that the complainants understood. 
H
T.A.  REED 
Day 3 -  12
 & CO. 

---

A
In due course, and this is the document that you have at 6(c), on instructions, Dr Southall’s 
solicitors, Messrs Hempsons, burst into print between pages 8 and 19 to give an explanation 
as to what these special cases files are and how they came into being.  I need not trouble you 
with the detail of this letter but you will have ample opportunity to read it at your leisure in a 
moment, and I am going to ask you to read all the reports at some time.   
Can I say in brief what I understand Dr Southall to be saying?  He indicates in this long 
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explanation that these parallel files have two separate purposes.  Firstly, and originally, they 
were to record multi-channel physiological data that he was obtaining on children non-
invasively on a research basis – that is what it says – to study ---  
I see shakings of the head.  The first main paragraph on page 9 of section 6 (c) states:
“Professor Southall first started using Special Case (SC) files in about October 1980.
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At that time he was working as a Senior Lecturer in Paediatrics at the Cardio-Thoracic 
Institute at the Royal Brompton Hospital.  He was involved in clinical research 
concerning the causes of what had been termed Apparent Life Threatening Events 
(ALTE) during infancy and early childhood. He was particularly interested in 
possible mechanisms for Sudden Infant Death Syndrome (SIDS).  His team developed 
long-term tape recording of physiological signals from non-invasive sensors 
measuring ECG --- ”  
D
For the benefit of the lay members of the panel, this is electrocardiogram which checks heart 
rates.
“ --- oxygen saturations, expired carbon dioxide, EEG --- ”  
That is an electro encephalograph which measures brain waves. 
E
“ --- and breathing movements.  The equipment used could be attached without 
discomfort for time periods long enough to capture any apparent life threatening 
events occurring in the baby/child during the period of the recordings.  At the 
conclusion of a period of monitoring the recordings were analysed for any 
abnormality and, if abnormalities were identified, Professor Southall and his team 
were able to advise the parents of their child’s problem and implement appropriate 
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treatment. 
 
As the team became adept at understanding and diagnosing --- ” 
This is clearly showing a research study, in my submission  
“ --- the causes of ALTE, infants and young children from all over the UK and from 
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abroad were referred in the hope that the team would be able to identify the causes of 
ALTE and ways of treating them, including the use of home oxygen monitoring and 
the training of parents in basic resuscitation.  The physiological recording systems and 
home monitoring equipment developed by the team was unique at the time and was 
used for clinical investigation and management.” 
H
T.A.  REED 
Day 3 -  13
 & CO. 

---

A
As I was saying, initially these S/C files were used to record data for study and treating 
ALTEs and the study, to use the word, was also connected with looking at possible 
mechanisms for SIDS (sudden infant death syndrome).  
Dr Southall, as I think I have read, developed equipment to capture this physiological data on 
a child, as I think I have also said.  It involves the child wearing a special type of jacket 
which had all these leads coming from it so that what was happening to a child’s heart rate, a 
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child’s breathing, a child’s brain waves and the like could be observed if and when a child 
was suffering from an apparent life-threatening event (at the time, for instance, of an apnoea 
or the like) and if a child had stopped breathing.
As a result, Dr Southall had tape recorded all these matters over a period of 8 to 12 hours, and 
he analysed and produced documents such as, if we look at C5 relating to Child A, the results 
of the analysis.  I anticipate that we will see that if we look at page 147.  One would see that 
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this is in relation to Child A as an example, and it says: 
“Report on 8-hour recording of ECG, breathing movements and oxygen saturation”.  You see 
the date of that tape and you see the SC or special cases number in the middle of the page, 
one-third of the way up. You will see the reason for the recording:  “Episodes of pallor and 
drowsiness”.  Then you will see the findings of the recordings.  The actual recordings are 
down the left-hand side.  Then the breathing pattern, it is said for instance in this case, is 
“Normal during episodes of pallor”.  We see that the date of the report is 6 July by Dr 
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Southall and that copies were to be taken for the department’s patient’s notes, the patient’s 
Brompton Hospital folder and the accounting file.  As I understand it, the department’s 
patient’s notes was the SC file. 
In parallel with this reporting or monitoring of the equipment attached to the child, a nurse or 
parent would compile something called a log of infant activity.  While the monitors where 
whirring, as it were, a parent or nurse would record what was actually happening to the child 
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at the time.  Here again, looking at the same file as we were just now and moving on to page 
153, one can see, though it is not completed here, on the top right hand corner, the special 
case number relating to this child.  One can see that this is headed “Log of infant activity – 
nursing-medical intervention” in relation to Child A and what was happening to the child at 
any given time during the running of the tape.  For instance, if we look at the tape counter at 
170, about two-thirds of the way down, an incident took place at 19.54.  It is there recorded 
that the child was drowsy, pale, floppy with small pupils, for instance.  That would be, as 
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I understand it, the process of the study that was going on at the Royal Brompton Hospital at 
the time and that would be compared with what was happening on the monitoring at any 
given time. 
According to Professor Southall, the compilation of this activity chart that we have just been 
looking at was over and above the ordinary nursing notes or Cardex. 
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Later on, in the course of his work in this area, it became apparent to Dr Southall that some 
parents were inducing or fabricating symptoms of ALTEs or apparent life-threatening events, 
in their own children, and he considered that there were considerable advantages in using his 
hospital monitoring to investigate this possible source of an ALTE.  So children came to be 
admitted for overnight monitoring initially at the Brompton to seek to establish both natural 
and unnatural causes of ALTEs. 
H
T.A.  REED 
Day 3 -  14
 & CO. 

---

A
Thus we come to the situation of the two reasons for having, according to Dr Southall, these 
special cases files:  firstly, to keep documentation relating to the specialised monitoring of 
children that he was undertaking; and, secondly, to store confidential documents relating to 
child protection issues.  These are the two grounds that are set out in C2, tab 6 at 6 (c) at page 
12 at the bottom of the page. 
It states:
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“Thus, Professor Southall used Special Casers files in two situations: 
1. To keep documentation relating to the specialised monitoring of children that he was 
undertaking.  In our submission these documents were not part of the usual medical 
records of the patient and it was entirely proper for them to be kept separately. 
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2. To store confidential documents relating to child protection issues.” 
Professor David broadly accepts reason 1, subject to a number of heavy provisos.   I will deal 
with Professor David on these files before we break.  Professor David broadly accepts the 
reason why, subject to a number of provisos.  The first proviso is that nothing was recorded 
in the activity logs and the like that should have been in the main hospital records, and 
particularly in the main hospital nursing records.  As you see, the nurse was being asked to 
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keep, as it were, two nursing files at the same time, the ordinary nursing cardex and this 
additional activity log on what was happening to the child at any particular time.   
Secondly, he accepts that it was appropriate to keep these files separate at a time when the 
child was in the hospital being monitored, or shortly thereafter if the child was continuing to 
be monitored on a home monitor where access might be required to these files in particular 
circumstances, but not thereafter.  There might be a time when it was appropriate to keep 
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these materials separate whilst there was an in-patient but not when there was no other reason 
for doing it. 
As far as the second matter is concerned, to store confidential documents relating to child 
protection, again you will hear from Professor David that he does not accept reason 2 in its 
entirety, and in particular where there is clinical correspondence contained in the SC files and 
nowhere else.
F
I can just end this passage by taking you to two paragraphs in Professor David’s second 
report which deals with appendix 1.  You will find that at C3, tab 7(b) at paragraphs 75 and 
76, which is at page 31 of that document.
(After a pause)  I need to draw your attention to paragraphs 75 and 75.  I can see that I have 
not won in identifying it to everybody yet.  Paragraph 75 says: 
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“Indeed it seems to me particularly important that correspondence between clinicians 
that voices child protection concerns should most assiduously be placed in the 
patient’s medical records.  It is an important general principle that this kind of 
information should be shared between professionals, and one would want any 
clinician who looked at the hospital records of a child to be fully informed about child 
protection concerns. 
H
T.A.  REED 
Day 3 -  15
 & CO. 

---

A
Ultimately, I suppose, the question is what is in the patient’s best interests?  Should 
information about child protection concerns be actively excluded from his or her 
medical records, or should there be a positive action to ensure that all such concerns 
are carefully filed in the patient’s medical records?  My answer would be that I cannot 
see how a patient could benefit by concealing this information, whereas failure to 
communicate this information with other health professionals at the hospital (by 
excluding it from the patient’s medical records) could possibly be harmful and could 
B
lead to inappropriate actions or treatments.” 
Madam, having given you that guide through the purpose and reasoning behind medical 
records and about special cases files in particular, I now need to take you to the individual 
patients and the individual special cases files. 
THE CHAIRMAN:  Would you consider this an appropriate time to have a little break? 
C
MR TYSON:  Entirely appropriate, madam. 
THE CHAIRMAN:  It is 11 o’clock, so we will break until 11.30. 
(The Panel adjourned for a short time)
D
MR TYSON:  Madam, could I start by making apologies for a technical error which I made 
apparently in the course of my opening this morning?  I indicated that when a child was 
undergoing this 8-hour monitoring some sort of special jacket was put on to which various 
leads were attached.  As I understand it, there was no special jacket; the leads are attached 
directly to the body of the child.  I apologise for making that technical error. 
In order to understand the individual allegations in Appendix 1 I need to give you a brief 
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history of each patient so that the document within Appendix 1 can be put into context.  Can 
I ask you please, in relation to Patient A, that one needs to have in front of one C2 at section 
3 and the only other bundle you need in this context, or we will come to, is C5, the first 
section, which also relates to Patient A. 
You can see, madam, by looking at Appendix 1, that the allegation is in respect of this child 
(whose SC number was 1209) that there was an original of an MRI scan found in the SC file 
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and that original report – I am sorry, it is not the scan itself, it is the report – of the scan is, we 
say, not found elsewhere in the child’s medical records. 
The story of this child can be divined by looking at section (d) under tab 3 which is a letter of 
referral from Great Ormond Street to the Brompton Hospital, undated, but I will give you the 
date when you locate the page.  This is a letter dated in January 1987 and we can see the date 
by reference to subsequent documents.  As I say, it is at C2, section 3(d). 
G
It is a letter addressed to the doctor there mentioned.  As I understand, technically at this time 
– nothing turns on it – in fact Dr Southall did not have admission rights in view of his 
particular post at that particular time at that particular hospital, so formally the letter had to be 
written to this particular doctor. 
You can see that the date of birth of this child was August 1986 and this was a letter written 
H
in January 1987, so the child would be about five months’ old at the time of this letter. 
T.A.  REED 
Day 3 -  16
 & CO. 

---

A
“Dear Dr …. 
Re:  [Child A] … 
Thank you for agreeing to take [Child A] for further investigation. 
B
He came to us for a third opinion about his episodes of unexplained pallor, hypotonia, 
shallow breathing and small pupils.  The problems started at seven weeks of age 
before which he was said to be a very alert active normal baby.  He was admitted to 
his local hospital … having been drowsy and quiet all day, although he had fed well.
He had two episodes of pallor shallow breathing and limpness during which his 
parents thought he may have stopped breathing.  At his local hospital further similar 
episodes were noticed, but no other abnormalities found.  Two days after admission 
C
he had several similar episodes witnessed by the medical and nursing staff one of 
which was associated with twitching of is limbs and which were thought, on balance, 
to be fits.  His parents described these as ‘grand mal convulsions’.  No cause for these 
episodes was found on EEG, ECG, LP, CT scanning or serum chemistry the results of 
which are to be found in the photocopy of his … discharge summary.  He was started 
on phenobarbitone and pyridoxine and discharged. 
D
His parents then had him referred to [a doctor in another city] and his parents sold 
their mobile home, father gave up his training to be a psychiatric nurse and they 
moved in with [the mother’s] parents, though they both actually lived on the ward 
during his admission.  His anticonvulsant medication was stopped, having been of no 
benefit in reducing the frequency of his attacks according to his parents.  Several 
episodes were noticed in hospital, none involving cyanosis or convulsive activity and 
most of his medical attendants thought that they were compatible with normal sleep.  
E
He was discharged and came back the next day having had a very severe episode, 
witnessed by his parents.  A further period in hospital revealed no change in the 
nature of the attacks yet on a trip to the city centre he had an attack sufficiently 
serious in his parent’s opinion to necessitate him being transported at great speed to 
the hospital by a rather panicky taxi driver.  His parents pushed hard for transfer and 
he was admitted under [the doctor’s] care on 10/12/86 and has been an in-patient 
since.
F
His past medical history is relatively unremarkable in that he was a normal vaginal 
delivery at 41 weeks gestation following a pregnancy complicated by a ‘flu’ like 
illness at 16 weeks and premature labour at 32 weeks treated with intra venous 
ranitidine.  During this episode mother’s blood pressure was witnessed by her 
husband to have dropped to 20 mm Hg for five minutes and the foetal heart monitor 
became irregular.  He was in good condition at birth and had no neonatal problems. 
G
He is the only child of unrelated Caucasian parents who are well.  His father is 41 and 
before training to be a psychiatric nurse (he was two years in his training when he 
left) has had jobs as a reporter for New Zealand Television and a soldier in the 
American army according to what he has told various people though we have not 
challenged him on these points.  His mother is a 28 year old lady who suffers from 
Reynauds”,
H
T.A.  REED 
Day 3 -  17
 & CO. 

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A
and as I understand it, for lay members of the Panel, that is a circulation problem particular in 
the outlying parts of the body, such as fingers and toes, 
“and who worked with mentally handicapped adults. 
On admission he was found to be thriving on breast feeds with his weight being
6.25 kg … his supine length 65 cm … and his head circumference 41 cm …  He was 
B
normotensive, developmentally normal and the rest of the exam revealed no 
abnormalities.” 
The letter indicates various investigations that were made and I will run through these 
quickly.  Biochemical were all normal, toxicology – no abnormal compounds, haematology 
normal, electro physiology – ECG normal, imaging CT brain scan normal, barium meal and 
swallow normal, sleep study normal transcutaneous carbon dioxide and oxygen. 
C
“CLINICAL COURSE: 
OPINIONS: 
Cardiology: normal examination and 2D echo.  No cardiac cause. 
Respiratory: No evidence of a respiratory problem. 
D
Gastroenterology:  Some features could be explained by gastro oesophageal reflux. 
OPINIONS: 
Neurology … :  Unlikely to be fits. 
Neurology … :  Diagnosis uncertain ?? migrainous (vertebro basilar) 
All consultants wondered about Muchausen-by-proxy. 
E
[Child A] had numerous episodes while on the ward most of which were very mild in 
that he was easily rousable when the ward staff arrived.  All attacks occurred when his 
partners were in the room apart from one which occurred within ten minutes of them 
leaving the cubicle.  None occurred at night.  We witnesses one severe episode during 
which his pupils were very constricted (a feature of even his mildest episodes) and he 
was unresponsive to pain, with shallow respiration.  His parents commented that the 
F
Pethco he had prior to the CT scan made him look similar and on that basis we 
attempted to reverse an attack with naxolone which we did convincingly on one 
occasion.  In view of the negative toxicology screen from Guy’s the significance of 
this observation remains unclear. 
He has otherwise been well apart from a recent upper respiratory tract infection with 
vomiting ang loose stools from which no bacterial pathogens have been isolated. 
G
His parents have remained with him thorughout his stay. 
Thank you again for taking him.” 
On the basis of that referral letter from Great Ormond Street to the Brompton the child was 
admitted and we can see that at subsection (e) in the next section.  I have just read to you 
H
from (d) and now I am taking you to (e). 
T.A.  REED 
Day 3 -  18
 & CO. 

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A
We can see that the child was admitted to the Brompton and you can see from the bottom 
left-hand corner that the child was admitted on 10 January 1987, which was why I gave that 
letter that I have just read out as January 1987.  The admission history is on page 2 and I need 
not take you to that.  You can just see at the top of page 4 an entry in the top left-hand corner, 
10/1/87.  This is the clerking history on transfer from GOS: 
B
“Admitted for monitoring. 
c/o attacks of apnoea [that is stopping breathing], deep unrousable stage, pallor, 
hypotonia and small pupils.” 
Much the same history is set out as was in the Great Ormond Street letter which I have read 
so I need not take you to that.  Going to page 5 just very quickly one can see that in the 
middle of the page he records the admission to Great Ormond Street Hospital in December 
C
1986 and about two-thirds of the way down we can see a history recorded: 
Had many attacks at GOS – easily rousable when staff arrived …”, 
and then four lines from the bottom: 
“Always has constricted pupils during attacks or moving pupils, often unresponsive to 
D
pain, shallow resps [respiratories] and apnoea, 15-60 secs. 
Goes an awful colour – waxy & pale.” 
Then the child was admitted and I need to take you to the observation of an episode by a 
medical member at page 7 on 11 January where it says: 
“(Relatively) minor episode observed”, 
E
and on examination: 
“Child
 limp with pinpoint pupils. 
Seemed asleep. 
o/e pale … 0 cyanosis 
F
pupils pinpoint.  Reactive to light … 
…
Limbs:  Tone – normal 
 floppy”, 
and it deals with reflexes.  Then it appears to say that on taking the blood pressure that woke 
G
him up.  Over the page: 
“Following waking – pupils immediately dilated 
Child alert moving normally …”, 
and the assessment we can see was: 
H
“Significant neurological signs 
T.A.  REED 
Day 3 -  19
 & CO. 

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A
? Fits 
? Raised intracranial pressure spikes.” 
Guy’s Poison Unit was contacted, and nothing positive found.  As you see, extensive 
investigations looked at the cause, including whether the child had taken anything that it 
should not have done.
B
Then there is another attack recorded as being seen by the doctor at page 9.  He indicates that 
it was a “moderate attack this morning.  Lasted in total 11 minutes, Nurse called at 2 minutes 
into attack.”  There the doctor clinician gave the description of the attack that was noted, a 
description not dissimilar to the description I have already read.  The impression, at the 
bottom of that page, by that doctor was “Obvious pathological process occurring”.  He lists 
some other view, but the photocopy does not permit me to indicate to the Panel what that 
other view was. 
C
Then on page 10 there was a clinical note of a long discussion with the parents.  This clinical 
note was made, as you see, by Dr Samuels, who was Dr Southall’s registrar: 
 
“They feel more ‘at home/ease’ here, then this mornings was about 8th major episode 
[Child A] has had.  In view of infrequency [and] unpredictability, they are [very] 
anxious about [the] episodes (? Could these plus [something] be causing brain damage 
D
to be revealed ….. Mum [was] in tears after 3rd major episode ….. worried about 
coping at home. 
 
Reassured that no transfer/discharge planned for next 7-10 [days]. 
 
Given opportunity to leave/take break for [24 hours] if they wish (mother may still 
express [breast milk] for [the child]).” 
E
Family history is recorded on the mother’s side and on the father’s side, and “? Is this 
cerebrovascular functional disorder” was a possible diagnosis. 
 
“Suggest ….. [blood pressure] monitoring 
 
BM stix in next major episodes. 
 
? need for cerebral angiogram.” 
F
Then there is at page 11 another note by the same doctor, Dr Samuels, about three weeks later 
on the 29th, indicating: 
 
“Occasional small episodes;  may go some days without. 
 
Gastro-oesophageal pH monitoring showed borderline oesophageal acidity [and] no 
clear fall in pH with a moderate episode and acidity showed no clearcut clinical 
G
change.
[Seen by]” - and I think those are the initials of a Dr Warner, who was a consultant at 
the premises - “Try gaviscon post-feeds for few days initially. 
David Southall saw moderately severe episode from onset to completion.  No obvious 
neurological/respiratory problem.  ? significance of pupillary reaction – may be 
H
response to light/movement/noise etc. 
T.A.  REED 
Day 3 -  20
 & CO. 

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A
Feels no need to perform further cardiorespiratory monitoring or video. 
Plan:  To [discuss with] Dr Leonard’s team” – Dr Leonard’s team were the Great 
Ormond Street team – “re:  probability of going home – support (medical/social) 
needed locally”. 
B
You see that there is reference there to the monitoring, and if one keeps that page open and 
turns to the SC file relating to this child, which is page 5, and go to page 144, we can see two 
examples of the kind of monitoring that I was talking about earlier.  In particular to this case, 
you will see on page 144 this is a report of eight hour recording on this child, giving the SC 
number in the middle as 1209 and setting out Dr Southall’s analysis of the monitors, and then 
on the next page is the “Log of infant activity – nursing-medical intervention”, which shows 
what was happening to the child at any give time.  So this could be cross-referenced to the 
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monitors.  Through the rest of this bundle you will see similar examples both of eight hour 
recordings and of logs of infant activity. 
We see we have now reached February, the child was admitted on 10 January, so all these 
bits of monitoring had been taking place, and I need to take you back to C2 to pick up the 
story at 3(e) 12.  There we see, in the middle, where it says, between 3 and 5 February, so 
after 5 February, the word “Conference”, and if I can ask you to go over the page, and you 
D
will see at the bottom in handwriting “From conference” on 4 February.  The significance of 
that is that in fact there was a child protection conference on 4 February involving a number 
of clinicians and members of social services.  For that we need to go back into C5, keeping 
page 13 open on this bundle, back to C5 at page 136.  There you will see that on 4 February 
1987 there was a case conference held in relation to the family, and you will see amongst the 
attendees there was David Southall, Senior Lecturer in Paediatrics at the Brompton, and 
Dr Samuels, who is a Paediatric Registrar at the Brompton, and also present were doctors 
E
from the two previous hospitals, and you can see that Dr Leonard from Great Ormond Street 
was there as well.  The significance of this is that Dr Southall gave a report on the child being 
there at page 137, and indicated that: 
 
“…[the child] had been referred from Great Ormond Street on 10 [January] ….. 
having been there for one month for investigations into episodes of pallor associated 
with drowsiness, loss of consciousness and small pupils.  These episodes have defied 
F
investigation at three different hospitals…” 
He indicates that: 
 
“One possible diagnosis was that the parents [were] inducing attacks by smothering 
and as the Brompton Hospital ….. had previous experience of this, and has facilities 
such as multi-channel tapes, EEG and video surveillance, [Child A] was referred 
G
there.
 
Dr Southall said that as the attacks were occurring so frequently, [Child A’s] 
breathing movements were taped for 22 hours.  He had two attacks during this time 
and there was no evidence of interference with the baby at the time of the attacks.  
[His] breathing was regular ….. as would be expected during sleep ….. no indication 
that video surveillance was necessary ….. not pursued. 
H
T.A.  REED 
Day 3 -  21
 & CO. 

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A
 
At Great Ormond Street , investigations were made into the small pupils and tests 
were made for abnormal levels of opiates, which may have been administered at 
feeding, but nothing was found.  Urine samples and samples of breast milk were 
examined by the police forensic team, but these proved negative.” 
So extensive research is going on to see the causes of these, including seeking to eliminate or 
otherwise any fault of the parents associated with this.  They say: 
B
 
“Another major issue was the parents’ unusual manner and behaviour and [Mr A’s] 
background history.  Although suffocation [had] been excluded as a cause of the 
attacks, other bizarre or unusual causes have not.” 
MR COONAN:   Could you read the rest of it? 
C
MR TYSON:   Yes, certainly. 
 
“Dr Samuels and Sister Bossom observed one episode when [Child A] had finished 
feeding.
 
Dr Southall asked if an EEG had been undertaken previously and Dr Darmady said 
that she had recorded in the notes that a 24 hour EEG was carried out in [the town 
D
there mentioned] and repeated in [the town there mentioned] and there was no 
difference.  Dr Southall said that a two channel ambulatory EEG would be useful to 
define what type of sleep [Child A] was in, and also an NMR (Nuclear Magnetic 
Resonance).  These could be carried out at the Brompton…” 
There were other discussions by other contributors to the debate, and I only need to pick this 
up at the bottom of page 140, where you see that it went into a general discussion area now, 
E
and over the page, and this is under “General discussion”, we see at the second paragraph on 
page 141 where Dr Southall was coming from here, it says: 
 
“Dr Southall [felt] that he would recommend that [Child A] is taken into care 
temporarily, so that he could be assessed without this parents being present.” 
In the penultimate paragraph: 
F
 
“It was agreed that [Child A] should be kept at the Brompton Hospital for the time 
being and [that] an EEG and NMR would be completed.  In the meantime, the Social 
Services Department will discuss with their legal department whether Wardship 
proceedings should be instigated.” 
So the recommendations were that [Child A] remained in hospital while further tests were 
G
undertaken, legal advice sought about wardship, another conference on the 13th.
So you can put the SC file down for a second and go back to page 13 of C2, section 3, tab (e).
We see effectively what appears to be Dr Samuels’ report back of that strategy meeting, 
where he says: 
 
“From conference 4/2/87 
H
T.A.  REED 
Day 3 -  22
 & CO. 

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A
 
Assess brain stem/possibility of narcolepsy. 
 
In view of very odd parental reaction:  father not left mother or baby in hospital, no 
attempt to sort out future/home, comments suggesting paranoia/delusional state e.g. 
NHS exploiting him to resuscitate his child (child has not required any formal 
resuscitation). 
 
For consideration of warship of court.” 
B
Then we go back from page 13 to page 12 and pick up the chronological story again, because 
we see that halfway down we come to 5 February, which is after the case conference, which 
we have seen, and this is another conference, a medical conference rather than a social 
services conference, here being mentioned on 5 February 87, and we see “For:  EEG – 24 
[hours] including polygraphic for REM ….. NMR – [9 o'clock Wednesday]”.  I think, 
although I will be instantly corrected if I am wrong, that what was in 1987 called an NMR we 
C
all now call an MRI scan.  “? Narcolepsy.  Re-discuss [on Friday 13th].”
Then we get to page 14, which is a record by, it appears again, Dr Samuels, of the second 
case conference.  Just keeping that document open a moment, and I will just take you to the 
fact of that conference, and so I ask you to have a quick look at C5, page 122. 
We see that there was a second case conference on 13 February and again present included 
D
Dr Southall.  As with the previous case conference, of course, one sees that the parents were 
not there.  This is, as someone who practises in this field, in the pre-Children Act era and so 
things were dealt with slightly differently then and parents did not have as many rights as 
they did after 1989.  But here we had these matters going on without the parent’s knowledge, 
behind their backs.  I think formally now, as you have seen in the M case, if one wants to 
discuss matters behind parents’ backs one now calls them “strategy meetings” rather than 
formal case conferences.  But that is by the by. 
E
Can I take you back, please, to that case conference where we see, at page 124, Dr Southall is 
telling that case conference that during the MMR the brain was normal and that the ECG had 
shown that during an attack the child was in deep normal sleep.  Dr Southall’s view was that 
the “attacks” were probably caused by his parent’s attempts to wake the child up during 
sleep.  He says, 
F
“He goes into a sleep deeply and very quickly.  There was nothing wrong with him; 
he was a normal healthy baby”. 
We can see in the general discussion on page 128, in the fourth paragraph, that after 
considerable discussion as to the appropriate timing, 
“it was decided to take out an originating summons to freeze the present situation”, 
G
via wardship.  I think the broad suggestion was that the child was perfectly normal but the 
parents were not.  That is recorded in the medical notes – I go back now to C2, section 3 at 
page 14.  There we can see that it is recorded by Dr Samuels that, 
“Medical investigations normal; felt that episodes of periodic hypersomnolence 
(narcolepsy felt to be excluded) were of no great life threat to [Child A]; i.e. no 
H
change in HR/oxygenation/breathing.  Still expression of concern from various parties 
T.A.  REED 
Day 3 -  23
 & CO. 

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A
involved in [Child A’s] case that parent responses (particularly father’s) are 
extraordinarily odd”. 
The decision – going two-thirds of the way down – at the conference was to make the child a 
ward of court.  Parents were talked to by Dr Leonard and were very upset and angry by the 
court order because they had had no warning.  The parents felt very wronged and that they 
would be scared for the rest of the child’s life. 
B
In the SC file relating to this child, there are a considerable number of documents, of which 
of significance in the context of this case is page 131.  This is the document in Appendix One 
relating to Child A.  If you look at Appendix 1, you will see that this is noted as the SC file, 
and it may be helpful to note that it is in fact the C file, page 131.  As you can see, this is the 
report of the MRI scan.  An original document was found in the SC file.  There is no MRI 
scan report in the child’s hospital medical records.  This MRI scan report can only be found 
C
in the SC file. 
On this point Professor David says that it is undoubtedly a medical record and should be in 
Child A’s hospital medical notes.  On this point also Dr Southall says that he agrees that it is 
an original medical record; he agrees that it should not be in the SC file; but he denies 
responsibility for it being there.  That is the Panel question to decide. 
D
Madam, Child A’s SC file is also considered under heads of charge 13 and 14, which you 
will see relates to the taking away of that paper file from the Royal Brompton to North 
Staffordshire; in other words, not following the child, if I can put it that way.  This SC paper 
file – one can see it is pretty large – was taken for uncertain reasons in its entirety to North 
Staffs by Professor Southall and, the complainants submit, making it even more inaccessible 
to clinicians or others at the Royal Brompton. 
E
I also need to deal with Child A later when I come to heads of charge 15 and 16, which relate 
to computer records held on this child as opposed to paper records held on this child, but I 
will come back to that issue later.  There is also an issue as to accessibility of this special 
cases file – or we would say, lack of accessibility – of this special cases file by Mrs A.  But 
this is a question which my learned friend and I need to have various discussions about before 
I am able to advance anything further on that and further develop that point.  I am hopeful 
that my learned friend and I can find a way in which this evidence can be presented, failing 
F
which it may be a matter the Panel have to determine.  But I am not opening nor dealing in 
any detail with the matter of Mrs A’s search for this file, if I can put it in those terms.  We say 
that goes to the issue of accessibility. 
I now turn to Child B, and so one can keep the same files out because C6 also includes the 
SC file relating to Child B, which is a very slim SC file compared with the others.  One 
needs, in relation to an understanding of Child B’s case, to be looking at C2 under Section 5 – 
G
hitherto we have been looking under Section 3.  You need to have available, for me to 
develop the background to this case in relation to Child B, C2, Section 5 and C5, Section (b), 
which is at the back of the file. 
I need to give you the brief facts relating to this case in order to put the Appendix into 
context.  The brief relevant facts relating to Child B can be ascertained by looking at Section 
5 of C2 and we start with a letter at Tab (a).  This is a letter dated 17 August 1993 from one 
H
consultant paediatrician at one London hospital to a consultant paediatrician at another 
T.A.  REED 
Day 3 -  24
 & CO. 

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A
London hospital.  It relates to Child B.  We can see from this that at the time of this letter 
Child B was about 11 months old. 
The letter says that the child was admitted to that district hospital on 6 August 1993 with a 
history of recurrent apnoeic attacks: 
“On the afternoon prior to admission she was said to have had four apnoeic episodes 
B
during which she went blue and stopped breathing. 
I am sure you will remember [the child] who had a Nissan’s fundoplication for reflux 
at St George’s Hospital” – 
that is the operation I was briefly describing yesterday to stop the stomach contents refluxing 
up and going into the lungs – 
C
“approximately four weeks ago and, as far as I can tell from the notes, was seen again 
at St George’s Hospital for recurrent apnoea post-operatively.  Further review of her 
notes reveals that she has been seen on several occasions at [three hospitals].  I can 
find only one documented episode of apnoea during a hospital admission and that was 
with you at [your] hospital during her admission of January 1993. 
D
[Child B] spent ten days on the children’s ward at [this district hospital] and was 
discharged by me this afternoon after speaking to both parents.  I think it is of great 
interest that absolutely no apnoeic episodes, or indeed anything abnormal, was 
observed during her entire admission, and anything that was observed was observed 
by the parents alone when she was off the ward.  During her time with us [the child] 
has had yet another EEG, this time with eyeball pressure, to see if her apparent 
apnoeic episodes could be mimicked in any way.  Her EEG has remained normal and 
E
there is no evidence during this test of reflex anoxia. 
As at least the fifth consultant to review this case, I have severe doubts about the 
symptoms reported by the parents now.  I can make no comment about neonatal 
events but there does seem to be a paucity of substantiated apnoeic attacks in a 
hospital environment, even during the early months of life.  I have spoken to our 
paediatric home care team and I have been in communication with the health visitor 
F
through our liaison ward health visitor.  These experienced nurses share my anxieties 
that, whatever the preceding events, the B’s are now presenting Child B with 
‘Munchausen’s-by-proxy’.  These thoughts are reinforced by the fact that my 
secretary has just received what amounts to a threatening phone call from Mrs B who 
said that she will ‘hold me personally responsible’ if anything should happen to Child 
B.  This phone call has come only three hours after I interviewed both parents on the 
ward in the presence of the ward sister and paediatric SHO.  At that time I explained 
G
to them that Child B had been entirely well during the entire ward admission and that 
the EEG was once again entirely normal.  I suggested they could either take Child B 
home, or perhaps they would prefer to stay in hospital with Child B until they saw 
you at your hospital tomorrow.  They both said they were happy to take Child B 
home. 
I hope that nothing untoward happens to Child B during the next 24 hours.  It will be 
H
of great interest if she presents to [the two hospitals] tonight.  I must restate, however, 
T.A.  REED 
Day 3 -  25
 & CO. 

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A
that I have severe reservations about the history as given by these parents now in 
Child B’s case.  I do not accept that it is possible for a child to spend ten days on a 
hospital ward and be entirely well throughout that time, only to find apnoeic episodes 
occurring off the ward and not reported to the nursing or medical staff at the time”. 
I can now briefly take you to the child who was discharged from that particular hospital on 17 
August, and we can see that if we go to (b)(i), which is the next page.  It should be a 
B
document entitled “Discharge Summary”.  We can see from that that two days after the 
discharge from the first hospital I have just mentioned she was admitted to another hospital.  
The history was that this young 11-month old girl was admitted to the ward on 19th following 
a telephone call from her mother.   
“Her mother gives a history of a 3 minute episode during which [the child] became 
pale, hypotonic and with a blank look.  There were no fits, cyanosis or apnoea, and 
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[the child] appeared well before and after the episode.” 
One can see the observations on the ward at the bottom of the page.   
“[The child] was attached to an apnoea monitor and an 02 saturation monitor.  During 
the 8 days of her hospital stay no apnoea or desaturation were noted.” 
D
Over the page it is recorded that the child was discharged home with a plan to supply the 
mother with a recorder.  That might have been what that registrar felt was going to happen 
but, in the event, the child was referred by the consultant to Professor Southall at North Staffs 
for assessment. We can see that the child was discharged from this hospital on 27 August and 
the child arrives at the North Staffs on 1 September.  We can see that by looking through to 
(c)(i).  The child was admitted under Professor Southall’s care, as we can see at 5 (c) (i) with 
a complaint of cyanotic episodes and there is a full note there.  We can see what was recorded 
E
at internal page 5 by Dr Samuels, who I think I said earlier had gone up to North Staffs with 
Dr Southall from the Brompton.  You see what was recorded was the history, the history of 
being awake and asleep, vacant, grey/white, blue around mouth, stops breathing, limp, no 
tone up to three minutes, and describing the episodes there.  At the bottom it records that 
there was a need for continuous recording of what is going on. 
To cut to the chase, the child stayed some 17 days at the hospital.  During the course of the 17 
F
days that the child was in the hospital, Professor Southall arranged a social services meeting 
as he was concerned as to whether the mother was fabricating the apnoeas. 
We see a discharge summary in relation to this child at 5 (c) (iii) where we see that the 
patient was referred with recurrent apnoea.  The matters were analysed by a DP sample with 
a normal recording and the clinical impression was Munchausen syndrome by proxy. 
G
As a result of these concerns, the child was initially placed with foster carers but later 
allowed back home to live with her parents. 
There is one original document in Child B’s SC file that is nowhere else in the medical 
records relating to this child.  That is the referral letter from the district hospital that referred 
the child to Professor Southall at North Staffs.  We see this letter in C5 in the section relating 
to Child B at the end.  It is at pages 33 and 34. It is in the latter section of C5 relating to Child 
H
B.  The beginning part of C5 related to Child A. 
T.A.  REED 
Day 3 -  26
 & CO. 

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A
You will be pleased to hear that at the end of this opening I am going to give you another 
little file which contains all the documents in Appendix One and Appendix 2 so that you do 
not need to rush around all the SC files to look for the.  You need to see them in context. 
This letter, which we see at pages 33 and 34, is the referral letter to the North Staffordshire 
Hospital from the hospital there mentioned.  It is an important clinical document.  It sets out 
B
the history and the investigations that have been made.  The only place where this original 
medical record can be found is not in the child’s hospital notes at North Staffordshire; the 
only place this original medical record can be found is in Professor Southall’s parallel record 
in his SC file. 
Professor David says in his report, and I need not take you to the point but you can write it 
down, at 7(b) paragraph 63, that the status of this letter is quite straightforward.  It is clinical 
C
correspondence and has to be regarded as part of a patient’s medical record.  Professor 
David’s report is at C3, section 7(b), paragraph 63.  Professor Southall’s response, and I need 
not take you to it but I give you the reference, is at C2, section 6(c) page 17.  His response to 
that is that he cannot say why this letter was not filed in the hospital medical records.  He 
denies placing it there.  The ultimate question for the panel is:  was it Professor Southall’s 
responsibility for this important original medical document being in the SC file?  It is the 
same question as you have to deal with under Child A. 
D
Now I will tell you about Child D.  One can put away C5 but keep C2 but this time in C2 we 
go to section 4. 
MR COONAN:  Before my learned friend does that, there is a small housekeeping matter.  
I have just noticed that the letter we have just been looking at is also copied in the C2 file.  It 
is just that my learned friend did refer to it and I did not want there to be any confusion about 
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it.  It is actually replicated twice. 
MR TYSON:  Yes, it is replicated in the C2 file for the purposes of history. 
MR COONAN:  That may well be right but I just rise to refer to it so there is no surprise that 
it is there. 
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MR TYSON:  I accept that it is in the C2 file, which is there for the purposes of history, but it 
is an Appendix One document being not found in the child’s hospital medical records at 
North Staffordshire. 
Section 4 of C2 deals with this Child D and this child’s special cases file.  It is so enormous 
that it has a file all to itself, which is C6.  For this section of my opening, you need to go to 
C2 and C6. 
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Child D is the child with multiple allergies whom I dealt with earlier when telling you about 
the incident in the corridor at North Staffordshire Hospital in December 1994, which is the 
subject of the allegation in Appendix Three.  I opened that letter in the first section of the 
report, Appendix Three, the Child D letter. 
This is a child, as I think I said, with multiple allergies.  I ask you to look at Appendix One.  
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You will see that Appendix One under Child D is divided into four sections.  There is a 
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section relating to incoming correspondence, which is section one; there is section two, which 
relates to original copies of letters between third parties; and there is a reference at section 
three to outgoing correspondence; then section four relates to one document to which I will 
come later. 
The principal allegation here in respect of Child D and the SC file is that Dr Southall kept 
original clinical correspondence relating to this child out of the hospital medical records and 
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in the child’s special cases file.  He seeks to justify this on the basis that all these matters 
related to child protection.  That is what he says, and I just give you the reference, at C2, 
section 6 (c), pages 17 and 18.  You have a blanket defence, as it were, for these matters 
being there. 
Pausing there, I think it is admitted, but I look to my learned friend and I should have brought 
this up earlier, that all the matters in Appendix One are in fact all original documents. 
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MR COONAN:  I need to double check.  Madam, I say that.  My learned friend is being 
overly delicate about that.  You will see there is a vast amount of documentation in this case 
and that exercise has not yet been fully concluded.  Rather than making a hasty admission, if 
it is correct, I will make the admission in due course.  I do not want you to be misled in any 
way.
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MR TYSON:  I am grateful for that.  I did not mean to bounce my learned friend but it has 
been an admission that I have been pressing for. 
Professor Southall says this is all child protection material.  Professor David disagrees that 
that, if it is a ground, is a ground to exclude it from the child’s medical records.  Here, I am 
sorry to have to say, I am going to have to refer you to yet another bundle, which is 
Professor’ David’s report.  That is at C3 at section 7 at internal section (b).  This is a report 
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you have not so far seen.  You will have the opportunity of so doing.  The first page should 
say that it is a report of 10 September 2006, amended on 31 October 2006.  You will see at 
paragraph 10 on page 9 what he is being asked to do in this second report. 
“Broadly speaking I have been asked to do two things.  One is to consider whether the 
items listed in Appendix 1 … plus two additional documents in the case of child D,  
can properly be said to be ‘medical records’ that fall within category 10 of my 
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analysis in relation to records as set out … in my ‘extract report’.  The other is to 
consider the responses provided in the letter dated 24 January 2006 from Hempsons.” 
If I say that is what Professor Southall says about the matter, those responses are the ones at 
C2 at section vi(c).
So, in relation to the correspondence matter can I take you, please, to paragraph 68, which 
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deals with internal correspondence, and picking it up at paragraph 68 you will see: 
“The letter from Hempsons dated 24 January 2006 says that these letters related to 
child protection issues, and that therefore there was no obligation to file the 
documents in the medical records.   
I do have some difficulty with this. As I see it, Hempsons are saying in their 24 
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January letter (and if I have misunderstood them then I apologise and no doubt they 
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will correct my error) that any letter that is in any way related to child protection 
matters need not be filed in the medical records.  I find it difficult to go along with 
this.  What percentage of a letter has to concern child protection matters for it to no 
longer need to be filed in the patient records?  Supposing that 95% of a letter concerns 
diagnosis and treatment, but 5% concerns a child protection concern, should that 
cause the letter to be removed from the medical records?  To put it another way, at 
what point does a letter between Dr A and Dr B about a patient cease to be ‘clinical’ 
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and become ‘non-clinical’ or ‘child protection’?  I find it impossible to answer the 
question.  So often there is a mixture of clinical and child protection concerns, and 
I have difficulty with the concept which seems to me to be implied here, namely that 
once there is any mention of the words child protection then a letter between doctors 
ceases to form part of a patient’s records and can be filed away elsewhere.” 
Then we come to the paragraphs that I dealt with earlier in my opening over the page at 
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paragraphs 75 and 76.  I need not repeat them, but he effectively says it is particularly 
important that correspondence between clinicians that voices child protection should most 
assiduously be placed in the patient’s records. 
In relation to third party correspondence, which is the matter set out in the second section of 
Appendix One relating to Child B, Professor David makes a similar point at paragraph 77, 
where he says: 
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“I have not analysed them in different categories as above, but my views about these 
documents are exactly the same as the items labelled ‘incoming correspondence’.   
At paragraph 79 he puts out a possible counter argument where he says: 
“I suppose a counter argument might be that all this correspondence flowed as a direct 
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result of Professor Southall’s initial child protection concerns.  I suppose the 
argument would be that once he had raised the concerns, all subsequent 
correspondence between doctors could be classed as relating to child protection issue.
I mention this only to say that I do not agree with the logic.” 
In relation to outgoing correspondence, which is the third section of Appendix One relating to 
Child D, we need to go to paragraph 103 at page 52.  Professor David says: 
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“Outgoing correspondence 
In my view these items are essentially covered by the above points.  Most of these 
documents carefully spell out Professor Southall’s concerns that the patient was at 
risk.  At the risk of repeating what has already been said above, in my view it was 
important that these concerns should be readily available to any member of staff who 
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had reason to consult the child’s medical records, and consequently these documents 
should have been filed in the patient’s medical records.” 
Madam, despite the fact that in Appendix One the documents relating to Child D are divided 
into three sections (namely incoming correspondence, original copies between third parties 
and outgoing correspondence) it will be easier if I take you to the SC file chronologically 
rather than divide it in that way and adding Professor David’s particular comments on any 
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item as you go.  In order, I first need to take you to the document at 3(a), which is the letter to 
Professor Warner dated 13 March 1995, which we see from Appendix One is at page 305.   
MR MACFARLANE:  Could you give us clearer references to which documents you are 
referring to? 
MR TYSON:  Yes.  I am now taking you to C6, which is the SC file relating to Child D and 
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taking you within that file, at the back, to page 305, which I hope you will find is a letter 
dated 13 March 1995 from Professor Southall to Professor Warner.  By cross reference to 
Appendix One you may wish to write on that letter “3(a) Appendix One”, or just “3(a)”.  As 
you see, on 3(a) under Child D --- 
THE CHAIRMAN:  Mr Tyson, did you say you were going to give us a separate file with 
these documents in them?  Forgive me, you are suggesting we write something on these ones, 
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but if we write it on these ones, will we then in practice be more likely to refer to the other 
copies that you are going to submit to us later?   
MR COONAN:  While my learned friend ponders on that, could I just add a comment of my 
own, I hope not to confuse.  Although I can see from my learned friend’s point of view the 
attraction – in fact the attraction for all of us – of having a slimmed-down volume of, in 
effect, just the documents in Appendix One, I think it is terribly important that certainly for 
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the present time, and maybe for some time, that the Panel sees the context in which these 
documents are being laid before you.  If you are going to be given at a too early stage just the 
documents themselves which are in Appendix One, you may – I say no more than that – be 
highly misled because you will not have the context in which the correspondence is 
emerging.  That is why I rise for the moment. 
THE CHAIRMAN:  I appreciate that point was made earlier by Mr Tyson.  It is just a 
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question of if we are adding notes and post-it notes and what-have-you to this file …
I merely wanted to question whether that was going to be practical. 
MR COONAN:  I think we will have to struggle with that because there are so many 
documents. 
THE CHAIRMAN:  Thank you. 
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MR TYSON:  It is a matter of presentation, madam.  I am going to give you a crib sheet, if 
I can put it that way, at the end, but I was planning to open it in the way I was, broadly for the 
reasons my learned friend indicated, in order to put these things in context.  So, I would ask 
you merely to write on these letters where they appear in relation to this particular charge.
I hope you have now found out my system, that when I say “3(a)” you can see where 3(a) is 
on this Appendix One and hopefully you can see that when it says 3(a) in Appendix One 
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relating to this child, it says “Letter to Prof. Warner 13 March 1995”, and in the SC file you 
may just want to put, in relation to this child, that the whole of this child’s SC file is in C6.
That may well help your cross-references because then we know you only have to go to C6, 
provided I have got my pagination right in Appendix One (and any errors in Appendix One 
are mine and mine alone with regard to the pagination) and you should get there. 
THE CHAIRMAN:  That is helpful.  Forgive me for just asking that.  As you mentioned it 
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I thought it was useful. 
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MR TYSON:  I am going to make you work, I am afraid, a bit more before I give the crib to 
you.
To put this in context, as my learned friend rightly says it is only fair that I do, the child had 
been in the hospital at North Staffordshire in December 1994 and did not return there 
thereafter.  I readily accept that all the items in Appendix One related to Child D are post- 
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admission documents and I do not for a moment say that that makes any difference as to 
whether this important clinical correspondence should or should not be in the child’s North 
Staffordshire medical records. We say absolutely they should.  This is all-important clinical 
correspondence between consultants to a broad degree.
THE CHAIRMAN:  Mr Tyson, I am just wondering whether this actually might be a good 
time, if you are about to begin the details of it. 
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MR TYSON:  Yes, I am reading the declaration and now I am going to turn to the 
documents. 
THE CHAIRMAN:  Would this be a good time to break rather than launching into the actual 
documentation? 
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MR TYSON:  It would.  I am sorry it is burdensome, but doing it all now makes the rest of 
the hearing so much easier.  I make no apologies for opening for so long.  It means the 
hearing is shorter. 
THE CHAIRMAN:  Thank you.  It is just a few minutes before one. We will break till  
2 o’clock now.  Thank you. 
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(Luncheon Adjournment)
MR TYSON:   I see everyone is full of anticipation about the next bit of my opening.  Can 
I say that what my suggestion is going to be is that I will finish my opening, which will be 
another hour or so, and then if I might invite the Panel to read the reports of Professor David, 
together with an important document that emanates from Hempsons, which is their document 
which I will take you to, and then ask the Panel to read those and start afresh tomorrow 
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morning with Professor David.  That is going to be my ultimate suggestion. 
Meanwhile, we are on Child D, and I was going to take you to the SC of Child D, which is at 
C6, and I was taking you to the first of the correspondence in chronological order, which is 
the document at page 305, which is a letter from Professor Southall, as he then was, to 
Professor Warner at Southampton, that reads: 
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 “Dear 
John 
 
Re:  [Child D] ….. 
 
Following our telephone conversation last week, I am sending to you with this letter a 
detailed summary of [Child D’s] medical history.  I have been through this trying to 
dissect out medical problems that have actually been seen to occur in [Child D] 
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compared with those that have been reported by his mother.  You will notice from this 
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that there have been some rather worrying, real medical problems which don’t really 
look like anaphylactic shock.  As far as I can see, the only manifestation of food 
allergy has been urticaria.  There is no doubt that [Child D] has an allergic tendency 
with eczema, urticaria and sometimes wheezing.  However, it is my own view that 
this is an example of factitious illness on top of an existing medical problem.  The 
way that [Child D] is being brought up is going to, in my opinion result, in a very 
damaged emotional make-up for him.  I would be very interested indeed in your 
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attempts to wean him from some of his drugs, from his need for adrenalin and finally, 
from his need for such a restricted diet. 
 
Thank you very much indeed for being willing to get involved in such a difficult 
case.”
This is what I anticipate Professor David would say is a classic piece of clinical 
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correspondence.  It is a referral from one consultant to another consultant.  Sure enough, it 
mentions Professor Southall’s view that this is an example of factitious illness, but merely 
because, as it were, in that correspondence there is a possible diagnosis that relates to 
possibilities of child protection does not mean that this document can be not placed in the 
hospital medical records at the North Staffordshire Hospital in relation to this child. 
The next letter in time is the letter 3(b), which is the letter at page 304, and again the Panel 
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might wish to write “3(b)” on that, and it is a further letter to Professor Warner of 24 April 95 
which says: 
 
“Re:  [Child D] 
 
Following our recent telephone discussion I enclose a summary of [Child D’s] 
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illnesses.  I have spoken to Professor Strobel and he is in full agreement with you 
assessing [Child D] in your Unit.  I have also spoken to [Child D’s] mother who is 
also in full agreement.” 
That is clearly again a clinical letter, we would submit.  Professor Strobel, as you can see 
from his full title in the copy at the bottom, is the Consultant Paediatric Immunologist at 
Great Ormond Street.  He was having dealings with this child before being admitted to 
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Professor Southall’s unit in May 94, and was dealing with this child for about three or four 
years before the end of 94, dealing, as I said when I was opening the other part of this case, 
he was dealing with sensitive food testing, food challenges on Child D. 
You will see reference in letter 304 to a summary of the illnesses, and I need not necessarily 
take you to it, but that summary is actually in C2 at section 4(i), and it is a document which 
you just need to know is there, but it is not one of my SC file allegations. 
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The next document in time is the one that we see at 1(a), which is 14 May 95, which we see 
at 281.  So again, were you to write “1(a)” on that letter it might be helpful.  You will see this 
is the response from Professor Warner back to Professor Southall: 
 
“Re:  [Child D] 
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Thank you for your letter.  I would of course be very happy to sort out further 
investigations on [the child] as we have discussed.  However, I would first like to 
have an outline of how this referral has been presented to the family.  I assume at your 
case discussion that criteria were laid down for the organization of our investigations. 
 
It is important for me to know for instance whether it will be possible for us to do any 
of the challenges without the mother actually being present.  Furthermore the 
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assessment will need to include a full psycho-social input.  I would intend to admit 
him to our Bursledon Unit [where] he would stay during the week with week-end 
leave.”
Again, a classic clinical letter, we would say, but not in the notes. 
Then we come to the letter at 1(b), which you will find a few pages back at page 279.  This is 
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a letter from Professor Strobel at Great Ormond Street to Professor Southall, and the 
manuscript there may or may not be of use because, as it were, if – and I make no positive 
assertions at this stage – if that manuscript is Professor Southall’s manuscript, then we have a 
direct reference to, as it were, matters being in the SC file rather than in the hospital medical 
records.  We see it is a letter from the Great Ormond Street Professor saying: 
 
“Thank you very much indeed for your very careful summary of [Child D’s] illness.  
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Looking at your careful summary there are several things (as you have pointed out) 
which do not quite add up although I have no doubt that [Child D] is atopic and food 
allergic in general.  This obviously does not preclude the suspicion of an exaggerated 
or even fabricated illness.  With your permission I would just like to comment on your 
last page referring to our discussion on the 15th December.  I just wonder whether the 
wording is too strong.  In my opinion I thought this could be an example of an 
exaggerated/fabricated illness. 
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I am grateful that John Warner has offered to review [his] ….. history”. 
Again, classic clinical correspondence, we would say. 
The next in time is a letter at 277.  This is the letter at 3(c).  It is a letter from Professor 
Southall to the Social Services Manager, with, if you look over the page, copies to all the 
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clinicians that have been involved in Child D’s case to date.  This letter indicates that: 
 
“You may remember that we held a multi agency strategy meeting to discuss [Child 
D’s] case earlier this year.  As a result I was given the task of trying to arrange for 
[Child D] to be admitted to the expert unit of Professor ….. Warner in Southampton.  
As part of arranging this I obtained consent from Professor Strobel and Dr Connell.  
I then wrote to Professor Warner enclosing a summary of my analysis of the notes 
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which I include with this letter. 
 
Professor Warner replied on the 14 May with the enclosed letter requesting that in 
essence the child would be admitted to his unit only if the mother agreed that she 
would leave him therefore the week and return at weekends to collect him.  This 
would allow unimpeded challenges to be undertaken and also permit [Child D] to 
participate in normal schooling. 
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Having reached this point I then contacted [Mrs D] who raised initial objections that 
[Child D] would find this very difficult to accept having spent most [of] his life very 
closely attached to her including, as you know, sleeping with her at night and having 
her in attendance when he is at school. 
 
I then spoke to Professor Strobel about this and we both agreed that perhaps it would 
be reasonable for the first few days of the first week that [Mrs D] remain with [Child 
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D] and then gradually that he was weaned from her to remain on his own in the 
Basildon Unit. 
 
Despite this [Mrs D] has now categorically refused to allow [Child D] to be left on his 
own in the unit to allow Professor Warner to undertake his investigations.  I think we 
are now therefore in the position of having no choice but to convene a child protection 
conference at which these issues are put to the mother.  I would very much value ….. 
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[your] opinion on the best way of organising this.  I have spoken to Dr Connell about 
my concerns and this letter will inform Professor Strobel and Professor Warner of our 
dilemma.  I have also copied this to the GP [as] he needs to know what is going on.” 
Perhaps that last sentence says it all, which is important clinical information is being passed 
here and important that the GP knows it and thus he has been copied in to know what is going 
on.
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Can I take you, please, to where Professor David has a particular comment on this letter, 
which we see at C3 at 7(b), paragraph 105, where Professor David says: 
 
“The letter to Mr Banks, Social Services Manager [dated 22 June 1995 …..] was 
essentially a paediatrician reporting concerns to social services.  It was important that 
this information was available to others involved in the care of the child, or 
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potentially involved in the future care of the child, and this letter should have been 
filed [with] the child’s hospital medical records.” 
Then we get to the next letter in terms of page 276 – we are going backwards through this file 
- and this is another original that should have been in the medical files, and this is 1(c).  
Again, I draw reference to the manuscript at the top right hand of this, and it is a letter from 
the GP to Professor Southall dated 29 June.  It says: 
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Thank you very much for your correspondence about [Child D], I do appreciate being 
informed ….. 
 
Out of interest I saw [Mrs D] last night and her version to me was that [Child D] was 
going to be admitted for 2 weeks and that she was not going to be allowed to see him 
throughout that time and that he was going to be placed on a unit where there was 
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little or no cover.  She was therefore refusing to allow ….. his admission.” 
The next letter is two pages back at 275, as opposed to 275a, and this letter is 1(d), and it is a 
letter from the Southampton Professor to Professor Southall: 
 
“Re:  [Child D] ….. 
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I am sorry to put a burden back on you in relation to [Child D].  I have discussed him 
with my colleagues.  [I] feel that the ground rules for admitting him must be clearly 
established before we go through the investigations.  Without this we will get dragged 
into the quagmire ….. I would have thought that his mother’s rejection of such an 
approach could be considered as further evidence in relation to formulating an 
understanding of [Child D’s] problems.  It is also worthwhile pointing out to his 
mother that it is only by truly objective assessments by totally impartial and 
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independent third parties that her very important observations about [Child D’s] 
severe allergies can be supported and then appropriately treated.” 
Then going back in this file to page 273--- 
MR COONAN:   Could you read the last sentence? 
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MR TYSON:   Certainly. 
 
“I look forward to hearing the outcome of the Case Conference.” 
Then we go back in this file to 273, and this letter is at 2(a), i.e. it is one of category 2, as you 
are familiar now, which is “Original copies of letters between third parties”, so these would 
be the letters in which Professor Southall would be copied in, as you see he was at 274. 
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This is a letter from Professor Strobel to the GP indicating that he had reviewed Child D 
again, who was attended by his parents: 
“he looked very well, was active and his eczema for his standards was reasonably 
well controlled”. 
He goes on to provide a lot of other clinical information about this child.  In the second 
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paragraph he says, 
“I am sure you are aware that our food introduction programme under Professor 
Warner’s supervision…has been rejected by the mother because of the modalities.
That is, she was not prepared to leave Child D in the hospital without her presence.  In 
order to gain some more headway I would suggest for the time being the following 
procedure.  Child D is going to be admitted under the Dermatologist Dr Atherton for 
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occlusion treatment of his eczema”. 
Pausing there, madam, there was a suggestion that the child be admitted to Great Ormond 
Street which is where the dermatologist was.  He continues, 
“I have suggested to use this period for food introduction after our supervision with 
experienced nurses and dieticians at hand.  I know that this is not the optimal way but 
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the mother agreed to leave him alone during the day while we perform our 
challenges”. 
Again, we would say, that is important clinical information about the child and offering a 
compromise as to how to move forward.  There is then a gap of about one year – we see this 
is September 1995.  We go to page 265.  This letter is at 3d and is outgoing correspondence.
It is a letter to the local authority from Dr Southall about Child D.  He says, 
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“I just wanted to ask if there was any progress with respect to Social Services 
involvement with this child.  As you know I have major concerns about his highly 
restricted diet and other activities concerning his care”. 
That is at 3d.  Professor David, at paragraph 105 – I need not take you to it again, but in 
relation to all correspondence we have seen either to or from the local authority with all the 
clinicians copied in, he makes a point that it is important that this information was available 
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to others involved in the care of the child, or potentially involved in the care of the child, and 
this letter should have been filed in the child’s hospital medical records.  He goes on in 
paragraph 105 to make specific reference to this letter. 
Then we get to the letter at 2b, which is at page 264.  This is a letter from Professor Strobel to 
the GP, with a copy as we see to Professor Warner and Professor Southall.  This is the letter 
at 2b.  it is a letter from professor Strobel to the GP about Child D: 
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“I reviewed Child D with regard to his recent poor health.  You will be aware that he 
had 2 anaphylactoid reactions recently which needed hospital admissions and 
Adrenalin either via a medihaler and/or intramuscular injection.  The first trigger 
might have been a raspberry ice cream which he had when the parents were visiting 
Legoland, the trigger for the second reaction had not been identified.  He also seemed 
to be relatively poorly and complained frequently about something in his throat.
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Occasionally these feelings subside on inhalation of the medihaler Epinephrine. 
On examination today I found him relatively well.  He did have a sore throat and a 
minor fluid collection behind his right ear drum otherwise there were no other signs of 
minor infections.  I wonder whether these intercurrent minor infections might well 
have changed his general well being and discussed with the parents that this may well 
have been the underlying pathology.  It seems that Phenergan administration is 
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helpful under these conditions and I have suggested a 7-day course of 0.6ml 
Phenergan once a day.  We will shortly be admitting him for food challenge to our 
ward.  In view of his atopic state and pronounced asthma I would ask you whether 
you would be so kind as to immunise him against Influenza according to the CMO’s 
instruction.  It would be appropriate for him to have an inactivated or a split virus 
vaccine”.
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I read that letter in full for a reason.  This letter is analysed at some length, I anticipate, by 
Professor David in his report.  Unfortunately I have got all the references muddled up.  That 
is 2b in the Appendix.  It is an important clinical letter giving important clinical information.  
I need to take you back to the letter at 2a, which is at page 273.  This is the letter where 
effectively Professor Strobel is offering to admit the child at Great Ormond Street because of 
the modalities, as he put it, of the child going to Southampton under Professor Warner.  
Professor David’s point is that this is a letter, as are all the others, which contained important 
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clinical information which should have been in the child’s hospital medical records.  He sets 
out his reasons, based on this letter, which are generic to all of them why he cannot 
understand and does not accept Professor Southall’s defence to all this saying that these are 
all child protection matters and therefore should not be in the hospital medical records. 
I need to take you, please, to Professor David’s report in Appendix One, which is at C3, 
Section 7(b) at paragraph 80, page 32 of the report.  This is Professor David’s comment 
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where he took this letter as an example of the point he was trying to illustrate as to why it 
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contains important clinical matters, and you might like to note down that this was re letter 2a.
He says, 
“Rather than attempting to categorise each item as with the previous subheading, let 
us take (just as an example) the letter dated 5 September 1995 from Professor Strobel 
to the GP .  What I have set out below is a list of the components of this letter. 
B
 
Child D seen by Strobel, along with his parents, at GOS on 5.9.;95. 
 
Child D looked well, and was active. 
 
Child D’s eczema for his standards was reasonably well controlled. 
 
Child D had only minor reactions on his face and elbows. 
 
Child D’s eczema on his ankles and knees was quite marked and excoriated. 
 
Child D’s weight was [that given] and height [that given]. 
Mother reported a 10-day episode when Child D refused to eat following an infection. 
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According to mother child D lost 8lbs during this period… 
 
On avoiding rice it seemed that his puffiness was reduced. 
Today, Child D’s appearance was much less swollen than when Strobel had seen him 
before.
Child D did have one episode of shivering possibly after extensive sweating and 
occasional pains in his hip and knees which prevented him walking for long periods. 
Food introduc5tion programme under Warner’s supervision in Southampton rejected 
D
by mother because of the modalities. 
 
Mother was not prepared to leave Child D in the hospital without her presence. 
 
To gain some more headway, Strobel suggested alternative procedure. 
Child D to be admitted under Dermatologist Dr Atherton for occlusion treatment of 
his eczema. 
Use this period for food introduction after supervision and with experienced nurses 
and dieticians at hand. 
E
Strobel knows this was not the optimal way but mother agreed to leave him alone 
during the day while challenges performed… 
Strobel wished to thank all of you for your efforts and hoped that in the end we will 
come to the bottom of his problems and maternal and child interactions. 
 
Please let me know about your thoughts. 
 
Copied to Warner Southall and Atherton 
F
 
The letter from Hempsons dated 24 January 2006” – 
That is the letter at C2, 6(c) – 
“says this letter related to child protection issues, and that accordingly it was denied 
that it was obligatory for this document to be filed in the medical records. 
G
I have real difficulty understanding how one could reasonably categorise the 
ingredients of this letter as relating to child protection issues. 
I have tried hard to comprehend this assertion.  As I see it, the child protection 
concerns had been in a major part that the reported food allergies were not genuine or 
were seriously exaggerated or distorted, that the child’s dietary elimination was not 
necessary and that other alleged interventions (such as using a wheelchair) were 
H
unnecessary and therefore harmful.  Clearly the doctors looking after the patient 
T.A.  REED 
Day 3 -  37
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wondered about the extent to which the allergies were genuine, a common worry in 
the management of such patients, and there was general agreement amongst the 
professionals that the way to establish the true position was to admit the child and 
perform food challenges.  The mother (as is so often the case in this type of patient) 
was worried about leaving her son for prolonged periods in a unit in Southampton 
with which she was unfamiliar, and so Strobel suggested an alternative plan whereby 
the child could be admitted to Great Ormond Street, a more familiar environment, so 
B
that his eczema could be improved and so that some food challenges could be 
performed, in other words, achieve much the same end (but with the added benefit of 
dermatology input) as had been intended in Southampton. 
As I look at this letter, which describes eczema, growth, a 10-day period of being 
unwell accompanied by weight loss and skin improvement, mother’s unwillingness to 
have child D admitted to Southampton for food challenges addressed by a similar plan 
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of action at Great Ormond Street, and finally soliciting the views of the recipients of 
the letter, it is hard to see how one could reasonably label the contents as being related 
to child protection issues. 
In trying to seek an alternative perspective, I did wonder if the argument is that 
because Southall had child protection concerns, that he therefore regarded the case as 
a child protection matter pure and simple.  I suppose the argument would then have to 
D
be that the eczema, the intercurrent illness and so on were no longer of any relevance.  
If by any chance that is the position, then I would not be comfortable about it.  It 
seems to me that the correct perspective is to look at the matter from the point of view 
of the child.  He had eczema, he had suspected food allergies, avoiding certain foods 
seemed to be associated with improvement, and his height and weight were recorded.
There were plans to admit him to hospital to further treat his eczema and to perform 
some food challenges.  These are all medical health-related issues.  Information about 
E
them properly belongs in the child’s hospital medical records.  It seems to me that the 
fact that there were child protection concerns cannot and does not negate the fact that 
these were all medical health-related issues”. 
Going on with the chronological jaunt through this SC file, I now need to take you to pages 
262 and 263.  This is letter 1e, and this is a letter which, in paragraph 105 of his report, 
Professor David says is a clinical letter, notwithstanding it emanates from the local authority.
F
It is a letter to Dr Southall relating to this child, 
“I am responding to your letter to martin Banks of October 12 as D’s care 
manager/social worker.  I meet with D’s mother every three weeks and D is usually 
present at every second session.  There is regular liaison with the Great Ormond 
Street Hospital social worker; less frequently with D’s school.  All report no particular 
concerns beyond the management of D’s condition; his performance at school is good 
G
and he mixes well with the other pupils and has made friends; and his visits to 
hospital have generally been a success with staff feeling they are able to work 
effectively with D and his mother. 
D has had several admissions over the last year due to adverse reactions to a variety of 
substances.  There has been no indication that these have happened due to the actions 
of Mrs D.  Indeed on one occasion D has acknowledged taking a decision to consume 
H
a food substance which was untested. 
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My involvement and that of the hospital’s is focused on enabling D to develop greater 
independence and ownership of his condition and his responses to it.  Allied with this 
is preparing Mrs D for this development.  D has been referred to a psychologist in…to 
look at strategies to enable him to be confident in playing on his own outside of adult 
supervision and to be able to control his response to breath difficulties etc if he goes 
into various stages of shock.  Hopefully it will enable D in time to carry his own 
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medication and administer it when necessary. 
Mrs D is very supportive of this approach to make D more independent.  She fully 
acknowledges she finds the idea of relinquishing control difficult.  The 
implementation of these strategies and Mrs D’s response will be monitored on an 
ongoing basis by myself and the psychologist. 
C
To summarise, it is my opinion that all appropriate steps to support D and reduce the 
risk to him are being taken and the situation continues to be monitored”. 
We see a manuscript  note at the end there, “No good”, and I will be putting to Professor 
Southall that that is his manuscript, but I am not asserting that that is a fact at the moment.  
That was a letter at 1e, particularly referred to at paragraph 105 of Professor David’s report of 
this matter, as being correspondence that should be in the hospital records and was not. 
D
The next letter is at page 229, and that is the letter at 1f.  It is a letter from the consultant 
paediatrician, Dr Whiting, to Professor Southall about the child D, saying, 
“This is the chronology I have prepared about Child D to date.  I would appreciate 
any comments at this stage.  It is in a process of trying to set up a professionals 
meeting”. 
E
Then we see the manuscript saying, “To SC file”.  Again, I make no positive averments at 
this stage, but I shall suggest to Professor Southall that it is his manuscript note.  We pick up 
the chronology there referred to at 231.  That is a wrong chronology setting out medical 
matters on each and every page.  We say that you can read it just by flipping through it. It 
may be, it may be not, that the manuscript thereon is Dr Southall’s.  Again, I make no 
positive assertions at this stage about that. 
F
I pick it up at 241.  We see that there is a record in December 1996 which is about the time of 
this letter of Mrs D and young D being seen by herself, Dr Whiting, and the community 
children’s nurse, and reporting medical matters in relation to that.  Over the page, we can see 
further medical matters relating to his current treatment and history, and over the page at 243 
and 244. 
G
The issue arises as to whether that covering letter that we have at both 229 and the 14-page 
chronology at (i)(g) are medical records.  This is a subject that Professor David himself dealt 
with in particular.  In his report at C3, (7)(b) paragraph 107, at page 54, he deals with the 
matter. 
It may or may not be helpful when you reach paragraph 107 just to write beside it that this is 
(i)(f) and (i)(g) of Appendix One relating to Child D that he is referring to. 
H
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There is a discussion which I need not burden you with at the moment but that may well be 
examined when Professor David gives evidence.  Can I pick it up at 112 where Professor 
David is asking himself, as it were, the exact question as to whether the letter, the 
chronology, should be considered to be medical records? 
“….or were these items rather like case conference minutes for which storage in a 
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location separate from the hospital medical records would be quite acceptable?” 
He says:
“Certainly, this is not straightforward clinical correspondence, for example reporting 
on the clinical condition of a patient.  The very brief covering letter indicates that 
Dr Whiting was preparing for a professionals meeting, and in the context of this case 
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there can be no doubt that this was part of a child protection process….” 
Professor David points to other letters in the SC bundle indicating the child protection 
concerns.
I can pick it up at 115 on page 56 in Professor David’s report.
D
“Clearly the letter and chronology were not non-medical purely legal documents like 
case conference minutes or letters from the local authority ….. 
 
In fact, the content of the chronology almost entirely concerned medical matters.  It 
was sent from one concerned paediatrician to another concerned paediatrician, the 
sender seeking the comments of the recipient.  In my view, the content and purpose 
places the chronology (and accordingly its covering letter) into the category of 
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medical records.” 
Copies of the letter should have been filed in the child’s medical records, he says. 
The next letter in time I need to take you to is 215 in C6, the SC file relating to this child. 
THE CHAIRMAN:  Dr Sarkar has a question. 
F
DR SARKAR:  Is there any particular reason why the chronology is filed twice in this 
respect? 
MR TYSON:  It is field twice.  Professor David deals with this matter.  I can go into the 
details if I need to but it is a matter covered in Professor David’s report, one being a faxed 
copy of the other. 
G
Going back to Professor David’s report, we can see that he deals the issue as to there being 
two copies of this matter at 109 and 110, page 54 (C3, 7(b), page 54). From 108 to 110, and 
thereafter there is an extensive discussion as to why there were two copies of the letter in 
there, and Professor David’s analysis of the situation, which I was not actually going to 
burden you with in my opening, but I could if you want me to.  I appreciate the panel’s 
attentiveness and that they have noted that there are some duplicates within this bundle. 
H
T.A.  REED 
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I took you back at C6, which is the SC file relating to this child, at page 215.  This is the 
letter at (iii)(e); i.e. outgoing correspondence.  It is a letter between two consultants related to 
Child D and thanking Dr Whiting for the chronology and seeking attendance at it. 
Professor David deals with this matter at his paragraph 105 and says that it is a letter that 
should have been in the child’s medical notes. 
B
The next letter in time is at 216 and 217.  This is the letter at (iii)(f) where Professor Southall 
takes up the cudgels again on behalf of this child and says that he is extremely unhappy with 
the situation with respect to it and he thinks that
“….more action should be taken to protect him from what I consider to be the harmful 
fabrications of his mother.  I have now also read through a chronology concerning 
particularly [Child D’s] recent history (completed by Dr Whiting) and once again 
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I am extremely concerned that his mother is grossly exaggerating his symptoms.” 
He goes on to deal with various matters arising out of the chronology and urges that there 
should be a case conference. 
Again, Professor David at paragraph 105 of his report at 7(b) indicates that this is clinical 
correspondence and it contained important information about this child. 
D
The next letter in time is at page 214, which is the original copy of the third-party letter.  This 
is a letter to Professor Strobel from Dr Whiting.  You see at 214a, Professor Southall is 
copied in to this letter.  This is a letter as at (ii)(c) indicating that there was sharing of a lot of 
concerns about Child D and his management and acknowledging that Professor Strobel had 
agreed to set up a multi-agency professionals meeting at Great Ormond Street, and 
Dr Whiting’s view that that should be without the parents at first instance. 
E
The penultimate paragraph on that page:  
“I am very keen to work with you and all the other professionals involved towards an 
agreed plan for [Child D’s] management, which covers all the angles, including the 
child protection ones.” 
F
We now go back to pages 208/209.  This is letter 2(d).  This is a letter from Professor Strobel 
to Dr Whiting with all the medical professionals involved in the case listed as recipients of 
this letter at page 209.  It is Professor Strobel’s recording of the results of the clinicians 
meeting which was held at Great Ormond Street Hospital, and sets out the aspects that were 
agreed, mainly clinical matters. 
“Every profession agreed that it would be most appropriate to work with the mother 
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and parents to find out about the extent of [Child D’s] existing allergies. 
Having reviewed the chronology…. it was felt that false reporting of the severity of 
[the child’s] symptoms …. remains a distinct possibility and needs to be ruled out or 
confirmed.” 
At the fourth bullet point:
H
T.A.  REED 
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“There was no doubt expressed that [the child] is an atopic boy who may suffer from 
occasional local and/or moderate systemic reactions ….  It was noted however that 
there were occasionally discrepancies …..” 
At the next bullet point: 
“In view of this background it was suggested that clarity about [the child’s] overall 
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clinical condition…. gained during an assessment on neutral medical grounds…..” 
And the like, and at the penultimate bullet point:   
“Failing appropriate collaboration on the parental side during this medical assessment 
one would need to consider other measures if this working in partnership could not be 
achieved.
C
“At that stage….. a case conference….” 
So that is March 1997 and that is at 2(d).  Professor David comments in particular on this 
letter at paragraph 106.  I am not taking you to Professor David’s report of this letter, but that 
is 2(d).  That is March 1997. 
D
Then we have 2(e).  This is June 1997 and there we need to go to page 75.  This is a letter 
from Dr Whiting to Professor Warner asking, effectively, Professor Warner to proceed with 
arranging in-patient assessment of Child D during the forthcoming summer holidays to  
undertake the appropriate food challenges, paediatric and psycho-social assessment.  One 
sees that copies of that are sent, including Professor Southall, and that is 2(e). 
The next letter in time is at page 196 and this is a letter (which is 3(g)) from 
E
Professor Southall to the local authority coordinator dealing with the matter, with copies to 
all the people involved from Professor Southall, indicating that he had heard there were some 
problems with regard to D’s admission to Southampton General Hospital for his alleged life-
threatening allergic problems and indicating, half-way down: 
“My understanding from Dr Whiting is that the mother is making all sorts of 
objections to the plan that we have agreed between us and I feel strongly that if she 
F
will not concede to [Child D] being admitted to Professor Warner’s unit that a case 
conference should go ahead …”. 
This is a letter that Professor David says in paragraph 105 of his report is clinical 
correspondence notwithstanding that it is addressed to a member of social services.  One only 
has to look at who the copies are made to. 
G
Then if one goes to page 185 and 186, this is letter 3(h).  I d not know if yours has a blank 
page in between the two pages. It is a letter from Professor Southall to the local authority 
relating to this child, saying: 
“I am sorry that you feel unable as yet to proceed with a child protection conference 
…”,
H
and setting out the clinical reasons why Professor Southall believed there should be one.
T.A.  REED 
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“1.  I consider [Child D] to be at significant risk of suffering harm as a result of his 
mother’s actions.  These relate to the fact that he is being given a very powerful drug 
adrenaline without, in my opinion, adequate evidence that he suffers form 
anaphylactic reactions.” 
Professor Southall sets out in paragraphs 2 and 3, 4 and 5, various other clinical matters as to 
B
why he believed that further action was required.  Again, Professor David says that that 
document should be in the medical clinical records.
I then need to take you to page 76 to 77.  This letter is 2(f), a letter from Professor Warner in 
Southampton to the GP, with copies to all the other consultants who we are now familiar 
have been involved in this case, saying that he had arranged to see Mrs D and Mr D to 
discuss issues relating to D’s potential assessment at Southampton.  He says there was a 
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consultation that ranged far and wide over the needs for the assessment and having discussed 
the matter he ends up over the page, at page 77, saying: 
“Obviously the issues about whether he comes down to Southampton or not are now 
totally out of my hands.” 
So he has given the mother the various indications of what the child should expect were he to 
D
come to Southampton.   
I pick up the story further at page 70.  This is an important letter (2(g)) because it shows that 
eventually the child did attend at Southampton and the various tests were carried out. 
Professor Warner was able to make the diagnoses there recorded on page 70 in relation to this 
child, namely extensive and severe allergies and asthma and episodes of acute angio oedema, 
urticaria and anaphylaxis.  He indicates in the main paragraph? 
E
“Further to my report of the 24th June 1997”, 
and that is 2(f) to which I have taken you, 
“I have now seen [Child D] and both his parents for an outpatient attendance to our 
Day Ward”, 
F
and he sets out the various tests that were carried out and in the middle of page 71 setting out 
the various allergy prick skin tests and indicating at the bottom of page 71: 
“On the present evidence I have no doubt that [Child D] has extremely severe allergic 
problems.  However, I also believe that it should be possible to achieve better control 
of his problems with an appropriate strategy.  Mr and Mrs D are now, I think, rather 
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more confident in my team …”. 
This is a very important clinical letter relating to this child, with a diagnosis from a professor 
at the University Hospital to which he had been referred by Professor Southall, and should 
absolutely obligatorily have been in the hospital medical records.  This letter, in particular, is 
a letter which Professor David mentions in his second report at C3, 7(b), page 32, paragraph 
78.  At paragraph 78 he is talking about third party correspondence: 
H
T.A.  REED 
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“Some of these items, for example the report from Warner dated 16 September 1997 
… is pure clinical information and opinion.  There is no mention of child protection 
other than the fact that the first named recipient of the letter was a child protection co-
ordinator for … Social Services.  One might say something similar about the letter 
from Dr Whiting to Professor Warner; the words ‘child protection’ do not appear.” 
It is in connection with paragraph 78 that I would just ask you to turn back the page to 
B
paragraph 75, which is a passage which I keep referring the Panel back to, that it is 
particularly important that correspondence between clinicians of this kind should be in the 
hospital medical notes.  Professor David is making the additional point in relation to this, that 
in fact it is an important clinical letter irrespective of whether there are child protection 
matters, and in fact there is hardly any mention of child protection matters in it in any event. 
To nearly complete this matter, can I take you to page 41?   This is a letter from a consultant 
C
psychiatrist Dr Macauley to Professor Southall.  This is letter 1(h) and he is enclosing an 
account by a Caroline Fynn in that letter, and the Caroline Fynn letter is at page 48 to 50. 
So page 48-50 is part of 1(h), and 48-50 is an account by one staff nurse dealing with her 
contact with Mrs D and making medical and other observations on Mrs D.  I need not take 
you to the letter in particular, but again Professor David said that the covering letter at page 
41 and the actual letter from the nurse at page 48-50 are items, 1(h), and are clinical medical 
records which should have been in the hospital files. 
D
If I can take you now to page 30, this letter is 1(i), and it is a letter from Professor Warner to 
Dr Southall about Child D. 
 
“Thank you for your letter ….. 
 
[Child D] certainly has acute severe allergy.  If he is exposed to any of the food 
E
allergens it may well be necessary for him to receive adrenaline, either inhaled or 
injected.  As the former has just been withdrawn from the British Pharmaceutical 
market we are only left with subcutaneous adrenaline.  Obviously, however, one 
would hope and expect that it would be a rare event for [Child D] to have any 
inadvertent exposures. 
With regard to being cared for in a wheelchair, as far as I am aware, this is neither 
F
necessary nor actually happening.” 
Again, I draw your attention to the manuscript on this document, which appears to say, “Can 
I have [Child D’s] hospital [and] S/C file ASAP”.  Again, we would say that is an important 
original clinical document which should be in the child’s medical records. 
Can I go further back, please, to page 25-27, which is 2(h), and is a follow up to the earlier 
G
September letter from Professor Warner.  The September letter from Professor Warner we 
have seen, and obviously the diagnosis remains the same, and over the page, that second 
paragraph:
 
“I have now agreed with [the] parents that we should arrange [for] a 36 hour 
admission”. 
H
Again, an important clinical record, we would say. 
T.A.  REED 
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Can I take you to page 21.  This letter is 1(g), a letter of 18 December 1997 from the 
Professor at Great Ormond Street to Professor Southall, dealing with the Dr Macaulay letter, 
which I have taken you through, and setting out that Professor’s medical dreams, as he puts it 
in the penultimate paragraph: 
 
“…is that [Mrs D’s] problems could be managed by continuing involvement of a 
B
limited number of professionals including mainly the GP, a Paediatrician and 
Consultant Psychiatrist.  I am aware that this may remain a dream but I have no other 
bright ideas at this moment.” 
That letter, as I say, is at 1(g). 
At pages 16 and 17 there is a further follow up of this child at Southampton.  Again, there is a 
C
diagnosis, there is in addition to the diagnosis of hyperimmunoglobulin E syndrome, as well 
as acute severe food allergies, asthma and eczema, and reporting progress by May 1998: 
 
“We have been very slowly and painstakingly working through a programme of 
double blind challenges on [Child D] to establish where dietary exclusions can be 
relaxed and where there is a need for them to be maintained.” 
D
A few lines further down: 
 
“Both [Child D] and his parents are very happy to follow through with this 
procedure.”
It sets out about corn challenges, lactose challenges, soy challenges, and the like.  Then it sort 
of issues a health warning on page 17, last paragraph: 
E
 
“I should emphasise that [Child D] and his parents are very happy with the current 
approaches to investigation and treatment.  There is no question about any issues 
related to his current clinical state and management.  However there appear to be 
continuing exchanges of correspondence between various individuals who have been 
involved with his management in the past, copies of which his parents have.  This 
obviously is having a major undermining effect and maintaining an acrimony which I 
F
feel ought now to be resolved.  I have said to his parents I would prefer to draw a line 
under all events that have occurred in the past.  I feel I am now very confident and 
happy that his diagnosis and management are entirely appropriate.  We are following 
through a plan of investigation which has been agreed by all.” 
This is a long saga, Madam Chairman, but it might be you can see the concerns of Professor 
Southall at the beginning had eventually been, one would hope, laid at some degree of rest. 
G
Taking you to page 9, this is 2(j), again it is another letter from Professor Warner to the GP, 
including all the professionals who had been involved, setting out further challenges which 
have been made in respect of a double blind soy challenge and the like, and things are 
improving, and these further challenges are going to be over the next six months for lactose, 
exercise, beef, wheat and rye.  That letter is at 2(j). 
H
T.A.  REED 
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Then we have the letter at page 2, this letter is at 2(k), and it is dated 10 November 1998, and 
again it is a letter form Professor Warner to the GP, again dealing with clinical matters 
relating to this child over lactose challenges, problems (over the page) with the eczema, good 
control over the asthma, and the reports about the exercise challenge and the like, and 
pointing out, at the last four lines: 
 
“…as I have indicated in previous letters there is exceedingly strong evidence to 
B
indicate that he is indeed exquisitely sensitive to some foods of which peanuts, tree 
nuts, fish and shell fish standout.” 
All this correspondence, Madam Chairman, in there we say should have been in Child D’s 
clinical notes, his hospital notes.  None of it was and all of it should have been.
There remains one last matter relating to this child, which is item 4, at page 313 in C6.  This 
C
is a document which we are going to come across in the future as well as now.  It is an 
original medical record.  One can see it is also a computer record, and we will be coming 
back to it when we are dealing also with Appendix 2, but it is a computer record that is here 
with the SC file, and we can see at the top left hand corner what Child D’s SC number is, 
which is 3874.  It is on a computer, a printout is in his SC file, but it is not in the patient’s 
hospital medical records, despite the fact that on its face it refers for this patient to the 
diagnosis of multiple allergies and low body temperature, and it gives clinical information 
D
about the child’s weight, height, age and the like, and why he was admitted to the hospital.  
Again, this is a medical record not in the child’s medical records. 
When I come to deal with head of charge 15 and 16, as with Child A, madam, here in Child 
D there are matters of accessibility of the SC file which, as I indicated in relation to the 
previous child, there is further ongoing dialogue between my learned friend and I as to 
whether that aspect of the accessibility of the SC file to the mother is a matter that should be 
E
developed further. 
Madam, I now come, putting away this file, to Child H. 
THE CHAIRMAN:   Mr Tyson, when you have dealt with Child H, does that conclude what 
you wish to do this afternoon, or should we be taking a break? 
F
MR TYSON:   I had not realised what the time was.   
THE CHAIRMAN:   We have been going for an hour and a half. 
MR TYSON:   Can I tell you, I need to deal with Child H, who I can deal with much shorter 
than I could with the previous child, who was the lengthy one, and then I need to come to the 
computer matters.  This would be a convenient time, madam. 
G
THE CHAIRMAN:   Perhaps we should take a break then.  We will take a fifteen minute 
break now until about quarter-to.  Thank you, 
(The Panel adjourned for a short time)
MR TYSON:  I turn now to Child H.  As you see in Appendix One relating to this child, there 
H
are some seven items.  Before one gets to this child in detail, one needs to have open Bundles 
T.A.  REED 
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C2 and C7.  C7 is the dauntingly large special case file in relation to this patient kept by 
Professor Southall.  Before one goes into it, can I, as a matter of mechanics, ask you to turn to 
(j) in C2?  There you will see a letter dated 30 March 1990.  This is one of the earlier tabs.
You should find there a letter from Great Ormond Street Hospital.  Can I ask that you put 
another letter in that tab, a letter dated 16 March?  (Document handed) 
I have already dealt with Child H.  This is the child that Dr Southall, when at the Brompton, 
B
wrote a letter, a rather unflattering letter about the parents with a copy to an unnamed 
paediatrician at the Royal Gwent Hospital.  Those are charges 7 to 9 and I need not go 
through those again.  As in other cases, this child has a parallel file maintained by Professor 
Southall.  The SC file is SC2026, and we can see that in Appendix One. 
You may recall that the child came into the Royal Brompton on two occasions, one in 
September 1989 and the second time in March 1990.  This was for overnight monitoring.  
C
You will recall that Mrs H thought she was going there to obtain a special device which she 
felt she needed to assist in home monitoring for her child.  There was a telephonic falling out, 
it would appear, between Dr Southall and Mrs H which led to the letter the subject matter of 
heads of charge 7, which is the letter at (i) under C2.  I need take you to that letter. 
At this time Mrs H had been told by Dr Dinwhiddie of Great Ormond Street that her child 
was suffering from something called “Ondine’s curse”.  This is the letter that I ask you to put 
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in at C2 under (j).  This was a letter which the consultant paediatrician at Great Ormond 
Street had given her, 
“To whom it may concern, this letter is to confirm that child H attends this hospital 
and he suffers from Ondine’s curse (irregular breathing pattern) weakness of the 
breathing tubes and asthma.  He also has a tracheostomy breathing tube inserted in the 
windpipe to help with his chest problems.  He will certainly benefit from an ultrasonic 
E
nebuliser for his treatment”. 
Not unnaturally, Mrs H was of the view throughout, having had that letter from the child’s 
consultant at Great Ormond Street that, (a) the child’s problems were real and had an organic 
cause, and (b), that the child needed the triggered ventilator which was what she was 
pursuing through Great Ormond Street via Dr Dinwhiddie. 
F
That is the background.  I now come to the SC file and would ask you to look first at the first 
item here in relation to this child, which is at pages 25 to 31.  I am going to take you to the 
document, then I am going to take you to what Professor Southall says about it, and then 
I will take you to what Professor David says about it.  In order to do that we need to have in 
front of us C7, C2 at section 6, which is the Southall response letter, if I can put it that way, 
and Professor David’s report. It may assist the Panel if you look at C2, 6(c), on the blank 
section under the word, “Hempsons”, 24 January 2006.  This is the letter of that date to which 
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Professor David makes lots of comments.  It is the letter from pages 8 to 19 which sets out 
Professor Southall’s case in relation to SC files, in particular some of the items in this file.  
So you need to have on one side C2 at Tab 6, and C3 at Tab 7(b), paragraph 136, page 64. 
If we look at the SC file, C7 at page 25, we see that this is a document headed with 
Dr Southall’s name, 
H
T.A.  REED 
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“Form to be used for collection of clinical data on all cases (with or without Down’s 
syndrome) who are referred for assessment and management of possible airway 
obstruction problems. 
To be used as an addition to not a replacement for) the form which is used for basic 
data collection on all clinical cases”. 
B
You see the name of the child there mentioned and the date of the recording of the special 
case number.  We go over the page where you can see it asks a lot of questions about the 
child’s health; for instance, on page 27, how does he sleep during the day on most days, or 
the like, and page 28, in the middle, 
 
“Over the past month have you seen him/her wake up with a startle or gasp”. 
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That word there is tracheostomy.  On page 29, in the middle, 
“Over the last week have you noticed him/her snoring or breathing loudly in sleep?” 
The answer was, “if tracheostomy blocked”.  Then, 
 
“When well does he/she sweat when asleep?”   
D
There is a whole series of, we would say, going up to page 31, clinical questions about the 
child, the original of this document not being in the medical records of this child whilst the 
child was at Brompton Hospital. 
If one looks at what Hempsons say about the matter, this is at C2, 6(c) page 19, in the third 
box down, it says:  “Infant Data form. No date”. This is what is said on Professor Southall’s 
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behalf in relation to this document that we have just looked at.
“A doctor or nurse completed this form.  Again, it was data specifically related to the 
investigations that were being undertaken and was in addition to data to be included in 
the main hospital file.” 
Speaking for myself, I do not think that makes any sense, but it is clearly medical data 
F
relating to this child – original documents, not elsewhere in the hospital medical records. 
Professor David deals with this document at page 64 of his report at paragraph 136 (C3 (7) 
page 64) where he says, picking it up at paragraph 139:
“The form indicated that it was to be used in addition to, and not a replacement for, 
the form which is used ‘for basic data collection on all clinical cases’.
G
This is a form for making a detailed record of the history.  It appears to be designed so 
as to ensure that a large number of standard questions were put to parents, questions 
that might well have not been included within a standard routine admission history 
taking process. 
No doubt this data as obtained so as to help interpret the results of monitoring, but 
H
I do not think that the ‘x-ray request form’ analogy can apply here because the 
T.A.  REED 
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information recorded is likely to be well in excess of that routinely recorded in the 
medical records.  These sheets can only be classified as medical records, and copies 
should be filed in the patient’s hospital records.” 
The next item you will see is on page 20.  In our submission, this is one of the most 
astonishing documents not to be in the child’s medical/clinical records.  It is a note of taken 
by MS, as we see at the bottom, and that is Dr Samuels.  It is a clinical note relating to this 
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child.  For reasons which I need not go into at the moment, the most likely date is 16 March 
1990, which is about the last day when the mother and child were in Brompton Hospital.  
This is shortly before the letter that caused concern (heads of charge 7 to 9).  This is a clear 
clinical note taken by Dr Samuels during the March admission of this child.  It refers, as you 
can see, to previous treatments.  It refers to the tracheostomy; it refers to cyanotic episodes; it 
refers to what is described as the parental view:   
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“ trachea ‘needed’,
see ventilation as being answer,
consider [Child H] neurologically normal, but has obvious tremor/ataxia,  
mother does not want him as a ‘cabbage’ 
Impression:     Mother used to [Child H’s] sickness:  ‘sick role’. 
  Wants 
trachea/ventilator 
D
   
likes 
rare 
disease/illness 
 
 
 treats [Child H] as he was as infant – re:  cyanotic attacks 
 
 
 
 
 
 
 
re: trachea….” 
And the other word beginning with ‘l’ and
“re:  general care. 
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“Needs:  PO monitor….. 
 
  Neb… 
              Trachea closed.” 
This is a medical/clinical note par excellence and it is a matter of considerable astonishment 
that the only way that this document can be discovered by a subsequent clinician is to be 
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aware of the fact that there is an SC file on this child and because the only source of this 
document is in its original form in the SC file and nowhere else, a matter compounded, you 
may think, that the SC file for this patient then left Brompton and nestled up in South Staffs 
where the child never was a patient, ever. 
As we can see, going back to what Professor Southall has to say about this matter, and that is 
at C2(6)(c), page 19 just below the entry that I have already taken you to, he says: 
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“This document looks like an original.  It is a note made by Dr Samuels.  I think it is 
the note made by Dr Samuels on 16 March 1990 when he reviewed [Child H] prior to 
discharge…..
Professor Southall did not write this note and he cannot explain how it came to be 
kept in the Special Case file.  It is denied that Professor Southall placed this document 
H
in the SC file.” 
T.A.  REED 
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As is obvious, and I need not take you to Professor David’s version of this, at paragraph 148 
of his report at C3(7)(b) paragraph 148, where he says that this document is something which 
should have been filed in the child’s medical records. 
The next three items in the SC file of which complaint has been made can be taken together. 
Can I take you to page 48? 
B
This is a letter from Dr Dinwiddie to Dr Southall, and again you see the manuscript list, that 
it was put in the SC file 2026: 
“Dear David 
Re:  [Child H[ 
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Thank you for your letter about [Child H].  I am very grateful to you for your help in 
the management of this case and I am sorry that they took up so much of our time 
without them agreeing to your recommendations as to treatment. 
We have very much taken on board your observations regarding the psychosocial 
aspects of this case and we will bear them in mind when we next review him here.  
D
I entirely agree that the whole situation is extremely difficult.  I do however very 
much appreciate your opinion based on such a large experience with his type of 
problem.  This is most helpful to us in our future management of his case.” 
We read that together with item 4 in the Appendix.  That is item 3 in Appendix One and item 
4 in Appendix One is on page 53.  This is a letter from the paediatrician at the University 
Hospital of Wales to Dr Southall, again with the SC number 2026, and one can see where this 
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letter was going from, as it were, Dr Southall to all the others, and then to end up in the SC 
file.  We see that from the manuscript entry on the right-hand side.  This lady is writing to 
Professor Southall (Dr Southall as he still then was) in 1990: 
“Thank you for writing to me again – I shall go immediately to buy a copy of my 
unfavourite magazine The Woman’s Own.” 
F
Pausing there a moment, this child had been featured in an article in that magazine. 
“I have almost lost sleep over this little boy and the problems, but have not succeeded 
in seeing him with his parents though I have tried a few times by writing to them to 
see him in my clinic.  I have also spoken with the Social Worker involved and the 
Nursing Officer for the Health Visiting and we have been trying to have a slightly 
more formal case conference which I will now get under way in the next week. 
G
One or two things here have delayed my being more active and intervening.  Firstly, 
the people who know them say that the little boy seems to be well and well related 
with all the members of his family (though not of normal development).  Secondly, 
there is a very real fear that if we become involved in too high a profile along the lines 
that both you and I are thinking of, that something really will happen to [Child H], 
that is that he is more at risk if we attempt confrontation or opposition to his mother’s 
H
pathological behaviour than if we quietly go along with it.  However, having read 
T.A.  REED 
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your latest letter I really will see what we ought to be doing and I will involve Social 
Services in a more formal way, which I have not done up to now.” 
Then she deals with her own position, as she had not been involved at the request of the GP.   
This letter, which is item 4 in Appendix One, should be read with the letter at page 55, which 
is item 5 in Appendix One.  That is another letter from the same Dr Weaver of 12 June, and 
B
the previous letter was 6 June.  She indicates that she had met informally with the child’s 
general practitioner, the health visiting nursing officer, social services and the educational 
psychologist.  She also indicates that she had taken some informal advice from one of the 
lawyer’s in the Welsh Office.  She also deals with the school history about the child, who was 
dyspraxic:
“I know that he is not really quite a 100% neurologically.  His mother attends the 
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school daily and makes herself useful to the staff, and apparently attends to [Child 
H’s] tracheostomy during break times, but the school have no problem with the little 
boy medically, nor indeed socially or emotionally.” 
She deals with the little boy being quite well adjusted and further matters and over the page: 
“If you feel very strongly that the use of a ventilator at night with [Child H] could 
D
cause damage, then I think I have to ask that you communicate directly with the 
family doctor …”, 
and also indicating, in the last paragraph: 
“I also agree that [Child H] ought to be investigated neurologically which we could 
easily do at UHW …”. 
E
Item 3, which is at page 48, item 4, which is at page 53, and this item 5, at page 56, are dealt 
with together by Professor David in his report at C3, tab 7(b) at paragraph 149.  It says at 
paragraph 149 on page 66: 
“Letters to Dr Southall
F
There are three letters, one from Dr Dinwiddie, and two from Dr Weaver”, 
and he sets out the pages.  He says that the letter from Hempsons makes no reference to these 
letters.
“The letter from Dinwiddie thanked Southall for his input and said that Southall’s 
observations regarding the psychosocial aspects had been taken on board.” 
G
At paragraph 152: 
“The letters from Dr Weaver basically said: 
she had not succeeded in seeing the boy and his parents 
she had almost lost sleep over the boy and the problems 
H
T.A.  REED 
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she had spoken to, and/or met with, the health visitor nursing officer, social 
services, the GP and the educational psychologist 
she had taken legal advice from a lawyer in the Welsh Office 
the boy was quite happy in an ordinary class, though he had dyspraxia and 
language problems and was not quite 100% neurologically 
the school had no medical, social or emotional problems 
other professionals were very aware of the mother’s ‘pathological attitude’ but 
B
felt that the boy was quite well adjusted, happy and well cared for in every 
other way. 
the feeling was that he was treated perfectly normally until anyone enters 
discussion about illness which then assumes enormous proportions and 
importance. 
‘we’, together with the GP, feel that any threat to intervene in this abnormal 
C
illness behaviour could possibly result in serious consequences for the child, 
thus ‘proving’ he had a potentially lethal problem. 
if Dr Southall felt very strongly that the use of a ventilator at night could cause 
damage, then he was asked to communicate directly with the family doctor 
and Social Services, indicating the danger to which he was being exposed by 
ill advised medical management. 
local feeling of exasperation, but fear that one could make matters even worse 
D
if one was not very cautious. 
agreed that the child should be investigated neurologically, could be done at 
UHW.
will wait to hear from Dr Dinwiddie (to whom the letter was copied)”. 
Then paragraph 153: 
E
“In my view these letters, which all contained important information, should have 
been filed in the patient’s hospital medical records at the Brompton Hospital and the 
Great Ormond Street Hospital for Sick Children.” 
They were not; they were not in the Brompton records of this child, they were kept in these 
parallel SC files, thereby, we say, being in accessible for others. 
F
The next item in Appendix One relating to this child is item number 6, which is at page 114.
The letter at page 114 is a letter of 25 July 1991 from the University Hospital of Wales to 
Dr Southall.  I need to put this letter in context.  By this time, which is a year or so after the 
child had been seen by Dr Southall, a court order had been obtained that the child should 
attend overnight monitoring at the University Hospital of Wales and that the tapes would be 
analysed at Dr Southall’s unit at the Royal Brompton.  That is the context of this letter. 
G
It is a manuscript letter from Dr Weaver’s senior registrar, Dr Mattles: 
“Dear Dr Southall 
Enclosed are the first tapes on [Child H] …  We have not had any problems since 
monitoring began on the 18/7/91.  However, I should be grateful if these tapes could 
be looked at so that we can ensure that there have not been any technical problems 
H
with the recordings.” 
T.A.  REED 
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I anticipate that when Professor David is shown this letter, which it appears that, extremely 
unusually for him, he overlooked when asked to comment on Appendix One, he will say that 
this is a hospital medical record that should have been filed in the hospital medical records 
and was not so filed.  Equally, Professor Southall is silent on this letter. 
The final item in the SC file relating to this child is item 7, which one sees at page 332.  This 
B
is October 1992, almost a year after the previous letter, and again, to put this letter in context, 
due to concerns about parental care the child had been fostered for a period and also the 
tracheostomy had been repaired, i.e. the tube taken out, as I understand it.  This is a letter at 
that period from Dr Weaver to Dr Southall, who was by then back at Stoke as a professor.  It 
says:
“You will be pleased to hear that [Child H] is now at home full-time, but that a 
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Supervision Order was recently granted to Social Services for a further 12 months.  
No orders were made in respect of …”, 
the children there mentioned. 
“We have had a pretty smooth run over the past year, I would say, in that we had a 
particularly good foster family and there were no major upsets.  [Child H] is needing 
D
help in school, but his health has been very good and, apart from a persistent slight 
tendency to leak from the tracheostomy site when he has a cold, there has been no 
medical problem. 
His parents were not keen for me to do anything about the tracheostomy site and I am 
happy to wait, although I think possibly in the future, it might need a little surgical 
attention.
E
Thank you for all the hard work you put into this case – it looks as though we shall 
proceed in a pretty normal way now and, perhaps, better than we all thought at first.”. 
You will see the manuscript, that this letter was to be placed in the SC file, about which 
Professor David comments at paragraph 157 of C3 7(b), paragraph 157 at page 68.  I can take 
you, cutting to the chase, to paragraph 160, where Professor David says, in relation to this 
F
letter: 
 
“In my view this letter, which contained important information, should have been 
filed in the patient’s hospital medical records at The Brompton Hospital ….. There 
was reference to a foster family, and a Supervision Order, but I cannot see that as 
being a reason to exclude the letter from the child’s hospital  medical records.”  
G
Madam, that is all I have to say in relation to SC files and Appendix 1 in relation to this and 
indeed any other patient, but this patient appears as a subject of head of charge 13 and 14, 
which, if I can take you to head of charge 13 and 14, is in my respectful submission self-
explanatory.  Head of charge 13(a) says: 
“a. 
You treated both Child A and Child H at the Royal Brompton Hospital, and 
there created an “S/C” file for each child, 
H
T.A.  REED 
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b. 
Each such “S/C” file contained original Royal Brompton Hospital medical 
records,
c.       You took, or caused to be taken, the “S/C” Files relating to both Child A and 
Child H away from the Royal Brompton Hospital and to the North 
Staffordshire Hospital;” 
B
Head of charge 14 reads the consequences of that.  We would say, not unnaturally, that if you 
take away a file about which little is known, and which contains original medical records, 
away from the hospital where those records belong, you are making the question of 
accessibility of these original medical records so inaccessible to subsequent clinicians we 
would say almost to the point of invisibility. 
Again, in relation to this case there are further issues as to accessibility of these records, and 
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this is the third matter which I need to discuss with my learned friend. 
Finally, can I come to the issue of computer records held by Professor Southall at the North 
Staffordshire Hospital, and then we deal with heads of charge 15 and 16 and Appendix 2.
Head of charge 15(a) says that: 
“a. 
On the computer system held at the Academic Department of Paediatrics, 
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North Staffordshire Hospital you maintained, or caused to be maintained, the 
medical records set out in Appendix 2,” – we will go to those - 
“b. 
These computer medical records are not contained in children’s hospital 
medical records at either the Royal Brompton Hospital (for Child A and Child H) or 
the North Staffordshire Hospital (for Child D and Child B), 
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c. 
Neither Child A nor Child H were treated at the North Staffordshire Hospital, 
but only at the Royal Brompton Hospital;” 
The case in relation to that is head of charge 16, and in particular we assert these amounted to 
keeping secret medical records on these children.  The point being, this is not on the hospital 
computer system, this is a local PC sitting in the Paediatric Department, this is Professor 
Southall’s own PC we are talking about, his own personal computer, that he kept computer 
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records relating to these children on his own PC at the Department.   
In our submission, these heads of charge are extremely serious.  The complainants only very 
recently learnt of the existence of the computer records held by Professor Southall.  Their 
discovery came back in a way which has been explained in a statement that my partner 
instructing solicitor has drafted, which I understand is now in a form that is agreed that I can 
put before the Panel in order to cut this matter short, and accordingly at the next C number, 
G
I will take you to various paragraphs of this document. 
THE CHAIRMAN:   We will call it C8.  (Document handed)
MR TYSON:   Document C8 is a witness statement of Sarah Louise Ellson, signed by her 
and dated 15 November 2006.  You will need to have one document in front of you when you 
read that, and this is bundle C3, at section 7, subsection (d), and within (d), (v), so it is C3 
H
7(d)(v), and it should be a document entitled “Security guidelines”. Just have that at one side 
T.A.  REED 
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as I take you through a number, but certainly not all, of the paragraphs of this witness 
statement.  If my learned friend wants me to take you to others I will gladly so, but the edited 
highlights, if I can put it this way, you will find at paragraph 1: 
 
“I, Sarah Louise Ellson will say as follows: 
2.
I make this statement to supplement my earlier statement ….. which dealt with 
B
my inspection of [the] original ….. (‘SC’) files. 
3.
In this statement I set out the background to documentation obtained from 
Professor Southall, via his solicitors Hempsons, from what I understand to be 
the Academic Department computer. 
4.
On 24 January 2006 Hempsons solicitors wrote to the General Medical 
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Council.”
Just pausing there, and that is the letter that we have been constantly looking at, giving 
Professor Southall’s version of the various events, which is 6(c) in C2.
It indicates that on a page of the letter that: 
D
 
“…reference was made to protocols being established by Professor Southall, 
including a protocol as to how Professor Southall would deal with confidential 
documents.  As a result of this letter I wrote to Hempsons ….. on 8 February ….. 
asking that they provide any particular written documentation relating to the 
protocol(s).  As a result, on 16 February 2006, I was provided with a one page 
document entitled ‘Security guidelines for Academic Department of Paediatrics’.” 
E
This is where I need you to cross-reference to, and it might be worth writing under paragraph 
4, “C3 7(d)(v)”.  If I can just take you to that North Staffs document for a moment, it defines 
what “information” is, and including (i), (ii), (iii), (iv) and (v), and (i) related to social 
services and medical information on a patient about child abuse;  (ii) were files relating to 
controversy on covert video surveillance;  (iii) were video tapes relating to covert video 
surveillance;  (iv) was recording tapes of events relating to child abuse;  and (v) was 
computer disks containing correspondence on any of the above. 
F
Returning to paragraph 5of this witness statement: 
 
“As pointed out by Hempsons in their letter of 16 February 2006 ‘information’ was 
defined to include computer disks.  Accordingly, on 1 March 2006 I wrote to 
Hempsons ….. stating ‘we trust that these [computer disks] have been securely stored 
and therefore now request your client provides all computer disks relating to the SC 
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files in this case’.” 
Then there is a history of various chasing – perhaps I need to read paragraph 6: 
 
“On 21 March ….. I wrote again asking for ….. further ‘information’ held by 
Professor Southall on computer to be provided as soon as possible.  I also wrote that 
day to the University Hospital of North Staffordshire, with whom I have previously 
H
had correspondence in order to obtain access to paper records.  I explained to them 
T.A.  REED 
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that I now had reason to believe that there might be material held on computers or 
word processors and I asked them to clarify what information was held on computer 
systems at North Staffordshire Hospital (both on the main system and any separate 
word processors). 
7.
On 23 May 2006, presumably as a result of my request, the North 
Staffordshire Trust wrote to Professor Southall indicating that I had made this 
B
request and asking him to consider whether he had any ‘structured or 
unstructured information including electronic or manual systems’ and asking 
him to consider the ‘HISS, PC and email files’.” 
Then there is a number of more chasing.  I need to pick it up at paragraph 13: 
 
“I had to write to Hempsons again on [the dates there set out] chasing for computer 
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information and a schedule of the analog tapes and chart recorder print outs ….. 
Finally on 18 August 2006 ….. I received 11 pages said to be print outs of the 
‘computer database’ held in the cases of [B, H and A].” 
I need to take you back to the middle of paragraph 9 where we were promised A, D, H and B, 
so on 18 August we got, as it were, three out of the four.  The statement continues, 
D
 
“We were told that there was no recordings file for M”. 
That is perhaps not surprising because M was never a patient at any time.  He was merely 
assessed with his eldest brother by the professor.  The statement continues, 
“The letter from Hempsons was silent on the issue of documentation relating to the B 
case despite earlier correspondence on 27 June 2006 indicating that there would be 
E
computer records for this child”. 
I need to take you to paragraph 18 where, sensibly, the solicitors agreed to try to sort out this 
matter of computer records, so they all met on site.  Paragraph 18, 
“I met with Professor Southall (with his solicitor from Hempsons) shortly after 11 am 
on Tuesday 31 October”. 
F
That is two weeks ago. 
“We met at the Academic Department for Paediatrics at North Staffordshire 
Hospital”.
Then I take you to paragraph 31, 
G
“I was then shown a computer in the Academic Department.  I was informed that this 
computer was stand alone and was not networked to other computers.  It was clarified 
that it was from this computer material had been printed and sent to Field Fisher 
Waterhouse”.
That was the material relating to the three patients. 
H
T.A.  REED 
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“It was explained that actually the computer I was being shown was a physically 
different computer than the one originally used by Professor Southall and his team.  
I was told that his computer was seized [for a period]…Professor Southall was given a 
new (upgraded ) computer onto which his files and databases had been transferred.  It 
was this computer being viewed today”. 
Paragraph 34, 
B
“Professor Southall explained that there were two databases on the computer, ‘SC 
File’ and ‘Recordings’.  When the computer was returned to him he found that the 
passwords had been altered for these databases and he had only recently (this 
summer) found out the new passwords (which in fact were the same as the old ones 
but with two additional digits at the beginning. 
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I asked who would have access to the computer and these databases.  Professor 
Southall thought that he, together with Dr Samuels and the Clinical Physiological 
Monitoring Technician (a nurse) would have known the password and would have 
been responsible for entering the data. 
In my presence Professor Southall opened the ‘SC File’ database first (it uses 
Filemaker software).  He demonstrated that there were a variety of layouts to display 
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the information held on each case but it appeared that ‘layout #1’ was the most 
comprehensive.  This creates documents which are headed ‘Patient’s Data’.” 
Can I pause there for a moment and ask you to look at the SC file relating to Patient H, which 
we have at C7?  Right at the back there should be a little tab and you will see on the third 
document in it is headed “patient’s data” in the middle.  In the top left hand corner it has, 
“Filemaker Pro”, and then “layout #8 Records 4449”.  It gives the patient’s SC number, 
E
which is 2026, and we see who the patient is, who the referring consultant is and gives a 
diagnosis of self-resolving cyanotic episodes, upper airway obstruction, “??Munchausen’s 
Syndrome by Proxy”, and the admissions that were made in September 1989 and March 
1990.
That was an example, going back to paragraph 36, of a cross-reference.  The statement says, 
F
“In my presence Professor Southall opened the ‘SC File’ database first (it uses 
Filemaker software).  He demonstrated that there were a variety of layouts to display 
the information held on each case but it appeared that ‘layout #1# was the most 
comprehensive”. 
In fact you can see in the top left hand corner that this was layout #8.  It continues, 
G
“This creates documents which are headed ‘patient’s Data’.  (In fact I noted when I 
reviewed the documents again that we have been provided with screen shots of layout 
#8 for D and A but I am reasonably satisfied that this is the same information as was 
on layout #1. 
Professor Southall indicated to me that he had searched for all the families relevant to 
the General Medical Council case on the database and had printed out and sent (via 
H
his solicitor) the ones he had found.  He had not previously been able to find anything 
T.A.  REED 
Day 3 -  57
 & CO. 

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A
for B, however, in anticipation of my visit he had tried again and on this occasion had 
located an entry for her.  We searched under B and the computer suggested that there 
were 30 or so records.  We then searched B and located the one entry for Child B. 
Professor Southall could not explain why he had not been able to find this entry 
previously and suggested that he was concerned that somewhere in the transfer of the 
databases to his new computer there may have been some form of corruption, he felt 
B
that the system was not now totally reliable”. 
Paragraph 39, 
“Professor Southall then printed out the page we had found for Child B.  He explained 
that a further problem created by the transfer of the database and/or the use of a new 
printer was that the layout when printed was not correct (some text prints over other 
C
text).  For this reason, for some of the printouts he has supplied Professor Southall has 
prepared a screen shot version of the data”. 
As I understand it, the document I was just showing you is a screen shot.
“The data printed out for B from this database consisted of one page.  I asked if there 
was other information held on this database about this family but Professor Southall 
D
informed me that the sheet printed out held the entirety of the information on that 
family (that he had been able to find). 
On this database there are 4449 records.  This figure can be seen for example in the 
screen shot version of the printout for D2”. 
We can see it on the example I showed you from C7.  Whether that indicates that there are 
E
4,449 SC files held by the professor is a matter that will have to be explored in evidence, but 
it is certainly indicative that there are a large number of SC files about.  It is said at paragraph 
42,
“We then repeated the search exercise for the other families.  On this database we 
found one entry for H, one for B and one for A.  We had earlier been sent these 
printouts by Hempsons on 18 August 2006. 
F
I was then shown the second database ‘Recordings’.  This database contains the 
template letter where the information, ‘We performed an x-hour overnight recording 
on the (date) with records and signals and result set out”. 
Pausing there a moment, as we are looking at C7, just turn back one page.  This comes from 
the recordings database as opposed to the special cases database. So there are two databases.
G
One is a recordings database and the other is special cases database.  We can see that this has 
a number of inherent problems, but let me deal with the positive aspects.  You can see that it 
is a letter to somebody relating to SC case 2026 indicating that, 
 
“We performed a 12 h overnight recording on the 28 September 1989”, 
and setting out what those recordings were and making a nil recommendation.  On the 
H
previous page you can see a similar matter from the recordings database relating to the earlier 
T.A.  REED 
Day 3 -  58
 & CO. 

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A
admission on 25 September 1989.  What is odd, of course, about this is that the title there, 
from the Academic Department of Paediatrics would be wrong, because this child was never 
at the Academic Department of Paediatrics, and you can see the date of this record is 19 June 
1990, and on 19 June 1990, Dr Southall, as he then was, was still at the Royal Brompton.  He 
did not go to the Academic Department of Paediatrics until 1992. Whether it is just a 
template glitch – I am at the frontiers of my computer knowledge here – and of any 
significance at all, I do not know.  I merely point out that it is slightly odd. 
B
That is an example from the recordings file.  Can I take you back to paragraph 44 of the 
statement? 
MRS LLOYD:  Excuse me, Madam Chairman, in the interests of justice I feel I have reached 
saturation point in terms of concentrating on this documentation.  It is very important, to be 
fair to the doctor, that we have our full attention when dealing with these matters.  The time is 
C
now 5 o’clock and I cannot absorb any more detail this evening. 
THE CHAIRMAN:  Noticing the time I was about to ask Mr Tyson how long he anticipates 
it will take to complete this. 
MR TYSON:  I take the point made by Mrs Lloyd, and it is a correct point.  There is no point 
in me banging on if no one is listening.  It is not fair to anybody.  I therefore intend to stop.
D
I have about 10 minutes more but this heads of charge relating to computers is important and 
rather complicated, I have to say, so it does need some degree of concentration.  I respect 
Mrs Lloyd for saying she has had enough and I will not proceed any further in my opening as 
a result of that. 
Where it takes us from now is if we can deal with some case management matters because 
my learned friend and I have some slightly different views about that.  Perhaps I can set out 
E
my views on case management hereafter. 
Lawyers are notorious for giving bad time estimates, but I do not anticipate that I will be 
more than a quarter of an hour more dealing with these computer matters.  Then I think he is 
right that you have an opportunity of reading the two material reports by Professor David, 
which are at C3, 7(a) and 7(b), together with the response to the special cases allegations by 
Professor Southall at C2, 6(c). I would ask the panel to read those and then I intend to call 
F
Professor David. 
We have only got Professor David for tomorrow and the next day.  We do not have him after 
Friday.  My learned friend has indicated to me, and I am grateful for that, that if there was 
some reading time for Professor David, he anticipated that Professor David would be 
completed by Friday. 
G
Anticipating what my learned friend might say to you that not only have you got to read the 
matters that I have mentioned but also all the medical material in this case before we reach 
Professor David, then I say that that is not right; it is inappropriate and we would never reach 
Professor David before the weekend. 
I am merely asking you to read his two reports before we call him, and Dr Southall’s reply.  
You have had an extensive opening in this case, and that should be sufficient, in my 
H
respectful submission, to fairly consider and take on Professor David’s evidence.  I anticipate 
T.A.  REED 
Day 3 -  59
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A
that, after I close my opening, you would want an hour or two to seek to master these reports 
and then we go straight into Professor David’s evidence and he would occupy the rest of 
tomorrow and the next day.  That is what I am asking you to do. 
THE CHAIRMAN:  Mr Coonan, did you wish to make a comment? 
MR COONAN:  I do.  My learned friend very helpfully has opened this case now for two 
B
days.  That is perhaps a measure of the complexity, certainly in some areas of this case, that 
we have to grapple with.  I say that deliberately; that includes us too.  We have to assess and 
deal with the case that is brought against Dr Southall and deal with documentation. 
May I just take a number of points to consider?  The first is that my learned friend, and it is 
no criticism and we, and me personally have enormous sympathy with Mrs Lloyd’s view --- 
C
MRS LLOYD:  It is not just my view but that of everyone. 
MR COONAN:  That may well be but whatever the view and however the extent it is shared, 
it is shared by others, certainly on this side.  The fact is that he has not closed his opening and 
it is important obviously that he does so that you amply know the extent of the case that we 
have to meet. 
D
Of course the first point that I make is that it would be entirely a matter for you the extent to 
which you feel you need to read more into this case.  I am very conscious that there are lay 
members on this panel.  So far, and I stress that, there is a limited amount of medical record 
material which has been placed before you.  I do not know the extent to which each of you 
have managed to absorb the content of those records as they have been referred to by Mr 
Tyson.  Again, it is no criticism, but it has taken a lot of time to absorb the cross-referencing 
and so forth and make a note of that. 
E
I was going to invite you therefore to consider not only taking some reading time but to read 
Professor David’s two reports, yes, together with Hempsons letter of 24 January, yes, but also 
such of the special cases material, or indeed any of the other material, which thus far you 
have not managed to absorb. 
There are two reasons I say that, and in particular it applies to case B and case H.  First of all, 
F
it is to do with what has been referred to already, the question of context, and, secondly, to 
aim to shorten at least my cross-examination, if not my learned friend’s examination, of 
Professor David.  If we have to go through enormous detail each of these documents again, 
there is a very, very strong risk that we would not finish by Friday.  It is disappointing to be 
told by my learned friend – I accept I knew before just now but nonetheless it is still 
disappointing to be told – that a case which is being brought on behalf of these complainants 
is limited in terms of time because his expert is only available until Friday night. 
G
With the best will in the world, on our side we will do what we can to accommodate 
Professor David, of course, but I can give no guarantee that the evidence in relation to 
Professor David will finish by Friday night.  You may have a significant number of questions 
for Professor David.  I do not know. 
The idea that there has got to be this time limited period within which the case is going to be 
H
articulated through the mouth of the respective experts in this way may be somewhat unreal.  
T.A.  REED 
Day 3 -  60
 & CO. 

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A
I am just simply stating – it is not intended to be said in any threatening or pointed way – that 
these are facts that you may have to grapple with in terms of timetable.  That is the first 
matter, whether you would find it of value to take some time to read – and I am not just 
simply saying, “read it overnight” because we are all human and there are limits to how much 
more we can do. 
The next matter concerns our position.  First of all, we have to grapple, as Mr Tyson fairly 
B
and correctly said, with this question of accessibility.  I am not going to burden you with the 
details but there is a certain amount of material which is going to require my attention – I 
have not been able to pay any attention to it before now – and for Mr Tyson and myself after 
that to discuss it.  What the result of that will be, I do not know. 
Secondly, I have not yet myself been able to look at any of the original records in respect of 
any of these four children, and I include the main medical records, if I can use that phrase, 
C
and the special cases file.  I refer to the original records available. 
I anticipate, from what I have been told by Ms Ball who instructs me from Messrs Hempsons 
and who has had an opportunity of looking briefly at the original special cases files for two of 
the families, that you may well have to examine some of these original records in relation to 
the charge or charges which are brought in relation to the special cases files, but in order 
obviously to prevent you from being burdened unnecessarily with that sort of exercise, again 
D
I at least on Dr Southall’s behalf need to spend a little time looking at these documents.  Two 
of the children’s files, medical records, were handed over to us I think round about 4.30 this 
afternoon.  I am just stating a fact that we have not yet had an opportunity of looking at them. 
The third matter concerns my ability to respond to Professor David’s evidence when he 
finishes it.  Obviously I have had quite a good indication of what that evidence would be for 
two reasons:  first, I have had the report; and, secondly, I have heard Mr Tyson’s helpful 
E
opening.  I have not yet heard the totality of Professor David’s evidence.  It may be that I will 
need some time in any event to be able to deal with some of the issues that Professor David 
raises during the course of his evidence.
All these factors are going towards this question of whether we can actually cram into a pint 
pot a gallon.  These are real issues which I just leave before you for the moment. 
F
Could I just return to the first point?  You may therefore find it helpful to take some 
significant time to read.  How much time you need is obviously a matter for you.  Whilst you 
were doing that, we could attempt to grapple with some of the other matters that I have 
identified and deal with them in parallel whilst you were taking some reading time. 
THE CHAIRMAN:  Mr Coonan, you well put what you anticipate as being various problems.  
If I may, I do not want to pursue trying to solve these problems at this time tonight.  You put 
G
the problems on the table, as it were, but I think that it is not going to be very constructive to 
try to solve them now.  We accept that there are problems.  Perhaps leaving it overnight will 
give both sides an opportunity to consider what ways forward there may be.  Further, in terms 
of what reading the panel may need to do in order to feel abreast of the material that has been 
presented to them, again I do not know, without consulting the panel to find out, how each 
individual feels and I have not had an opportunity to do that. 
H
Clearly I understand none of us have read those reports in detail, but how much extra time we 
T.A.  REED 
Day 3 -  61
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A
need to take in the details of the documents referred to in the SC reports, again I am not sure 
how much people took in and want to spend more time on it. 
What is clear is that we cannot unduly rush matters that need to be taken in their proper 
course.  If I may, unless there is something that has to be said now, I would rather re-open 
this matter in the morning. 
B
MR TYSON:  I just want to say one thing now.  I have got every sympathy with the panel 
absorption of material and any panel difficulties.  I have no sympathy whatsoever for any 
difficulties that my learned friend may have or may think he has because he and I and our 
respective teams have been involved in this case for over two years now and we have had 
plenty of time to absorb all the materials and documents within those two years.  Panel 
difficulties, yes; my learned friend’s difficulties, ignore. 
C
MR COONAN:  I do not really want to get us into an argument about it but I am rather 
dismayed to hear my learned friend say that.  We are normally the best of friends but he must 
understand that the way a case develops, the way in which original documents, for example, 
and statements are served in a particular form today and yesterday – and I exaggerate not – 
requires attention.  It is only through the good offices of the defence that you have had placed 
before you an agreed statement by Ms Ellson.  We have looked at that and were able to agree 
that, to spare her the necessity of giving evidence. 
D
THE CHAIRMAN:  It is very clear that we do face a difficult situation.  I think perhaps 
everyone is tired now and that we should think about this overnight and revisit it in the 
morning.  I am now going to adjourn until 9.30 tomorrow morning. 
(The Panel adjourned until 9.30 a.m. on Thursday, 16 November 2006)
E
F
G
H
T.A.  REED 
Day 3 -  62
 & CO. 

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GENERAL MEDICAL COUNCIL
FITNESS TO PRACTISE PANEL (PROFESSIONAL CONDUCT)
Thursday 16 November 2006
44 Hallam Street, London, W1W 6JJ
Chairman:   
  
Dr Jacqueline Mitton 
Panel Members:
Mrs Leora Lloyd 
Mr Alexander McFarlane 
Dr Sameer Sarkar 
Mr Arnold Simanowitz 
Legal Assessor:   
Mr Robin Hay 
CASE OF: 
SOUTHALL, David Patrick 
(DAY FOUR)
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 JOLLIFE 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) 

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I N D E X 
          
 
 
 
 
Page 
No
 MR 
TYSON, 
Opening 
continued 
    1 
TIMOTHY JOSEPH DAVID, Sworn 
Examined by MR TYSON 
 
 
 
                      16 

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A
THE CHAIRMAN:  Good morning, everyone.   
MR COONAN:  Madam, can I mention one small matter.  I have mentioned this to 
Mr Tyson.  You may see sitting at the back of the Chamber Dr Margaret Crawford, who is 
a consultant paediatrician.  She has arrived to assist us with Professor Southall’s case.  I have 
mentioned this matter to Mr Tyson and he has no objection, but of course it is a matter for 
B
you as to whether you permit her to sit in. 
THE CHAIRMAN:  The Panel is happy for Dr Crawford to sit in. 
MR TYSON:  Of course I do not object, madam.  I have only one observation.  If 
Dr Crawford is going to give evidence on behalf of Dr Southall, then we would like to see 
any report that she may produce. 
C
Madam, there is one matter of housekeeping this morning.  Can I ask you to replace one 
document with another?  Turn, please, to C7, page 20.  I indicated that there might be some 
words missing at the foot of that page.  We have now got a better photocopy and I ask you to 
take out the existing page and replace it with the new one that is being handed out.
(Document handed) 
D
Secondly, I promised the Panel I would put all the appendix documents into one file and that 
file I now produce as C9.  (Document handed)  Can I say straightaway that in C9 is the 
incomplete page 20 document that I have just asked you to replace.  We will make 
appropriate arrangements for that to be sorted out. 
We reached a stage where I had burdened you for too long and too technically last night, so 
what I intend to do now is to say one thing more about Appendix One and start again on 
E
computers.  Appendix One sounds complicated but in my submission it is in fact simple if 
you just ask yourself four questions in relation to each item.   Question 1: is it a medical 
record?  Question 2: is it an original?  Question 3: is it not elsewhere in the child’s medical 
records at the relevant hospital?  If the answer is yes to those three questions, you then go on 
to ask question 4: why is it only in the SC file? 
To assist you on Question 1, Professor David has given you in his first report – C3 – at page 
F
7(a), a general description of what is a medical record.  That is at page 227, paragraphs 355 to 
356.  To assist you on whether a particular item is a medical record, one has to look at 
Professor David’s second report, which is at C3, 7(b).  As will become clear, he deals with 
each child page by page and his comments relating to Child A start at page 14.  His 
comments on Child B start at page 21.  His comments on Child D start at page 28, and his 
comments on Child H start at page 58.  I anticipate that certainly by some time tomorrow 
I will have produced a spreadsheet which will tie in each and every item of Appendix One to 
G
the particular paragraph in Professor David’s report to assist you on Question 1: is it a 
medical record? 
So far as Question 2 is concerned – is it an original – I anticipate that this matter can be dealt 
with by way of admission, but my learned friend is coming back on that, otherwise I can 
provide it through a particular witness.  So far as Question 3 is concerned – is it not 
elsewhere in the child’s medical records – again I hope that that can be dealt with by way of 
H
admission, and again I look to my learned friend to come up with that in due course as a 
T.A.  REED 
Day 4 -  1
 & CO. 

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A
result of his current investigations.  I do not anticipate therefore that you will have much 
difficulty on Questions 2 and 3.  Indeed, I do not anticipate you will have much difficulty on 
Question 1.
So far as Question 4 is concerned, which is the real issue, there are broadly two answers 
given by Professor Southall to that question: why is it only in the SC file?  Answer one is, 
“Yes, I agree it is a medical record and I cannot understand or explain why it is in the SC 
B
file”.  The second main answer that he gives is that, as a matter of policy he determined that it 
should only be in the SC file because it related to matters of child protection.  As you can see 
by that analysis, you do not have to master the detail of precisely what any document in C9 is 
saying.  You merely have to look at each item and see whether or not you agree with 
Professor David or Professor Southall that it is or is not a medical record.  You do not have to 
go into the detail of what precisely was said.  You just have to follow the exercise that 
Professor David guides you through in his report, and say whether or not you think it is a 
C
medical record.  You do not have to get up to speed on any particular test.  An overall view 
should be sufficient. 
Thus you do not have to go through each and every one of the SC files in this case, from C5 
to C7, absorbing all the material.  All you have to do to answer the first question is look at C9 
and, based on the evidence before you, decide whether each and every item there is or is not 
a medical record or clinical document of some sort.  If you concentrate on those four 
D
questions, your task will be much easier.  Question 4 is, of course, the vital one: why is it 
there? 
I now come to the heads of charge 15, 16 and Appendix Two, which relates to the computer 
information.  You will recall that what is alleged here under head of charge 15 – perhaps 
I can take you to that – is that, 
E
“On the computer system held at the Academic Department of Paediatrics, North 
Staffordshire Hospital, you maintained, or caused to be maintained, the medical 
records set out in Appendix Two”. 
If you glance at Appendix Two you will see that in relation to four children it is alleged that 
the documents there listed are computer records held on the paediatric department’s own 
computer relating to those four children.  To assist you with that, the Appendix Two 
F
documents have been collated together.  They are also in your SC files but I will distribute 
a new document which I will label as C10.  (Document handed) 
Going back to head of charge 15(a), it reads, 
“On the computer system held at the Academic Department of Paediatrics, North 
Staffordshire you maintained, or caused to be maintained, the medical records set out 
G
in Appendix Two”. 
Those are the C10 documents.  You will recall also that heads of charge 15(a) is admitted by 
the practitioner.  Head of charge 15(b) says, 
“These computer medical records are not contained in children’s hospital medical 
records at either the Royal Brompton Hospital (for child A and Child H) or the North 
H
Staffordshire Hospital (for Child D)”. 
T.A.  REED 
Day 4 -  2
 & CO. 

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A
So the assertion is clear that the C10 documents are not elsewhere in the appropriate medical 
records held by the hospital.  Charge 15(c) takes us one step further and that too, you will 
recall, is admitted, that, 
“Neither Child A nor Child H were treated at the North Staffordshire Hospital, but 
only at the Royal Brompton Hospital”. 
B
We maintain that the consequence of the matters set out in head of charge 15 are those set out 
in head of charge 16.  You should note head of charge 16(b) where we are asserting that this 
amounted to keeping secret medical records on the children.  We submit that these allegations 
are serious as well as being self-explanatory.  These relate to the matters found on 
Professor Southall’s own computer in his own department; they are nothing to do with the 
main hospital records at all.  The complainants have only recently learnt of the existence of 
C
these computer records held by Professor Southall and the discovery came about in a way 
which is explained by the statement of a partner in my firm of instructing solicitors, Field 
Fisher Waterhouse, which is a document I started to take you through before exhaustion set 
in, document C8. 
I now need to take you to C8 and I need to take you to paragraph 4 to begin with: 
D
“On 24 January 2006 Hempsons solicitors wrote to the General Medical 
Council…reference was made to protocols being established by Professor Southall, 
including protocol as to how Professor Southall would deal with confidential 
documents.  As a result of this letter I wrote to Hempsons solicitors on 8 February 
2006 asking that they provide any particular written documentation relating to the 
protocol(s).  As a result, on 16 February 2006, I was provided with a one-page 
document entitled ‘Security guidelines for Academic Department of Paediatrics’.” 
E
That document you will find in C3, Tab (d)(v). This is a document that was provided to my 
instructing solicitors in February of this year, and you will see that the objectives included the 
second objective, 
 
“To ensure information relating to child abuse matters is kept in a secure place; 
To introduce a procedure for the storage and retrieval of information relating to child 
F
abuse matters”. 
You will see the bottom third where it says, “Information is defined as”, and at (v), 
 
“Computer disks containing correspondence of any of the above”. 
I need to take you back to paragraph 5 of C8, where it says, 
G
“As pointed out by Hempsons in their letter of 16 February 2006 ‘information’ was 
defined to include computer disks.  Accordingly, on 1 March 2006 I wrote to 
Hempsons solicitors stating, ‘we trust that these [computer disks have been securely 
stored and therefore now request your client provides all computer disks relating to 
the SC files in this case’.” 
H
T.A.  REED 
Day 4 -  3
 & CO. 

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A
So the request in March was quite specific.  We are now told that there are computer disks 
relating to these matters.  Please produce any computer disks relating to the special cases for 
files in this case. 
I am sorry, I need to take you to paragraph 9 where we were told in June 2006 that there were 
computer records in relation to the children A, D, H, and B.  You can see that in the middle of 
paragraph 9. 
B
Taking you to paragraph 13, having been told in June that they had them you will see on  
18 August we got the printouts relating to D, H and A, but not B.  The statement goes on as to 
various chasing and how it could be sorted, and I need to take you to paragraph 18 where 
eventually it was agreed that Professor Southall would take the solicitors for each side 
through the computer system, as well as the other matters.  Therefore, the solicitors on each 
side met at the hospital on Tuesday 31 October.   
C
Then I need to take you to paragraph 31 and we can see: 
“I was then shown a computer in the Academic Department.” 
Pausing there a moment, as I understand it, the Academic Department consisted effectively of 
a portakabin in a car park outside one of the four main hospitals in North Staffs.  Then 
D
paragraph 31: 
“I was shown a computer in the Academic Department.  I was informed that this 
computer was stand alone and not networked to other computers.” 
Pausing there, I do not know the extent of the computer knowledge within the Panel, but 
stand alone means just that; it is not connected to any other system, and in particular it is not 
E
connected with the hospital system.  That stand alone computer, as I understand it, is merely 
for the use of the department and if you wanted to retrieve matters on the hospital computer 
or the hospital files, a different computer was required for that.  It was not part of what they 
call the hospital network. 
“It was clarified that it was from this computer material had been printed and sent to 
FFW”, 
F
so effectively it was from the stand alone computer that the material in C10 was obtained. 
Paragraph 32: 
“It was explained that actually the computer I was being shown was a physically 
different computer than the one originally used by Professor Southall and his team.  
G
I was told that his computer was seized …”, 
in the circumstances there set out. 
“On return from suspension Professor Southall was given a new (upgraded) computer 
onto which his files and databases had been transferred.” 
H
Paragraph 34: 
T.A.  REED 
Day 4 -  4
 & CO. 

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A
“Professor Southall explained that there were two databases on the computer 
‘SC File’ and ‘Recordings’.” 
I do not know that I need to go into any technical explanation of what a database is, but, 
effectively, if you tap in the word “SC File” you will find a whole lot of documents behind 
those words, and if you tap in “Recordings” you find a whole lot of other documents under 
B
that file. 
Paragraph 35 indicates who had access to this particular computer and those databases.
“Professor Southall thought that he, together with Dr Samuels and the Clinical 
Physiological Monitoring Technician (a nurse) would have know the password and 
would have been responsible for entering the data.” 
C
It is important, madam, because it links these, what we say, secret documents, to, at most, 
three people responsible, of which the head of department is of course Professor Southall, as 
he then was. 
Paragraph 36: 
D
“In my presence Professor Southall opened the ‘SC File’ database first …  He 
demonstrated that there were a variety of layouts to display the information held on 
each case but it appeared that ‘layout #1’ was the most comprehensive.  This creates 
documents which are headed ‘Patient’s Data’.  (In fact I noted when I reviewed the 
documents again that we have been provided with screen shots of layout #8 for D and 
A but I am reasonably satisfied that this is the same information as was on layout 
#1)”.
E
Can I just see what we are talking about there?  Can I take you, please, to C10?  What you 
have to grasp is that the SC files relate to documents that are headed “Patient’s data.”  If we 
look, say, at the first document in C10, this relates to Child D and we can see that it gives 
clinical information relating to this child, including the date when the data was inputted, 
which is the 13/12/1994; the date of birth of the child, details of the parents, the address, the 
source of referral and the like, including the diagnosis which we can see three-quarters of the 
F
way down; then clinical information about the birth weight and the age of referral and matters 
like that at the bottom.  Also, how many admissions and the reason for the admission, and 
here it was for continuous recording.  You see that the only case reference is in the top 
left-hand corner, which says, in this one, “Case No 3874.”  That is a reference to the SC file 
number, not a reference to the hospital number, so it directly links this information with 
information arising from the SC file as opposed to from the hospital medical records. 
G
In her witness statement at paragraph 36 Ms Ellson indicated that there was a difference in 
layouts and if you look at the top left-hand corner you will see a reference to “Layout #8.”  
That is where she is getting the reference. 
DR SARKAR:  Madam Chairman, can I make an observation?   
THE CHAIRMAN:  Yes. Do you need some clarification on this? 
H
T.A.  REED 
Day 4 -  5
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DR SARKAR:  Yes.  Mr Tyson, I am not wishing to steal your thunder, but if I am not 
having a case of déjà vu, have we not gone through all of this yesterday, in putting layout 1 
and Ms Ellson’s witness statement in the same detail you have done it today? 
MR TYSON:  I understood that I was asked to repeat this because not everybody was taking 
it in towards the end of yesterday, so I said when I opened I would start again on computers 
because the computer information was being not fully absorbed.  That is why I have started 
B
again.  I did it, as I understood, at the request of the Panel.  If you do not want to hear it, so be 
it.
THE CHAIRMAN:  If I could explain to Dr Sarkar, we did indeed suggest to Mr Tyson that 
he should review rather than leap in in the middle of this, that he should recap, because this 
was a stand alone and it was clear that towards the end of yesterday there was a question 
mark over whether everybody was feeling that they were totally taking it in.  He was asked to 
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recap, I think. 
MR SIMANOWITZ:  The only problem is that the referencing now is to C10 rather than to 
the other references, and while I accept we do not want to leaf through all those pages, could 
we have the reference to the bundle as well, otherwise there is going to be a lot of confusion. 
MR TYSON:  Yes, certainly. 
D
THE CHAIRMAN:  Thank you.  If that is possible, Mr Tyson, that may help some Panel 
members. 
MR TYSON:  Yes, certainly.  I can give you the references.  In any matters relating to Child 
D you will see that in C6, right at the end there is a separate tag that says “Computer 
Records.”  That, with all the SC files, is a separate tag that says “Computer Records.”  In 
E
relation to Child H you will find that in C7, right at the back under a separate tag that says 
“Computer Records.”  In relation to Child A and Child B you will find the information in C5, 
again under the tag sign that says “Computer Records” relating to each of those children. 
I also pointed out, and I point out again, that this is material from, as it were, the SC file 
material.  I just merely point to the figure on the left-hand side that says “Records” and the 
patient’s data in the SC files, it appears, where it says “Records”, that there are 4,449 of such 
F
records held. 
Madam, it may assist in the long run if we can just do a bit of housekeeping and together 
number all the documents in C10.  I hope you have all reached 14.  The records relating to 
Child D are pages 1 and 2 of C10, the records relating to Child H are pages 3 to 9, the records 
relating to Child A are pages 10 and 11 and the records relating to Child B are pages 12 to 14.
Anything that says “Patient’s data” on it comes from the SC file. 
G
If one looks at pages 1 and 2 you can see that they are effectively the same document 
produced in a different way.  As I understand it, page 2 is if you just press the print button 
and you get a rather difficult printing system, and page 1, which is exactly the same, but that 
is, as it were, a picture of what is actually on the computer as you look at it.  Page 1 and 2 are 
the same, but it is just easier to read them in the page 1 form.  Similarly, from the SC files 
would be page 5 relating to Patient H, and that is a document that is in all material respects 
H
similar to page 7.  So, page 5 comes from, as it were, the SC file selection.  Similarly, relating 
T.A.  REED 
Day 4 -  6
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to Child A, page 11 comes from the SC file part of the computer, as did page 12 relating to 
Child D. 
Can I take you back now we have familiarised ourselves slightly with the documents? 
MR McFARLANE:  Madam Chairman, I would like to ask Mr Tyson a question please? 
B
THE CHAIRMAN:  You need some more clarification? 
MR McFARLANE:  Yes.  Mr Tyson, can you tell me what is the difference between the 
document that we have called page 8 and the document that we have called page 6, apart 
from perhaps there being a bit more toner in the photocopier on page 6? 
MR TYSON:  In order to assist you with that you need to look at pages 3 and 4, which are the 
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better versions of those two documents, and they relate to different dates of admission.  This 
child was admitted twice and you can see from page 3 that one relates to the admission on 
28 September 1989 and page 4 relates to the admission on 16 March 1990.  The two 
documents you took me to, sir, would say the same things, but because of the printing 
difficulties there was a technical glitch in producing those documents, thus pages 4 and 5 are 
easier to read. 
D
MR McFARLANE:  I am most grateful to you for the explanation.  Thank you. 
MR TYSON:  Can I take you back please to paragraph 36 and we can re-read it and now 
understand it: 
“In my presence Professor Southall opened the ‘SC File’ database first (it uses 
Filemaker software).” 
E
Just pausing there a moment, look at page 1 and you will see at the top left-hand corner the 
words “Filemaker.”   
“He demonstrated that there were a variety of layouts to display the information held 
on each case but it appeared that ‘layout #1’ was the most comprehensive.  This 
creates documents which are headed ‘Patient’s Data.’ ” 
F
She goes on,
“(In fact I noted when I reviewed the documents again that we have been provided 
with screen shots of layout #8 for D” 
–  and we can see that on page 1 where it says “layout 8” on the top left-hand corner. 
G
Paragraph 37:
“Professor Southall indicated to me that he had searched for all the families relevant 
to the GMC case on the database and had printed out and sent…. the ones he had 
found.  He had not previously been able to find anything for B…. However in 
anticipation of my visit he had tried again and on this occasion had located an entry 
H
for her.  We searched under [the first name of that child] and the computer suggested 
T.A.  REED 
Day 4 -  7
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that there were 30 or so records.  We then searched the second name of that child] and 
located the one entry for [that child].” 
You may like to put that that is C10, page 12.  There we see this is another patient’s data.
I need to emphasise again that anything that has patient’s data on it is a reference from the SC 
file part of this case. You see the diagnosis and the admission, and the date of admission is 
1Septembr 1993. 
B
So this document was produced, I think for the first time, at that meeting but I will corrected 
if I am wrong about that. 
Paragraph 38:
“Professor Southall could not explain why he had not been able to find this entry 
C
previously and suggested that he was concerned that somewhere in the transfer of the 
databases to his new computer there may have been some form of corruption.  He felt 
that the system was not now totally reliable. 
39.   Professor Southall then printed out the page we had found for [Child B].” 
This is page 12. 
D
“He explained that a further problem created by the transfer of the database and/or the 
use of a new printer was that the layout when printed was not correct (some text prints 
over other text).  For this reason for some of the printouts he has supplied 
Professor Southall has prepared a screen shot version of the data.” 
This goes to the answer to the question that Mr McFarlane was asking earlier.  If you print 
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out, you get something that looks like 12.  If you go for what is technically known as a screen 
shot, you get something like page 1. 
Paragraph 40:
“The data printed out for B from this database consisted of one page.” 
F
That is our page 12. 
“I asked if there was other information held on this database about this family but 
Professor Southall informed me that the sheet printed out held the entirety of the 
information on that family (that he had been able to find). 
40.    On this database there are 4449 records.  This figure can be seen for example on 
G
the screen shot version of the printout for D.” 
That is on page 1.  I have taken you to that figure. 
Paragraph 42:
“We then repeated the search exercise for the other families.  On this database we 
H
found one entry for [H]…” 
T.A.  REED 
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You will see that at page 5. 
“…and one for [D]…” 
You will see that at page 1. 
B
“…and one for [A]…” 
You will see that at page 11. 
“We had earlier been sent these printouts by Hempsons on 18 August 2006.” 
That is the SC part of his database.  He then has another completely separate database entitled 
C
“Recordings”.  Ms Ellson goes on to deal with that at paragraph 43.
“I was then shown the second database ‘Recordings’.  This database contains the 
template letter where the information ‘We performed a x hour overnight recording on 
the {date}’ with recordings and signals and result set out. 
44. There are 1856 records on this database (this figure can be seen on the screen shot 
D
version of the print out for B)”. 
We can see it, for instance, on page 3.  This is, as it were, a standard letter held on the 
computer and you just fill in the little bit relevant to this particular patient.  This is under the 
“recordings” section.  You can see at paragraph 44 that Ms Ellson is making reference to the 
fact there are 1856 records on this database.  You can see that at page 3 in the top left-hand 
corner where it says “Records”. 
E
Paragraph 44, second sentence:
“Again Professor Southall demonstrated a search in relation to each of the relevant 
families.  We found entries for B (this was apparently found on the morning of my 
visit…” 
F
If I can take you to the B numbers found on the morning of the visit, this is page 13, what 
they call the screen shot version of that, and page 14 is how it happened when it was printed 
out.   You see it is equivalent to a technical document called a discharge summary where it is 
a report back to the referring clinician about the results of the admission.  Here we can see, by 
looking at 13 and 14, that it was a letter to the referring clinician at the hospital there 
mentioned.  It says: 
G
“Your patient was referred with”, going back to 13, “recurrent apnoea …. We 
performed a continuous recording on 1 September 1993”.   
It gives the results of that recording.  This is under what we call the recordings section.  It 
says, “We found entries for B…” which I have taken you to. 
H
T.A.  REED 
Day 4 -  9
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Back at paragraph 44:
“There are in fact two entries for H both of which have previously been provided 
(marked record 1 and 2…..)  Professor Southall indicated that this was because of the 
two recordings undertaken on H.” 
Can I take you to page 3, the reference?  You will see that record H is referring to an 
B
admission on 28 September 1989.  In the top left-hand corner, just above the word “records” 
you will see a numeral 1.  On the next page, page 4, you will see that there is a numeral 2 in 
the same spot and that this, as we see, relates to –   
“Your patient was referred with 
We performed a 12h overnight recording on 16th March” 
C
Page 1 relates to the admission on 28 September 1989, hence the 1, and 2, on page 4, relates 
to the second admission on 16 March. 
THE CHAIRMAN:  Mr Tyson, may I ask for clarification here?  On Appendix Two, as we 
have had it revised, under Child H, under the medical records and under (iii), it says 
“Discharge letter referring to 19 June 1990”.  I see that 19 June 1990 is the date that has come 
up as the date of the letter.  Should that in fact be 16 March?  I notice under (ii) it says 
D
“Discharge letter referring to 28 September…”. 
MR TYSON:  Madam, you are absolutely right.  There are some bizarre dates, which is the 
middle column, that bear no relation to when the child was actually there, but you are right, it 
does relate to that, and I seek leave to amend Appendix Two under Child H (iii) to 
“Discharge letter referring to 16 March 1990”. 
E
THE CHAIRMAN:  I take it there is no objection to that? 
MR COONAN:  No, absolutely none.   I do not accept they are bizarre dates. 
THE CHAIRMAN:  But you accept that it needs correcting? 
MR COONAN:  Yes. 
F
THE CHAIRMAN:  Thank you. 
MR TYSON:  I am grateful for that, Madam. 
Whilst we are on Appendix Two, looking at it, the panel may find it useful to write beside 
Appendix Two under Child D that the reference to that is at C10 at page 1.  In relation to 
G
Child H, the first document is the patient data document we find at page 5.  The discharge 
letter relating to the entry for  28 September one finds at page 3.  The discharge letter relating 
to the 16 March 1990 entry is at page 4.  The patient’s data relating to Child A you find at 
page 11.  The patient’s data relating to Child B you will find at page 12.  The discharge letter 
referring to that entry you will find as a combination of 13 and 14. 
Madam, can I take you back to a paragraph 45 of Ms Ellson’s witness statement, which is 
H
C8?   
T.A.  REED 
Day 4 -  10
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“We could not find entries for D (although we searched under [all the names there 
listed] or for A [though we looked under all the names there listed].  Again I asked if 
the database contained more information than that shown in the printout.  I was told 
that it did not. 
46.  I was asked whether either or both databases…” 
B
That is the SC file databases and the recordings database. 
“…had ever been copied.  Professor Southall indicated he did not know exactly what 
had happened when the computer was taken away [during the period there 
mentioned].  He told me, in answer to my questions, that he did not have a copy of 
either  database either on disc or on his laptop.  He added that he viewed the 
C
information as confidential which is why he would not have it on his laptop.” 
The Complainants rely heavily on that last sentence because this is confidential information, 
acknowledged to be confidential information, by Dr Southall that is being kept on a stand-
alone computer in his department, about which, it appears, no one was aware. 
MR COONAN:  I am sorry to interrupt.  My learned friend has mentioned “about which no 
D
one was aware”.  I just wonder what the evidential basis for that is. 
MR TYSON:  I also said the words “it appears”. 
MR COONAN:  The panel, having heard the evidence of Ms Ellson earlier in her witness 
statement as to the accessibility by others, I just wonder therefore what the basis for the gloss 
on that comment was. 
E
MR TYSON:  I am grateful to my learned friend for interfering with my opening, but I will 
answer the point that he made.  No one was aware, apart from the three people there 
mentioned earlier in the witness statement, and in particular not other clinicians, hospital 
administrators or patients, which is the gravamen of the charge. 
MR COONAN:  I am grateful. 
F
MR TYSON:  Paragraph 47:
“I asked about the request which I understand the Trust made some time ago that all 
material relating to children who were not patients at North Staffordshire Hospital 
should be removed from Trust property.  Professor Southall said that he had not fully 
complied with this request.  He said that he had removed the physical SC files for the 
G
relevant families…” 
Those are the paper files. 
“…(indeed his solicitor confirms that she now has (from Professor Southall) the 
original SC files for H and A).  He said that he had removed such SC files to a secure 
storage site. 
H
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46.  Professor Southall said that he had refused to remove the tapes.  He felt they 
should remain at the hospital secured in a secure room.  Following discussion with the 
Trust it was agreed that the tapes could stay.  In relation to the databases, he could not 
easily remove part of them:  he agreed that the databases included children who had 
and had not been Trust patients.” 
I need not take you to any more of Ms Ellson’s statement. 
B
To go back to my last submissions on this matter, we submit that all this reveals a truly 
extraordinary story that on his own computer in his department not linked to the hospital 
computer, Dr Southall held all these secret files on these children.  What is more 
extraordinary, in our submission, is that in the cases of Child H and Child A, held on his 
North Staffordshire computer, these were children who had never been treated at North 
Staffordshire. These children were old Brompton Hospital patients.  One has to wonder at the 
C
motive and reasoning behind holding these files.
There is one document that I need to refer you to in C3 and it is C3, Section 7(d)(i).  This is 
a document from the National Heart and Lung Institute, which is at the Brompton Hospital, 
which is where Dr Southall was working at the time.  It is a document dated 12 December 
1990.  It is a letter from a paediatric registrar, Dr Jawad, copied to Dr Southall and the ward 
clerk.
D
THE CHAIRMAN:  I think it is 14th December, Mr Tyson.  You said 12th.
MR TYSON:  I do apologise.  It plainly does say 14th . 
“Dear Madam, 
E
This is to inform you that following discussions with Dr David Southall, it was agreed 
that all the cases admitted for overnight monitoring will not require any discharge 
summaries except for the complicated cases which require further procedures and 
management.  Dr Southall is quite happy with a copy of the computer sheet which 
usually sufficiently states the aim of the admission and the possible diagnosis and the 
recommendations.  The computer sheets are usually typed and provided by 
Dr Southall’s department which should be filed in the notes by the Ward Clerk.” 
F
We would say and submit that that is evidence as to the proper practice that the computer 
discharge summaries should be filed in the notes and were not so filed. There is a manuscript 
on the right hand side which appears to say “Copy of all [overnight] monitoring records must 
go into [hospital] notes”.  That is the manuscript down the right hand side.  The significance 
of this letter and that manuscript addition will have to be explored in the course of the 
evidence.
G
So my submissions on the computer aspect of this case are effectively six:  firstly, that the 
advice in 1990 at the Brompton Hospital was that these records, certainly the records or 
discharge letters, should be filed in the hospital medical records;  secondly, none of these 
computer printouts were filed in the hospital medical records either in the case of A and H at 
the Brompton, or C and B at North Staffs;  thirdly, and I will not take you to it now but I just 
ask you have a look at one of them that appears in the paper special cases file, and that is the 
H
one relating to Child D at C6 at page 313;  the fourth point I would like to make is that the 
T.A.  REED 
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existence of these computer records has only been discovered and disclosed late this year;  
the next point I wish to make, they are clearly medical records;  and the next point I would 
make is that they are also clearly secret medical records held on these children, of which the 
complainants, it appears, the hospital administrators and certainly subsequent clinicians were 
completely unaware because they were just held on this computer, and this we say is 
inappropriate.
B
Madam, you will be delighted to hear that that is the end of my opening submissions. 
The question is where do we go from here? 
THE CHAIRMAN:  Thank you, Mr Tyson.  I understand we now need to discuss the matter 
of the Panel reading. 
C
MR TYSON:  Can I tell you what my suggestion is.  My suggestion is that the Panel reads 
the two medical reports of Professor David, which are to be found at C3, at section 7(a) and 
7(b).  They should also read Dr Southall’s explanation of the SC files, which they will find at 
C2, section 6(c).  In my submission, you should not at this stage read anything more.  You do 
not need to read anything more, although I cannot stop you.  You are the masters of your own 
procedure and you prepare for this case as you think fit, but, as I said, if you want to glance 
through Appendix 1 and Appendix 2 to familiarise yourself with them, C9 and C10, fine, but 
D
please do not get bogged down in the detail.  All you need to do is answer the questions that 
I posed in relation to them.  Do not try and understand, as it were, everything about each of 
the individual children’s things, because you would get bogged down and it is not relevant to 
the issues that this Panel has to decide under the heads of charge.  So my reading course to 
you is certainly the two reports of Professor David, certainly Professor Southall’s explanation 
of the SC files, and glimpsing at C9 and C10, and that, I anticipate, may take a bit more of 
this morning. 
E
THE CHAIRMAN:  Thank you, Mr Tyson.  I think obviously, if I can address this to both of 
you, the important thing is what the Panel is understanding at the next point where evidence 
is being given so that they have got appropriate background, and obviously, as you say, the 
Panel itself will set for itself certain objectives, but we appreciate your guidance, both of your 
guidances, on what would be helpful for us so that we can appreciate the next stage of the 
evidence.
F
MR TYSON:  Can I give you the witnesses in the order that I intend to call them, which may 
assist you.  I intend to call, as soon as you have finished your reading, Professor David, and 
I anticipate that his evidence will last until Friday evening, and he can make himself 
available, if we cannot finish him this Friday, in the afternoon of next Friday by video link 
from Manchester.  Next week I intend to call Mrs A, Mrs H and Mrs D, and, subject to 
conversations that I have with my learned friend, the administrator of Brompton Hospital, or 
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the Head of Administration.  Then I will have to read out various agreed statements, but those 
are going to be my live witnesses, and I anticipate, again subject to what my learned friend 
says, that I might be able to close my case on that basis on about Wednesday or Thursday. 
MR COONAN:  The solicitor Ms Parry. 
MR TYSON:  I am grateful to my learned friend.  I have this poor lady, who has been here 
H
for rather a long time, who is the solicitor to Mrs M, who was going to come and give us 
T.A.  REED 
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some evidence.  I have sent her back to the county where she comes from, and she can give 
evidence on Tuesday at nine-thirty.  I am grateful to my learned friend for pointing out the 
witness’s plight. 
THE CHAIRMAN:  Mr Coonan, what are your observations on how the Panel should best 
prepare itself for the next stage? 
B
MR COONAN:  Well, again, just simply to be helpful, I do not want to make any prescriptive 
demands at all.  What I suggested yesterday remains a suggestion:  it is entirely a matter for 
you the extent of your future reading now. Whether you accept Mr Tyson’s view that a 
slightly wider reading of the material is or is not relevant, again is a matter for you.  You 
must decide collectively what approach you should take, bearing in mind that the next 
witness is to be Professor David, and he is bound, with Mr Tyson, at least to look at the 
documents within C9.  So that is the first point.  Again, a matter for you.  So to that extent 
C
I agree with Mr Tyson that some reading is in order, and it may well be it will take, with the 
break, pretty well most of the morning, I know not. 
The next matter concerns the timetabling.  I understood yesterday that Professor David was 
available on Thursday afternoon and Friday, but now I am told it is reduced even more.  
Quite how inflexible all of this is, of course, is another matter, but what I am saying, looking 
ahead to this, is that Professor David is clearly going to deal with quite a deal of evidence, 
D
and certainly, as you know, I also yet have to deal with – well, you may not know, but I do 
have to deal with the computer aspect of this, and of course it is an issue which has only 
arisen relatively recently.  I have not had the advantage of having Professor Southall at all for 
more than a week before this case began. 
So there are a number of difficulties, as I indicated yesterday, which I need to iron out before 
I am in a position meaningfully to cross-examine Professor David.  So what I am suggesting 
E
is that that matter, in other words the question of when I cross-examine Professor David, we 
might just leave for the moment.  It is not a matter, with respect, that needs to be rigidly 
factored into the timetable.  Subject to that (I do not want to jump too many fences in 
advance) I go along with Mr Tyson in inviting you to decide the extent of your reading now. 
THE CHAIRMAN:  Thank you.  It seems to me that although it is correct in one sense to 
anticipate possible problems so that suitable planning can be made, we can do no more than 
F
move forward stage by stage, conducting each stage with the time that it takes to do it 
properly, and then solve the problems if and when they arise. 
MR COONAN:  I respectfully agree. 
THE CHAIRMAN:  Thank you. 
G
MR TYSON:  It seems to me that my learned friend and I are basically agreed on your 
reading list. 
MR COONAN:  Could I just add this?  I do not want to go back on any of the cautionary 
comments I made, because I agree with what you say.  My learned friend and I also have 
outstanding business to conduct in relation to questions that he indicated to you yesterday.  
They are not questions that can be dealt with in five minutes between us.  I have not actually 
H
read the material yet, and I have to read it, take instructions and then have discussions with 
T.A.  REED 
Day 4 -  14
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him.  In all our interests, and indeed in your interests, we need to sort this out before the close 
of business on Friday, because it is going to have a knock-on effect with the intention to call 
any further witnesses, as regards administrators and other witnesses on the question of 
accessibility, next week.  They have to be factored in and arrangements made.  So at some 
stage he and I are going to have to ring-fence time, and I will have to ring-fence time with my 
client, in order to sort this out.  Well, my learned friend shakes his head, but he is the one 
who has carriage of this prosecution, material is served, I have to deal with it.  It is as simple 
B
as that. 
THE CHAIRMAN:  I think all we can do now is move forward a stage at a time.  There is 
now going to be some period when the Panel are engaged in reading.  Hopefully this will be 
time that you can also use for some things that you need to do.  After that, when we come 
back together, I think all we can do is take it stage by stage.  You have flagged up your 
concerns, but we must consider it as it arises.  I see that a Panellist has a question. 
C
MR MCFARLANE:  I just wanted one point of clarification on one piece of evidence that 
Mr Tyson was opening on, which was the letter he drew our attention to, which you corrected 
him and clearly is dated 14 December, and I was just wondering was this letter supposed to 
have retrospective effect? 
MR TYSON:  I cannot assist on that. 
D
THE CHAIRMAN:  May I suggest that we will reassemble no earlier than two, if that may be 
helpful.  I think the suggestion is that the Panel will need some time.  Is that a reasonable 
suggestion?  If, after two o'clock, the Panel still needs more time we will let you know, but let 
us all aim to begin with Professor David at two. 
MR TYSON:   I am grateful. 
E
(The Panel adjourned to read documents)
THE CHAIRMAN:   Good afternoon.  I can confirm that the Panel has completed its study of 
the documents that have been recommended.  I think it is fair to say that we would not be 
looking to sit beyond five, or very very shortly afterwards, so if we can look for an 
appropriate place to adjourn when we do reach around five o'clock that would be helpful. 
F
MR TYSON:   Madam, before I come to call Professor David, I have just two more bits of 
housekeeping.  They both come with apologies from me.  Can I ask the Panel, please, to look 
at bundle C3 at 7(d)(vi).  It should be a document with a bird on it.  Can you take out that 
section because the wrong bird was photocopied, if I can put it that way, and you will be 
given the correct set now.  (Document distributed)  Madam, can I apologise for the 
administrative error that led to the wrong document being put into the Panel’s bundle. 
G
The second and last administrative matter is this, that in your bundle C9, about six documents 
from the back, you will get to the manuscript note, at page 20 at the bottom there is a 
manuscript note which you have all seen, and can I ask you to add at the bottom the 
following words under “needs”:  “neuro opinion/local paediatrician”. 
For my next witness you will only need, I anticipate, C3, C9 and C10, and I call Professor 
H
David.
T.A.  REED 
Day 4 -  15
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A
TIMOTHY JOSEPH DAVID, Sworn
Examined by MR TYSON
MR TYSON:  Sorry, there is another document that you will need to have, and I would ask 
for Professor David to have it, and that is a copy of the heads of charge.  (To the witness)
Could you give to the Panel, please, your full names. 
B
A 
Timothy Joseph David. 
Q Your 
professional 
address? 
A 
Booth Hall Children’s Hospital in Manchester. 
Q 
Are you a Professor of Child Health and Paediatrics at the University of Manchester? 
A Yes. 
C
Q 
For this matter have you produced two reports of which the Panel is aware, and could 
I ask you, please, to look at Panel bundle C3, which should be in the documentation at your 
left foot.  It is actually out.  If you look, please, under tab (a), right at the beginning under 
7(a).  Is this an extract, relating to medical records, of a report that you prepared for Field 
Fisher Waterhouse on 24 July 2005? 
A It 
is. 
D
Q 
You also produced a second report relating to these matters, and can you look under 
tab (b), please, and is that a report that you prepared in relation to these matters on 10 
September 2006 and amended on 31 October 2006? 
A It 
is. 
Q 
Do we see, looking at the first report under tab (a) at page 6, the introduction, and do 
E
you there give in paragraphs 1 and 2 a very brief curriculum vitae indicating your 
qualifications and experience? 
A Correct. 
Q 
Just picking up from that, have you been a Consultant Paediatrician for 23 years and 
have you held the post of Professor of Child Health and Paediatrics at the University of 
Manchester for 13 years? 
F
A Yes. 
Q 
Are you the editor or author of over 350 medical and scientific publications, and do 
those include approximately 30 books and conference proceedings? 
A Yes. 
Q 
Turning now under tab (b) to deal with any possible conflicts of interest, can I ask 
G
you, please, to look under tab (b) at page 5, your paragraph 3.  Have you worked on behalf of 
the General Medical Council in the capacities you set out in paragraph 3 and, as we see at 
3.1, have you acted as lead assessor for the General Medical Council in paediatric matters? 
A 
That is correct. 
Q 
Have you participated in the development of aspects of the performance assessment 
procedures for the General Medical Council? 
H
A Yes. 
T.A.  REED 
Day 4 -  16
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A
Q 
Over the page, have you given lectures on the subject of the General Medical 
Council’s performance assessment procedures to the people listed in paragraph 3.3? 
A I 
have. 
Q 
Including to your Royal College? 
A Yes. 
B
Q 
Have you trained members of the General Medical Council’s referral committee? 
A Yes. 
Q 
Have you acted as specialist adviser for a number of the General Medical Council’s 
committees, including the Health Committee and the IOC? 
A I 
have. 
C
Q 
Have you also been involved with General Medical Council activities in the 
Professional and Linguistic assessment Board in various capacities? 
A Yes. 
 
Q 
Have you also acted on behalf of the General Medical Council’s main solicitors – 
Field Fisher Waterhouse – as an expert in cases that have come before the Professional 
D
Conduct Committee and the Fitness to Practise Panel? 
A I 
have. 
Q 
In relation to Professor Southall himself, have you acted in the past as an expert in 
previous proceedings involving Professor Southall? 
A Yes. 
E
Q 
Have you also acted in some child protection cases in which both you and 
Professor Southall have been involved? 
A 
I have.  I am not really sure that these last two paragraphs, 12 and 13, really come 
under the heading of previous work for the General Medical Council.  These two really have 
no connection with the General Medical Council at all. 
Q 
They show involvement with the doctor in this case. 
F
A Correct. 
Q 
Did Professor Southall contribute a chapter on home oxygen therapy to a book of 
which you were the editor? 
A He 
did. 
Q 
In relation to any children in this case, have you reported in another capacity in 
G
relation to Child D in the circumstances that are set out at page 28 of your second report at 
(b) at paragraph 65? 
A Yes. 
Q 
In relation to Child H, looking at page 58 of your second report under Tab (d), were 
you involved in that case many years ago? 
A Yes. 
H
T.A.  REED 
Day 4 -  17
 & CO. 

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A
Q 
Dealing, Professor David, with matters of paediatric medical records, would you 
indicate to the Panel the basis upon which you felt able to write what you have about these 
matters for the Panel? 
A 
I am not sure I follow the question. 
Q 
Can I take you, please, to your first report at page 223? 
A 
Yes, paragraph 345. 
B
Q 
You indicate there that you have no special expertise in the subject of hospital 
medical records and the regulations that govern them and their use.  The question I ask, 
therefore, is on what basis do you feel able to provide the guidance you have to the Panel? 
A 
Really based on my experience as a doctor, and I have also looked at the medical 
literature, when I was preparing the original report, to see what I could find in relation to 
regulations or advice in relation to the preparation of medical records. 
C
Q 
So is it a combination of experience and what you have researched for this report? 
A Yes. 
Q 
Can I go, please, to your first report at page 222, paragraph 344?  Do you there set out 
10 questions that you asked yourself and in the body of the report do you seek to answer 
those questions? 
D
A 
That is correct. 
Q 
Can I turn to the first question which you asked yourself, which was about medical 
records, and ask you please to look at page 227, paragraphs 355 and 356, and do you there set 
out your understanding of what the term, “hospital medical records” encompasses? 
A I 
do. 
E
Q 
When in paragraph 355 you say, 
 
“a record is anything which contains information (in any media)”, 
what media did you include? 
A 
I did not specify.  It covered all media. 
F
Q 
Does that media include information that is held on a computer? 
A Yes. 
Q 
You set out at paragraph 357 the essential purposes you saw of medical records, at 
357.1 as a factual record of information; point 2 as a means of communication.  At the second 
sentence you say, 
G
“They may contain information of vital importance to those caring for the patient in 
the future; e.g. information about an operation, an investigation or a drug allergy”. 
Would you like to expand on why notes are important for, as it were, future clinicians? 
A 
The medical records of a patient are the only way that other healthcare providers can 
be aware of a child’s previous history. 
H
T.A.  REED 
Day 4 -  18
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A
Q 
Over the page at 357.3 you set out that they provide important information about past 
illnesses, and in 357.4 you come to legal documents which are an essential resource.  Can 
you indicate in the case of paediatricians why the legal aspect becomes important? 
A 
I guess there are three.  The first would relate to a complaint, if the hospital receives 
a complaint.  If there is litigation then clearly it is essential that the medical records are intact.  
The other kind of situation which is particularly relevant in a child protection context is if the 
child is subject to care proceedings or there are criminal proceedings ongoing in relation to 
B
injuries to a child.  So for those three main reasons the integrity of medical records is 
extremely important. 
Q 
In those last two matters, child protection cases and criminal cases, in your experience 
is there full disclosure of the notes to the relevant parties? 
A 
It is essential that there is full disclosure. 
C
Q 
How essential is it that there is not only disclosure, but full disclosure, of everything 
possible?
A 
The answer is that a case can hang on one piece of paper or one laboratory result.  
I can give examples of that but that is the simple fact: the devil is in the detail, or may be in 
the detail. 
Q 
I will come back to that aspect in a moment.  At paragraph 358 you deal with a 
D
Department of Health circular in 1999 which sets out various principles.  It will doubtless be 
pointed out to you that this document is dated after some of the patients involved in this case.
Do you have any observations of the value of the guidance notwithstanding that? 
A 
I do not think there is anything in paragraph 358 that is new.  This merely summarises 
and codifies what was existing understanding.  People just had not bothered to put it together 
in this way.  I do not think there is anything new here. 
E
Q 
Paragraph 361, page 230, you set out a section from one of the appendices of that 
circular: 
 
“4.1  What are the general principles to follow?” 
You set out, 
F
“Records are valuable because of the information they contain and that information is 
only usable if it is correctly and legibly recorded in the first place, is then kept up to 
date and is easily accessible when needed”. 
There are various other references to the question of accessibility, but who should these 
records be accessible to? 
A 
Any health professional with legitimate access to the records – doctors, nurses, other 
G
members of the healthcare team in the hospital. 
Q 
Other than healthcare professionals have others got the right to see these documents? 
A 
I do not know the exact regulation, but patients have the right to see their own 
medical records and can apply to see them. 
Q 
You set out at 4.2, 
H
T.A.  REED 
Day 4 -  19
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A
 
“Good record keeping ensures that”, 
and we see the third bullet point, the point has already been covered in a sense, that, 
“those coming after you can see what has been done, or not done, and why; 
any decisions made can be justified or reconsidered at a later date”. 
B
In your view are those both important bullet points in record keeping? 
A They 
are. 
Q 
Over the page, under paragraph 4.4 of the guidance we see it says, 
 
“It is therefore vital that you always”, 
C
and then the Panel can read the first two bullet points.  I want to take you to the third bullet 
point,
“It is therefore vital that you always…put it where it can be found when needed”. 
Is that an important principle in your opinion? 
A 
It is, and it is simple common sense.  There is no point in having a medical record if it 
D
is not accessible to other people. 
Q 
Over the page at paragraph 363 you make the statement, 
“A patient’s hospital medical records are regarded as sacrosanct and inviolable; 
i.e. must always be kept intact as a very high priority”. 
E
Do you stand by that statement in these proceedings? 
A 
That has always been the case and has always been regarded as very important. 
Q 
I now take you to Question 4, which you answered at page 239 at paragraph 389. 
You ask the question: 
“Is it acceptable for certain medical records to be kept apart from the main hospital 
F
clinical records file for a patient?” 
and you indicate at paragraph 390: 
“In general this is not an issue, because in many if not most hospital units the medical 
records for in-patients are kept in a relatively inaccessible (to parents) area such as the 
ward manager’s office.” 
G
Then you lead on to a discussion that in some units in-patient medical records are left by the 
bedside, and at the bottom of the page you indicate that this could lead to a problem, and you 
say:
“…this open system does not lend itself to clinical situations when a full sharing of 
clinical thinking with parents could be counter productive.” 
H
T.A.  REED 
Day 4 -  20
 & CO. 

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A
You go on, at paragraph 391: 
“Thus it is that in certain child protection cases, and in certain hospital units, while 
a patient is in hospital, a separate set of records is created.” 
Just having laid that trail, as it were, are you dealing in those two paragraphs only with an 
in-patient situation? 
B
A Yes. 
Q 
Once the investigatory aspects of child protection are, as it were, over – and I think it 
is a phrase you used in one of your reports, “the cat is out of the bag” – is it appropriate then 
to keep the records separate or to return them to the medical records? 
A 
I do not think the cat being out the bag is anything to do with it.  The expectation is 
that the two bits of records would be reunited once the child went home. 
C
Q 
After the in-patient stay in which they had been kept separate? 
A Yes, 
correct. 
Q 
Would the separation then be only for that short period while the patient was an 
in-patient? 
A 
Whatever length of period the child was in hospital, yes. 
D
Q 
Can I take you, please, to your answers to question 5, which we pick up at paragraph 
397 at page 243?  Here the question you asked yourself was about separate case files and the 
question you asked yourself we can all read there.  You put at the bottom of page 243: 
“If it is true that special separate files were set up, the ultimate question is whether or 
not it is appropriate for a paediatrician to create and store a separate file of documents 
E
relating to a case.” 
At paragraphs 398 and 3999 you indicate that you do not know the origin and purposes of 
these SC files and I will come back later to Professor Southall’s possible explanations for 
them.  In paragraph 400 is the key, that much depends on the purpose of keeping such files. 
A 
That is what I have written, yes. 
F
Q 
In paragraph 400 you deal with the question that if they were to provide a failsafe, 
that is not something that you would endorse, and at paragraph 401 you deal with the 
question that if they were for the purposes of research then other considerations come into 
play, such as whether research ethics approval or the like has been obtained and informed 
consent has been obtained. 
A Correct. 
G
Q 
In paragraph 402 you deal with the question if they were kept purely for 
administrative convenience to assist at home, as it were, when working on reports, and you 
say it is hard to see what criticisms could be made. 
A That 
is 
right. 
Q 
Then you carry on at paragraph 403 to say what you there say, that you are not aware 
of any regulation prior to 2000 that disallowed paediatricians from keeping separate 
H
photocopies of selected medical records.  You go on to say: 
T.A.  REED 
Day 4 -  21
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A
“… in the period under consideration it is unclear to me on what basis one could 
seriously criticise the practice, provided: 
that the files contained only carbon copies or photocopies and did not ever 
contain any original medical records for a patient”, 
B
and the second bullet point relates to the matters not being in any way connected with 
research unless appropriate consent had been obtained.  Can I ask you about the first bullet 
point, that the files contained only carbon copies or photocopies and did not ever contain any 
original medical records for a patient?  What is the risk or potential risk, Professor David, of 
having an original medical record not available elsewhere and in a separate file? 
A 
The risk is that that information is unavailable, either to other people looking after 
that patient or subsequently in any litigation or court proceedings. 
C
Q 
I think you said earlier that you could illustrate this, and perhaps you would like to 
illustrate the potential risks to the Panel? 
A 
I believe you yourself referred to Mrs Sally Clark, who served three years in prison 
before a single set of results became available and she was released on appeal.  You could not 
get a more graphic illustration.  I can think of others that I have been involved in; I can think 
of one particular, very complex child protection case, where in fact the whole court 
D
proceedings, the care proceedings, revolved around a single piece of paper, and there was one 
very alert barrister who spotted a piece of information on that which really had a major effect 
on the outcome of that hearing.  It was a good illustration that it may just be one piece of 
paper that has some key bit of data that affects the outcome of a case. 
Q 
That was question 5.  Can I ask you, please, to go to your question 10, which we see 
at paragraph 414 at page 247?  This covers the situation where a paediatrician has either 
E
removed or failed to place an original medical record in the child’s medical records and there 
is no copy or anything else actually in the medical records, so that the information is simply 
not there or the document is simply not there.  You make your criticisms of that practice in 
paragraphs 415 to 417 and you use words such as “tampering” and “quite unacceptable”.  
Would you wish to expand upon any of those matters to the Panel? 
A 
You could not practise medicine in this country without being aware of pretty 
constant warnings that you get from defence organisations who send circulars of cases and 
F
warn about the importance of keeping good records, the importance of keeping records intact 
and the need to avoid removing items from medical records.  I have not brought any 
examples with me, but it has been a constant theme and as long as I have been practising 
medicine people have been warned about the dangers of interfering with an original set of 
medical records.  The integrity of those records is important and the word “sacrosanct” has 
been used, and that is how I was brought up, if you like, that they really were absolutely 
fundamental and I cannot think of the number of warnings that I have seen reminding doctors 
G
of the importance of that. 
At the bottom of page 247 in paragraph 415 you deal with the issue of accessibility or lack of 
accessibility to those involved in the care of the child if such a practice is made. 
A That 
is 
right. 
Q 
Finally, on this section you see that in paragraph 418 you refer to a policy there which 
H
in turn refers to a policy called the North Staffordshire NHS Trust Policy on Clinical Record 
T.A.  REED 
Day 4 -  22
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A
keeping.  Since the date of that report in July 2005 have you been asking for a copy of that 
policy on clinical record keeping? 
A 
I did ask the instructing solicitors for a copy. 
Q 
Do you understand that the instructing solicitors have been seeking to obtain a copy? 
A 
That is my understanding. 
B
Q 
Have you in fact received any copy of that document? 
A No. 
Q 
Can I ask you, please, to go to your second report now, which is under tab (d) in the 
same bundle.  Can I take you to paragraph 10 of that report on page 9.  Do you there set out 
the purpose of your second report, namely that you were asked to consider whether the items 
in the Appendix One that you then had, if I can put it that way, were medical records, and 
C
secondly, were you asked to comment on the responses provided by Messrs Hempsons on 
behalf of their client, Professor Southall? 
A 
That is correct. 
Q 
Can I ask you, please, to go to the heads of charge, which should be in the yellow 
pages down to your left, and can I take you to the documents in Appendix One, or the 
Appendix One with which you have been provided? 
D
A 
I have got both copies.  By that I mean I have got the copy I used originally plus the 
latest version. 
Q 
Just for the sake of the record, is the latest version the one that I gave you this 
morning? 
A Yes. 
E
Q 
For the sake of the record, can I indicate to the Panel that the one that Professor David 
saw this morning is the one I opened and gave to you at the beginning of my opening, if I can 
put it that way.  (To the witness)  Can I ask you, please, a global question in relation to the 
documents in Appendix One.  Can each and every one of those items properly be said to be 
medical records that fall within category 10 of your analysis? 
A Yes. 
F
Q 
I need to take you to some in particular in order to indicate to the panel where you 
have made particular comment on any particular document.  Will you look at the document 
C9?  Can I tell you that C9 is all the documents in Appendix One in the same order as they 
appear in Appendix One?  With any luck, the first document that we see in C9 will relate to 
Child A, and you deal with that particular document at paragraph 27 of your second report 
that the panel has at C3(7)(b).  Do you have any problems, Professor David, with that being 
a medical report? 
G
A 
No.  It is a straight forward MRI report. 
Q 
Where should one find it? 
A 
In the medical records. 
Q 
When we refer to medical records, are these the medical records relating to the child 
at the hospital where the child there is? 
H
A 
That is correct. 
T.A.  REED 
Day 4 -  23
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A
Q 
Dealing with the third page in this document, we see that it is a referral letter relating 
to a child we know a Child B, addressed to the Registrar, to Professor Southall, from an 
associate specialist there named.  Do you have any problems with any description of that 
document, Professor David, as to whether it is a medical record or not? 
A 
No, that is a medical record. 
B
Q 
We then turn to Child D, and just glancing at Appendix One, do we see that 
principally there are three aspects to that:  that it is incoming correspondence, copies of letters 
between third parties; and outgoing correspondence? 
A Correct. 
Q 
Can I take you to your second report where you consider the matter of clinical 
correspondence generally and incoming correspondence in particular to paragraph 68 of you 
C
report at page 29?  Do you set the tone to your subsequent discussion by referring to the letter 
from Hempsons, which the panel will have seen, which is at C2 (6)(c), where they say that 
these letters related to child protection issues and therefore there was no obligation to file the 
documents in the medical records?  Do you comment on that suggestion, in particular starting 
at paragraph 73 of your report? 
A 
I comment on it starting at paragraph 69. 
D
Q 
Is part of your conclusion in the middle of the page in paragraph 73? 
A 
That is correct. 
Q 
Do you conclude in the middle of paragraph 73:  
“… I would classify the above listed documents as items that should all rightfully 
belong in the patient’s medical records.” 
E
A 
That is correct. 
Q 
Do you expand on that aspect in paragraphs 75 and 76 of your report on page 31, 
where you indicate that it was
“particularly important that correspondence between clinicians that voices child 
F
protection concerns should most assiduously be placed in the patient’s medical 
records”? 
A Correct. 
Q 
Would you like to tell the panel a bit more about way you think that they should most 
assiduously be placed in the patient’s medical records? 
A 
I think it is self-evident.  If somebody else in the hospital is looking at the child’s 
G
medical records, it is obviously fundamental that that other member of staff is able to see that 
there are child protection concerns.  It would obviously be an important aspect of the case, 
and anybody looking at those  records needs to be aware of that. 
Q 
Because there are lay and other members on the panel, why is it important that 
clinicians should know that there may or may not be child protection aspects to a case? 
A 
It is a fundamental piece of knowledge to members of the health care team at the 
H
hospital.  They need to be aware that the child is suffering from an illness or has injuries 
T.A.  REED 
Day 4 -  24
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A
where there is a suspicion that these have been caused unnaturally in some way.  It is 
important that everybody looking after that child knows that.  One of the basic principles of 
child protection work is good communication.  That is a thread that has come out of all the 
inquires that have been held into child protection cases that have gone wrong or where bad 
things have happened, and the need for good communication between professionals, which 
may be positive – a doctor reporting a worry – or it may be simply that things are in the 
records for people to see.  It has been repeatedly stressed. 
B
Q 
At paragraph 76 you look at it from the point of view of what was in the patient’s best 
interests and you conclude in the third sentence:
“My answer would be that I cannot see how a patient could benefit by concealing this 
information, whereas failure to communicate this information with other health 
professionals at the hospital (by excluding it from the patient’s medical records) could 
C
possibly be harmful, and could lead to inappropriate actions or treatments.” 
Is that broadly what you were saying when I asked you that? 
A 
Yes, I think that sums it up. 
Q 
In relation to the category of documentation in Appendix One relating in Child D to 
original copies of letters between third parties, do you deal with that at paragraph 77 of your 
D
report just under the paragraph we have been looking at, and do you indicate that there is no 
difference in principle from that which you have been discussing under incoming 
correspondence? 
A 
That is correct. 
Q 
To complete the picture, at paragraph 103 of your report at page 52, do you make 
a similar point about outgoing correspondence basically falling into the above category, and 
E
do you make the additional point there that most of these documents emanating from 
Professor Southall carefully spell out Professor Southall’s concerns that the patient was at 
risk.
“At the risk of repeating what has already been said above, in my view it was 
important that these concerns should be readily available to any member of  
staff who had reason to consult the child’s medical records, and consequently these 
F
documents should have been filed in the patient’s medical records.” 
A 
That is correct. 
Q 
I need to take you to some, but by no means all, of the records relating to Child D in 
the medical records because you deal with them in your report.  Can I ask you to go within 
C9 and, after about five pages, where you will find that we start coming to correspondence, 
G
for instance, from Southampton University Hospitals, with numbers and we see the first 
number is 281. 
A Yes. 
Q 
Going through these numbers, which are descending, I would ask you to look at page 
229, which I hope will be a letter from the Community Health NHS Trust there listed from 
a Dr Whiting, and accompanying it should be a chronology. 
H
A 
I have that. 
T.A.  REED 
Day 4 -  25
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A
Q 
Keeping that file open a moment, can I please take you to your report where you 
analyse that letter and the chronology.   It is your second report at paragraph 107, which we 
find at page 54 of the report.  There are two aspects I want to ask you about, both of which 
you cover in the section of your report dealing with this letter, which goes from paragraph 
107 to 117.  Dealing with the aspect as to whether they are medical records or not, could 
I take you to paragraph 116 at the bottom of page 56 and the top of page 57?  You state that –  
B
“… the content of the chronology contained almost entirely concerned medical 
matters.  It was sent from one concerned paediatrician to another concerned 
paediatrician, the sender seeking the comment to the recipient.  In my view, the 
content and the purpose places the chronology (and accordingly its covering letter) 
into the category of medical records.” 
C
A Correct. 
Q 
You repeat the point on its own at paragraph 117 about where the letter and the 
accompanying chronology should be filed in the medical records. 
A That 
is 
right. 
Q 
Are there aspects of this letter concerning the fact that you found both two copies of 
D
the letter and two copies of the chronology when you were going through the SC file? 
A 
That is a fact. 
Q 
This was picked up by an alert medical member of the Panel, who asked about it, and 
do you (without going into any details), do you deal with your discussion about the fact that 
there were two copies of either at paragraph 108 in your page 54? 
A I 
did. 
E
Q 
You conclude that discussion about the two copies and the possible consequences of 
that in between paragraphs 108 and 111? 
A Yes. 
Q 
If you are asked about the matter, you can expand upon those paragraphs, if 
necessary? 
F
A 
Well, I can try. 
Q 
Dealing with some of the third party letters relating to this child, we see that the first 
one referred to in Appendix 1 is the letter 2(a) from Professor Strobel to Dr Rogers dated 
5 September 1995, and we see that that is a matter upon which you comment in particular, 
and I may, because there is independent pagination of this document, but it can be found 
about halfway through C9, but I can take you to the original if this is otherwise rather 
G
burdensome, and perhaps that might assist.  The relevant original file I would ask you to look 
for is C6 at page 273 and 274, and you will be relieved to hear that C6 is actually paginated 
in ascending order.  Do you have that letter, Professor? 
A I 
do. 
Q 
Could I ask you to keep that letter open, and go in your report, please, to paragraph 
80, your second report in relation to this case, and that is at page 32 of your second report.
H
T.A.  REED 
Day 4 -  26
 & CO. 

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A
Can I take you first to paragraph 79 on page 32, where you set the scene, as it were, where 
you say: 
 
“I suppose a counter argument might be that all this correspondence flowed as a direct 
result of Professor Southall’s initial child protection concerns.  I suppose the 
argument would be that once he had raised concerns, all subsequent correspondence 
between doctors could be classed as relating to child protection issues.  I mention this 
B
only to say that I do not agree with the logic.” 
That remains your view? 
A It 
is. 
Q 
Then you say at paragraph 80: 
C
 
“Rather than attempting to categorise each item ….. let us take ([for] example) the 
letter dated 5 September 1995 from Professor Strobel to the GP Dr Rogers ….. What 
I have set out below is a list of the components of this letter”. 
Then do you seek, in all the sub-clauses of paragraph 80, from 80.1 down to 80.20, do you set 
out the aspects of this letter as you have analysed it? 
A Yes. 
D
Q 
It is pointed out at 81 that the view of Dr Southall is that it related to child protection 
matters and accordingly it was obligatory for this document to be filed in the medical records.  
You set out in the next four or so paragraphs why you disagree with that, but perhaps if you 
can just make it clear to the Panel orally as to why you consider that this letter, as an example 
of many others, should have been in the child’s hospital medical records. 
A 
Well, I am not sure I can improve on what I have written.  I mean, I have said in 
E
paragraph 82 that I did not see how one could categorise what I call the ingredients of this 
letter, which are listed in paragraph 80, I did not see how one could categorise those as 
relating to child protection issues. 
Q 
Perhaps I should take you and the Panel to paragraph 85, after your analysis in the 
previous paragraphs.  You say: 
F
 
“In trying to seek an alternative perspective, I did wonder if the argument is that 
because Southall had child protection concerns, that he therefore regarded the case as 
a child protection matter, pure and simple.  I suppose the argument would then have 
to be that the eczema, the growth, the intercurrent illness and so on were no longer of 
any relevance.  If by any chance that is the position, then I would not be comfortable 
about it.  It seems to me that the correct perspective is to look at the matter from the 
point of view of the child.  He had eczema, he had suspected food allergies, avoiding 
G
certain foods seemed to be associated with improvement, and his height and weight 
were recorded.  There were plans to admit him to hospital, to further treat his eczema 
and to perform some food challenges.  These are all medical health-related issues.  
Information about them properly belongs in the child’s hospital medical records.  It 
seems to me that the fact that there were child protection concerns cannot and does 
not negate the fact that these were all medical health-related issues.” 
H
Have you said it all there? 
T.A.  REED 
Day 4 -  27
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A
A 
It sums it up. 
Q 
I need to take you to two other matters in relation to this child in particular.  In the 
outgoing correspondence you will see at number 3, we see letters (c), (d), (f), (g) and (h) – 
perhaps I will take those again, letter 3(c), (d), (f), (g) and (h) – all, as you have noted, appear 
to be letters written to a member of social services.  Can we just look at one, for example, 
while we have C6 open, and can we look, please, at page 277 at C6, which is letter 3(c) in the 
B
appendix.  We see that this is a letter from Professor Southall, as he then was, making a 
number of points, and copying his concerns to Professor Strobel at Great Ormond Street, to 
Professor Warner at Southampton, to Dr Rogers, who was the general practitioner, and to 
Dr Connell, who was the paediatric consultant at the hospital there mentioned.  Having 
shown you that letter, can I take you, please, to your report in relation to this matter, and it is 
at paragraph 105 at page 53.  Do we see there, Professor David, that you deal globally with 
all those letters, where you say that: 
C
 
“The letter to Mr Banks, Social Services Manager [dated – and it gives a date] was 
essentially a paediatrician reporting concerns to social services.  It was important that 
this information was available to others involved in the care of the child, or 
potentially involved in the future care of the child, and this letter should have been 
filed in the child’s hospital medical records.” 
D
You make the same comments in relation to all the other letters that are in the appendix. 
A 
That is correct. 
Q 
So does it make any difference as to whether it is “clinical correspondence” that one 
of the recipients happens to be a member of the social services department at all, if the 
information is important clinical information? 
A 
No.  We have already made the point that it is important that other members of the 
E
healthcare team are aware that somebody has child protection concerns. 
Q 
The last matter relating to this child is again if we look, staying in C6, at 313, and 
there are several items and it is item 4 in Appendix 1 relating to this child.  Looking at this 
document, Professor, is that a typical medical record? 
A It 
is. 
F
Q 
Dealing with the question of clinical correspondence and the like, have you had the 
opportunity of looking at a number of protocols with which you have been provided in this 
case?
A 
I have, and they are listed in this report, I think they are at paragraph 88. 
Q 
Yes.  If we go to your second report at paragraph 88 at page 37, and do you list, as we 
can see by 88.1 onwards, do you list over the next pages all the way up to page 44 nine 
G
separate protocols which you have looked at? 
A 
I do list them. 
Q 
Sorry, it even goes further than that.  There are thirteen different protocols you looked 
at, or thirteen matters relating to medical records, going up to page 47. 
A Yes. 
H
T.A.  REED 
Day 4 -  28
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A
Q 
Can I take you, please, to paragraph 89 at page 48.  Were you assisted by studying 
those protocols that deal with matters with Brompton Hospital and the North Staffordshire 
not only hospital but also Area Health Authority, was there anything in those protocols that 
you examined that helped you find the answer to whether or not it was appropriate to have 
clinical correspondence without the ordinary hospital medical records? 
A 
Well, the answer to the question is the first sentence of my paragraph 89: 
B
 
“I cannot find an instruction in these documents that clinical correspondence (such as 
the letter from Professor Strobel to Dr Rogers described above) should not be filed in 
the patient records once child protection concerns had been raised.” 
Q 
Going further than that, Professor David, you did not find anything in the protocols 
and the like which you were provided;  have you found any such guidance in any other 
document? 
C
A 
No, I have not. 
Q 
Have you looked for other guidance elsewhere? 
A 
Well, in my original report I did my best to look at guidance on medical record 
keeping.
Q 
Just to put it another way, as you are aware from having read the Hempsons’ letter of 
D
January 2006, the basic line, if I may put it that way, in relation to this clinical 
correspondence, was that it was appropriate to file that elsewhere.  Have you found any 
protocol, either local or national, that supported that line? 
A 
I could not find one. 
Q 
I will now take you in Appendix One to Child H.  The Panel can see matters relating 
to Child H right at the back of C9.  You will find that about 15 pages in from the back.  The 
E
document has the number 25 at the bottom and is entitled, “Dr D P Southall Cardiothoracic 
Institute”.
A 
I have that. 
Q 
It is a questionnaire pro forma which is filled in in manuscript.  Can you look at your 
second report, while keeping that page open, at paragraph 141?  To put it in context perhaps 
we ought to look at page 64, paragraph 136.  Between paragraphs 136 and 140 do you 
F
analyse the nature of that document? 
A I 
do. 
Q 
Do you come to the conclusion that you do at paragraph 141, that, 
“because the information recorded is likely to be well in excess of that routinely 
recorded in the medical records.  These sheets can only be classified as medical 
G
records and copies should be filed in the patient’s hospital records”. 
A 
That is what I said. 
Q 
If you carry on in the numbering in C9 you should get to a manuscript document in 
what appears to be a clinical document with the full names of the child at the top and it is 
manuscript throughout.  It has page 20 at the bottom. 
H
A 
Yes, I have that. 
T.A.  REED 
Day 4 -  29
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A
Q 
You deal with this document in your report, Professor David, at page 65, paragraphs 
146 to 148.  We see from the letter written by Hempsons in January 2006 that the suggestion 
is that this is an entry by a Dr Samuels in March 1999.  Do you have any observations on 
whether this document should have been not in the child’s hospital medical records and only 
in the child’s SC file? 
A 
My views are summarised in paragraphs 147 and 148.  It is quite clear that these are 
B
medical notes and should have been in the medical records. 
Q 
Dealing earlier with clinical correspondence relating to an earlier child, you indicated 
that this correspondence should have been in the child’s medical records.  I suspect with 
correspondence at least one could see it in another file of the recipient or the sender.  Does 
that apply to this kind of record? 
A 
I think what you are trying to do is to distinguish between an item that is to be found 
C
in other hospital records, like a letter from Great Ormond Street to this hospital, in which case 
you ought to find a copy in the patient’s medical records in both hospitals, but the difference 
here is that this is clearly a document that is handwritten at one hospital, and it is either in 
those records at that hospital or will not be available for anybody to see.  So it is in a slightly 
different category, if you like. 
Q 
In terms of seriousness, so far as the Panel have to consider that concept, as it is in 
D
a different category and not available in any other hospital records, is it a more serious 
document to be found here than anywhere else? 
A 
I would not say that.  I think a patient’s medical records should be intact, period, and 
either everything is in them or everything is not.  Whether it is a handwritten note or a typed 
note, the integrity of the record has been lost and the principle is that. 
THE CHAIRMAN:  Mr Tyson, we are looking to have a short break.  Are we nearly at a 
E
point where it would be convenient to do so? 
MR TYSON:  I should like to finish Appendix One in relation to Child H and then we can go 
on to other matters.  I suspect I shall be no more than five minutes.  Going back to Appendix 
One, we see after that manuscript note which the Panel have in front of them, three letters.  
Page 48 is a letter from Dr Dinwiddie to Dr Southall.  The next letter is a letter from 
Dr Weaver to Dr Southall, and the third letter, at pages 55 and 56, is a letter from Dr Weaver 
F
to Dr Southall.  Do you deal with these letters in your report at page 66, beginning at 
paragraph 149? 
A Yes. 
Q 
Do you analyse them at pages 66 and 67 and come to your conclusion at paragraph 
153 on page 68? 
A I 
do. 
G
Q You 
say, 
“these letters, which all contained important information, should have been filed in 
the patient’s hospital medical records”. 
A 
That is correct. 
H
T.A.  REED 
Day 4 -  30
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A
Q 
After the Dr Weaver letter of 12 June of 1990 there then comes a manuscript letter 
numbered 144 – the penultimate document in C9.  It is a manuscript document dated 
25 July 1991 addressed to Dr Southall from the senior registrar to Dr Weaver.  Is this 
a medical record? 
A It 
is. 
Q 
Should it have been in the child’s clinical records? 
B
A It 
should. 
Q 
The last letter which we see is one numbered 332.  Do you comment on this letter at 
paragraphs 157 to 160, pages 68 and 69 of your report? 
A Correct. 
Q 
Do you conclude that, notwithstanding the references to a foster family and a 
C
supervision order, this is a letter that should have been filed in the patient’s hospital records? 
A 
That is correct. 
MR TYSON:  Madam, that might be a convenient time. 
THE CHAIRMAN:  We will adjourn now for 15 minutes. 
D
(The Panel adjourned for a short time)
MR TYSON:  Professor David, we have just been going through Appendix One of the heads 
of charge.  In relation to Appendix One can I ask you to look, please, at the heads of charge 
themselves?  We have been looking initially at head of charge 10, which is creating or 
causing to be created an SC file where the allegation is that certain original medical hospital 
records were placed.  You see the allegation is that the cited medical record is not elsewhere 
E
in the medical records.  The allegation in head of charge 11 is that the placing or causing to 
be placed such original medical records in an SC file, (a) amounted to tampering, and (b) 
caused such item to be inaccessible to others.  You see that in head of charge 12 there are 
various descriptions of the actions set out in heads 10 and 11 above.  I wonder whether, 
despite the fact that I am fully aware that this is the Panel’s function, as to whether these 
descriptions are correct or not, you had any observations on them? 
F
MR COONAN:  I have not had any notice of this, it is not in the Professor’s report, and as 
my learned friend has rather indirectly put to you, this is a matter for the Panel.  It has 
nothing to do with Professor David. 
THE CHAIRMAN:  I think the Panel has some concern.  Indeed, the Legal Assessor took 
that view as well. 
G
MR TYSON:  Perhaps I can make my own submissions and then you can rule against me, or 
otherwise, as the case may be.  In my respectful submission, it is entirely proper and happens 
in all of these cases that an expert comments on appropriateness.  He can comment on 
whether any action is appropriate or inappropriate and he can also, in my respectful 
submission, comment on 12(a), but certainly 12(b), in relation to his own expertise.  He is 
permitted, and people usually do, in my experience in these kind of hearings, and the expert 
is permitted, with due deference to your fact-finding function, which is exactly how I placed 
H
it, to comment on the appropriateness or inappropriateness. 
T.A.  REED 
Day 4 -  31
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A
THE CHAIRMAN:  Perhaps it depends a little on how you phrase it, Mr Tyson. 
MR TYSON:  I will phrase it as openly as I can. 
THE CHAIRMAN:  I see that there is still some expression of concern.  If you put your 
question, then I will see whether there is any formal objection to it or advice against it. 
B
MR TYSON:  I will put the question, but I will  not expect Professor David to answer.   
(To the witness)  In terms of the heads of charge set out in paragraphs 10 and 11, 
Professor David, if all found proved, would you consider the actions or otherwise of the 
doctor to be appropriate or inappropriate? 
C
MR COONAN:  I am sorry, I do object to that. 
MR TYSON:  I will not waste any time on it.  My learned friend has made his point and 
I have made my point.  Let us get on with it. 
(To the witness)  Can we please now look, Professor, at heads of charge 15 and 16, which 
relate to the documents held on the computer system at the academic department of 
D
paediatrics.  Can I ask you to look at C10? 
MR COONAN:  Could I just mention one point.  I am not stopping my learned friend nor 
inviting you to stop him, but I have not had any advance notice of any of this which 
I anticipate to follow.  As I say, I am not objecting in principle, but I do not know what is 
coming and nor do you, because it is not in the Professor’s report.  That may or may not 
cause me difficulties, but we will have to wait and see. 
E
MR TYSON:  I am intrigued by what my learned friend has to say and I would ask him to 
bear with me as to how I put it. 
MR COONAN:  Yes, certainly. 
MR TYSON:  (To the witness)  Can you look, please, at C10.  Have you had an opportunity, 
F
as you set out at page 45 of your report, to see the documents in C10? 
A I 
have. 
Q 
To be fair to you and to my learned friend, there are two documents there that you 
may not have seen or you would not have seen at the time you wrote the report because they 
had not actually been produced, which were the ones related to Child B.  I do not know if 
your C10 is paginated, but they are at pages 12, 13 and 14, the last three documents in the 
G
bundle.
A Right. 
Q 
The format will not surprise you, but perhaps you can just look at that.  To use your 
own expression, Professor, the exam question is:  Are each and every one of the documents in 
C10 medical records? 
A They 
are. 
H
T.A.  REED 
Day 4 -  32
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A
Q 
Should they have been in the child’s hospital medical records? 
A They 
should. 
Q 
Can I ask you, please, to look at page 44 of your second report and paragraph 88.9 
and could I also ask you to look, perhaps keeping your finger or whatever there, in C3 to 
section 7 under the tabs and to get to subsection (d) and tab (i) within that (d)? 
A 
I have got it. 
B
Q 
You should have in front of you a document from the National Heart & Lung 
Institute, dated 14 December 1990.  In your report at page 44, 45 and 46 do you deal with 
your observations on that letter? 
A I 
do. 
Q 
In relation to the reference in the letter in (d)(i) which I just took you to, when it is 
C
said, three sentences in: 
“Dr Southall is quite happy with a copy of the computer sheet which usually 
sufficiently states the aim of the admission and the possible diagnosis and the 
recommendations.  The computer sheets are usually typed and provided by 
Dr Southall’s department which should be filed in the notes by the Ward Clerk”, 
D
that is a document that relates to a possible diagnosis and recommendations.  If you look, 
please, at C10, and turn to the third document in there, is that a document that indicates the 
possible diagnosis and the recommendations?  Does it have the ability so to do? 
A 
It says, “Your patient was referred with” and there is no comment as to that, and it 
says that a 12-hour overnight recording was performed and it describes what the instrument 
was and what measurements were made, and the result was normal recording.  The clinical 
impression was no comment and the recommendation, there was none.  “Follow-up:  Control 
E
Recording if CE occur.”  That is it. 
Q 
This kind of letter, of which another example or other examples we can see under the 
last or the penultimate page in this document (page 13) appears to be the same proforma the 
patient was referred with, and then gives what the patient was referred with, that a continuous 
recording was made, the clinical impression given and a recommendation.  Do you see that? 
A Yes. 
F
Q 
In relation to, say, that sheet at page 13, in your view is that kind of document the one 
being described in the document dated 14 December 1990, the letter from the National Heart 
& Lung Institute? 
A 
I have said in my report I assume it is.  I do not know that for a fact. 
Q 
Turning now to a completely separate matter, and that relates to heads of charge 7 and 
G
8, this is the final matter I will be dealing with, Professor David.  You see it relates to a letter 
involving Child H that was written by Professor Southall to a Dr Dinwiddie.  Could you look 
please at bundle C2 at (i)?  Do you have that? 
A I 
do. 
Q 
This is the letter referred to in head of charge 8 and the allegation in relation to this 
head of charge relates to, on page 24, the third person who is therein copied, namely a 
H
consultant paediatrician at the Royal Gwent Hospital? 
T.A.  REED 
Day 4 -  33
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A
A Right. 
Q 
Have you at one time, Professor David, written a report on this aspect of the case? 
A I 
have. 
Q 
Madam, that is not the report that is before you, may I emphasise.  Dealing with 
aspects of what you say about this case, looking at head of charge 8(c)(i), in which it is said: 
B
“you did not seek, nor obtain, Child H’s parents consent,
i.
to the fact of involving a local paediatrician in Child H’s care …”, 
is it your conclusion that that is a purely factual matter for the Panel to decide one way or the 
other? 
C
A Correct. 
Q 
In relation to the issue of consent generally, could you indicate to the Panel, please, 
your views about involving another paediatrician in the child’s care?  What kind of consent is 
required or what kind of information is required to the patient, in your opinion, to provide 
a valid consent? 
A 
If the consent is to be valid then the person giving the consent has to know what the 
D
contents of the letter will be, or at least what the thrust of those contents will be. 
Q 
We see in the letter at page 24 at the bottom of the first major paragraph, it says:   
“We also feel that it is vital that [Child H] has his overall care managed by a local 
paediatrician.” 
E
We see that a paediatrician is listed in item number 3 there.  In your opinion, is a letter such 
as this, a copy of a letter such as this, sufficient to enable Child H’s overall care to be 
managed by a local paediatrician? 
A 
A letter like this would normally accompany a letter of referral, so one might refer 
a patient to another paediatric colleague, explain why, and then say, “Please see a copy of the 
letter I have just written which gives you some further information”. 
F
Q 
If you felt that it was vital that a child had his overall care managed by a local 
paediatrician, would it be important or otherwise to seek to identify a local paediatrician? 
A 
It would, otherwise the letter risks floating around on receipt with the mail room or 
whoever not quite knowing what to do with it. 
Q 
Could you look at 2(o) within C2?  Do you there see a letter dated --- 
A 
I have not got 2(o). 
G
Q 
(Copy handed to witness)  Have you had an opportunity to read that letter? 
A Yes. 
Q 
Do you have any observations on the last paragraph in respect of a local 
paediatrician? 
A 
The writer of the letter obviously knows the local arrangements and has pointed out 
H
that where this family lives is on the border between two units and that either of them would 
T.A.  REED 
Day 4 -  34
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A
be appropriate.  Presumably this person could have suggested somebody suitable at either or 
both of them. 
Q 
Going back to the original letter at (i), page 24, and bearing in mind the fact that it 
appears that this patient’s home lay between the two possible hospitals, how does that assist?  
I am looking at the fact that it was felt by the writer of this letter to be vital that the child’s 
overall care was managed by a local paediatrician? 
B
A 
My worry is that this letter might not achieve that objective.  It would have been more 
efficient to have actually addressed it to a named consultant saying, “Please would you look 
after and get involved in this child”, and, if one was not certain, then one could ring up or 
write to Dr Weaver saying, “Who would you suggest, given the circumstances here?  Which 
unit and which consultant should I write to?” 
Q 
If you were seeking a local paediatrician to have his overall care managed by that 
C
paediatrician, would this letter as the sole accompaniment to the letter to the named 
paediatrician suffice? 
A 
No, it would not.  There would need to be a letter of referral. 
Q 
For the benefit of the lay members of the panel, what kind of things would one 
include in a letter of referral? 
A 
One would write to a named person and say that one wanted them to either be 
D
involved in or take over the care of a particular child, and one would spell out the reasons 
why one had selected that person and that hospital, and then one would give whatever 
medical information and background information one felt would help the person one was 
writing to and one might enclose with that letter copies of other letters that have recently been 
written.
Q 
If it was suggested to you that the purpose of this letter was to alert ‘a’ or ‘the’, I do 
E
not know whether there is one or more than one, consultant paediatrician in the Royal Brent 
Hospital of child protection concerns, do you have any comments about that? 
A 
It would not be a very effective means of communication because there is a risk that it 
does not actually arrive on the desk of a named consultant.  It might do.  It may well do at the 
end of the day, but it might be delayed whilst it gets passed around. 
Q 
If it was suggested to you that this letter had been written with the consent of the 
F
Child’s H’s patients (sic), does that fit comfortably with the idea of a child protection letter? 
A 
I do not quite follow the question. 
Q 
If it is suggested that the involvement of the local paediatrician was for child 
protection purposes, and if it was also suggested to you that this involvement of the local 
paediatrician was for child protection reasons – so I am putting two bases to this question – 
would the two be compatible? 
G
A 
I will have a go but I may miss the point of the question, in which case I apologise. 
Q 
If you are not happy with the question, it is my fault and I will re-phrase the question. 
A 
Shall I have a go and then we will see whether we are along parallel lines or not? 
Q 
Pause there a moment.  Perhaps you would just like to remind yourself of what you 
say at paragraph 515 of your report relating to this particular patient. 
H
A Right. 
T.A.  REED 
Day 4 -  35
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A
Q 
Which the panel do not have. 
A 
Shall I read out that? 
MR TYSON:  Do not read it out.  Just answer the question. 
MR COONAN:  Put the question again. 
B
MR TYSON:  If it is suggested to you that the parents have given their consent to the 
involvement of a local paediatrician, that is basis one, and if it is, secondly, suggested to you 
that the reason for sending this letter to the local paediatrician was because of child protection 
concerns, that is basis two, would this letter on those bases achieve either of those aims? 
A 
It is not a referral letter anyway, so it would risk not achieving those aims. 
C
Q 
If one asks the parents to agree the involvement of a local paediatrician, is that 
compatible, asking their consent, with ongoing child protection concerns? 
A 
Let me try to dissect that out.  If one is saying to parents, “I think it would be a good 
idea for your child to see a local paediatrician.  Would it be all right if I write to them?” and 
they say “yes”, that is straight forward.  If the letter actually says, “The reason I am writing to 
you is that I am worried; I have child protection concerns” and you have not said that to the 
parents, then I think that puts into question whether you have actually obtained their consent. 
D
MR COONAN:  Madam, these are matters of fact.  (inaudible) 
MR TYSON: I am about to end this matter and end my examination of this witness.  It is all 
good stuff but you know it is not going to go any further.  Thank you very much, Professor 
David.  Those are all the questions I have in chief. 
E
THE CHAIRMAN:  I know it falls to you, Mr Coonan, but I suspect you may not wish to 
begin at this time.  Is that so? 
MR COONAN:  Madam, you are right.  In the light of the indication you gave about rising at 
about 5, I would be extremely loath to start.  I would only end up duplicating whatever effort 
I had put into it tonight.  In any event, it has been a long day and I think, in the interests of the 
doctor, it would be better if I deal with it one of a piece.  I can promise to be much more 
F
efficient and shorter. 
MR TYSON:  Madam, I was wondering if I can float for consideration, bearing in mind the 
extreme difficulties of this doctor being with us after Friday, the possibility of starting at 
9 o’clock rather than 9.30 tomorrow? 
THE CHAIRMAN:  I think I would need to consult the panel about this because without 
G
notice, of course, that might not be possible. 
MR TYSON:  I am not asking for an instant decision.  I was wondering, if we retired for 
a moment, if you could discuss it amongst yourselves. 
MR COONAN:  Can I help?  I do not mind Professor David hearing this.  I am not going to 
be at great length and so I do not think there is much danger of the Professor’s evidence not 
H
T.A.  REED 
Day 4 -  36
 & CO. 

---

A
finishing tomorrow night.  I do not give any guarantees.  That may help your management on 
timing for tomorrow morning. 
MR TYSON:  My learned friend might not be long, and he usually is quite expeditious in his 
cross-examination, but I know not how many and how wide-ranging the questions of the 
panel might be.  An extra half an hour would assist case management, if I can put it that way. 
B
THE CHAIRMAN:  Why not give us a couple of minutes and I will consult the panel? 
Professor David, I know you are a very experienced witness. I know I do not need to remind 
you that you should not discuss the case while you remain on oath. 
THE WITNESS:  I understand. 
C
(The Panel retired for a short while)
THE CHAIRMAN:   Mr Tyson and Mr Coonan, the Panel is willing to aim for a 9.00 a.m. 
start, and that is transport willing, and so on.  We think that we can be here by nine as long as 
nothing untoward happens, and we are happy to aim for a start then, and we think that might 
assist us, and that we would certainly prefer perhaps to put in any extra time in the morning 
than in the evening, if that is acceptable. 
D
MR TYSON:   I am very grateful indeed. 
MR COONAN:   Thank you very much. 
THE CHAIRMAN:   So we will adjourn to nine o'clock or as soon thereafter as everybody is 
here.
E
(The Panel adjourned until 09.00 on Friday, 17 November 2006)
F
G
H
T.A.  REED 
Day 4 -  37
 & CO. 

---

GENERAL MEDICAL COUNCIL
FITNESS TO PRACTISE PANEL (PROFESSIONAL CONDUCT)
Friday 17 November 2006
44 Hallam Street, London, W1W 6JJ
Chairman:   
  
Dr Jacqueline Mitton 
Panel Members:
Mrs Leora Lloyd 
Mr Alexander McFarlane 
Dr Sameer Sarkar 
Mr Arnold Simanowitz 
Legal Assessor:   
Mr Robin Hay 
CASE OF: 
SOUTHALL, David Patrick 
(DAY FIVE)
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 JOLLIFE 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
 
PROFESSOR  DAVID, Timothy Joseph, recalled   
 
 
 Cross-examined 
by 
MR 
COONAN 
   1 
 
Questioned by THE PANEL   
 
 
          26 
 
Further re-examined by MR TYSON  
 
          42 
MRS A, Sworn 
 
Examined by MR TYSON 
 
 
 
          48 
 
Questioned by THE PANEL   
 
 
          64

---

A
THE CHAIRMAN:  Good morning, everyone.  We continue with Professor David. 
PROFESSOR TIMOTHY JOSEPH DAVID, Re-called
Cross-examined by MR COONAN
MR COONAN:  Professor David, could I deal first of all with a preliminary matter of 
B
terminology?  In other words, the subject of what is or what is not a medical record.  The first 
part of my cross-examination is not really by way of a series of questions to you; it is really 
by way of setting out, with your assistance, the platform for the questions which are to 
follow.  Could you take Appendix One, and obviously I invite the Panel to follow this process 
as well.  Do you have that? 
A Yes. 
C
Q 
I am going to proceed on the basis that all the documents in Appendix One, save 
possibly Item 2 – I will explain why in a minute – in respect of Child H -- that is the 
manuscript entry on page 20 purportedly signed by Martin Samuels MS, you may remember 
that; I will not bother to turn it up; the Panel has seen it -- I will proceed on the basis that all 
those documents, save possibly that one which may have to wait for further evidence, are 
indeed medical records for the purposes of this hearing.  I want that to be a given for the next 
questions.  It follows from that that, again for the purposes of my cross-examination, all those 
D
documents that I am accepting are medical records, and all the documents in the special cases 
file, and all the documents in the main file, are or should be accessible to health 
professionals.  You would agree with that, would you not? 
A Yes. 
Q 
Secondly, it would follow that all those documents are at least potentially disclosable 
in the event of a complaint or legal action, care proceedings and criminal proceedings, and 
E
you would agree with that. 
A 
I am not an expert in the law.  I think you would need a lawyer to say what is and 
what is not disclosable.  That is outside my expertise actually. 
Q 
I fully understand that.  That is why I used the word, “potentially”, subject to 
prevailing legal rules. 
A 
It makes common sense, yes. 
F
Q 
So with those preliminary observations in mind, I am not going to be suggesting to 
you that there is a separate category of records here which are not medical records.  Do you 
understand?
A 
I think so. 
Q 
In other words, whatever ground Professor Southall relies on for the filing of certain 
G
of these documents, it is not based upon the concept that they are a different category of 
record.  They are medical records.  Right? 
A Fine. 
Q 
In contradistinction, an example of records which would be in a wholly different 
category, a different animal, would be an expert report which was compiled by Professor 
Southall or indeed you, following instructions from instructing solicitors. 
H
A I 
agree. 
T.A.  REED 
Day 5 -  1
 & CO. 

---

A
Q 
Having set the scene, can I move on to the next question?  Again it is by way of 
background and it really addresses this question of the extent and ambit of the debate 
between us.  In Appendix One, I want you first of all to accept from me for the minute, that 
there are five items in Appendix One, or at least information in the five items – I stress that – 
that should have been placed ideally in the main file, whether or not they were in the special 
cases file as well, and filed at the appropriate time.  I will come to the five in a minute.  In 
B
accepting for the purposes of the debate that these five should have been in the main file, the 
question of whether all or any of those five actually are or at least were at some time in the 
main file and if not why not, must be a matter of evidence. 
A Correct. 
Q 
By that I mean evidence yet to be given to the Panel. 
A Correct. 
C
Q 
Can I take you smartly, then, to the five items that I want for my purposes to take out 
of this debate?  Firstly, Child A, the MRI report 11 February 1987, special cases file page 
131.  As a matter of proposition, that clearly, or at least the information in it, should have 
been in the medical files. 
A We 
agree. 
D
Q 
Child B, the Crawley referral letter of 2 September 1993, special cases file page 33, 
that document ought to have been in the main file, whether or not it also went in the special 
cases file.  Do you agree with that? 
A I 
do. 
Q 
Next, Child D, item four.  This is the patient data.  Do you have that? 
A 
I do not have the actual page but I have the entry on the appendix. 
E
Q 
That will do, the patient data form 13 December 1994; special cases file page 313.  
Again, I am not going to ask you to turn it up.  The Panel have seen that.  Child D, that is a 
document which, for the purposes of my questions it is accepted should have been placed in 
the main file, at least as well as the SC file.  Next Child H, and there are two items that fall 
into this category for these purposes, Item 1 is the collection of clinical data form of 28 
September 1989, special cases file pages 25 to 31.  Again, you would agree that that should 
F
have been in the main file as well, at least, as in the special cases file. 
A Correct. 
Q 
Item six --  
A 
I am on four actually.  I must not have written one down.  Child A one item; Child B 
one item; number three was Item 4.  Have I missed one out? 
G
Q 
I am now on Child H.  Item one, and I am going to item 6.  
A 
sorry, |I thought you meant there were six items because I have only got five. 
Q 
There are five altogether. 
A 
So it is Item 6 in Child H. 
H
T.A.  REED 
Day 5 -  2
 & CO. 

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A
Q 
Yes.  This is a letter from Dr Matthews to Dr Southall, 25 July 1991, SC file page 
114.  That is the letter which, for present purposes, should have been – whether or not it was 
in the special cases file – at least in the main file, and we agree about that. 
A We 
do. 
Q 
As I said earlier, five items where we agree they should have been in the main file, 
even if they were also in the special cases file.  There is one further item I want to draw 
B
attention to.  That comes back, in Child H, to Item 2, the manuscript clinical entry at page 20.  
Earlier I just set the scene in relation to that and suggested that it may or may not turn out to 
be a clinical record depending on further evidence; in other words, if I can give you an 
indication, it may depend upon the purpose for which that document was created.  Leaving 
that aside, again for our purposes – you and I – if it is a medical record then I accept that it 
should have been in the main file as well, and you would agree with that. 
A Yes. 
C
Q 
Therefore, if I ring-fence for the moment those documents where I accept they should 
have appeared in the main file, what we are left with in relation to Child A, for example, is 
nothing; in relation to Child B nothing; in relation to Child D, all the correspondence.  Do 
you agree? 
A Yes. 
D
Q 
Which on my mathematics, and if I am wrong somebody will tell me, is 28 letters.  In 
relation to Child H four letters.  I am sorry to be pedantic but it has got to go on the record. 
A Our 
maths 
tally. 
Q 
Therefore, for the purposes of this exercise, we are looking at letters only and it is 
again admitted so that you are clear where I am coming from, that that correspondence, the 
28 and the four, is not in the main file.  Moreover, it consists of a mixture of original letters 
E
or original top copies or copies from third parties.  I think you agree with that. 
A 
I cannot comment on how many are original and how many are not because I do not 
have that information. 
MR COONAN:  You have not done the exercise. For my purposes it does not matter.  I am 
accepting that there was that mixture.  I think Mr Tyson’s case is to the same effect. 
F
MR TYSON:  I will be asking my learned friend to make formal admissions in light of this 
cross-examination in due course for the record. 
MR COONAN:  If Mr Tyson had not asked me I would have put it in in any event to help the 
balance, so he is pushing at an open door.  Professor David, I hope setting the scene has been 
helpful to you and I hope to the Panel before we then just engage in what I call the debate. 
A 
Was that a question? 
G
Q 
No, it was a comment before I come to the questions.  If you find the exercise thus far 
to have been unhelpful then please say. 
A 
I do not find it unhelpful but I do have a query.  However, it is not my position to ask 
questions.
Q 
I have said for my purposes I am putting them to one side.  Why I put them aside is a 
H
matter of further evidence.  I just want, for my purposes to concentrate therefore on what is 
T.A.  REED 
Day 5 -  3
 & CO. 

---

A
now a total of 32 letters in respect of two patients, D and H.  Would you agree that a proper 
question to pose in relation to dealing with this debate is to ask oneself the question whether 
the filing of this correspondence was reasonably justified in the special cases files alone. 
A 
I may have misunderstood the question and if I have I will be corrected, but my 
position is that my view was that these are medical records and should have been placed in 
the original patient medical records.  I have got no views, or I have never expressed any 
views on what should or should not have been placed in the special case files.  My concern, if 
B
you like, has been solely the integrity of the patient records rather than the integrity of the SC 
files, which has not been something I have addressed. 
Q 
Let me put the question in a slightly different way.  Is there a useful question to ask 
whether it was reasonably justified in not filing the correspondence in the main file? 
A 
Well, I must have failed to make my position clear, but my view is that these items of 
correspondence comprise medical records and should all have been in the patient’s medical 
C
records.  It therefore follows that I would be unhappy if that had not happened. 
Q 
Having come here to give I appreciate not particular expert opinion about medical 
records, but nonetheless posing the question in that way to the Panel may be a helpful method 
for them to approach it, do you agree? 
A 
I do not follow the logic, I am afraid. 
D
Q 
Right.  Well, I do not want to get involved in a semantic discussion, but you have in 
effect said, and made your position clear, that this correspondence should be in the main file 
even if it is in the special case’s file as well? 
A Correct. 
Q 
Let us just see where the fault line is.  First of all, as you have correctly identified, 
Hempsons’ letter, at C2 6(c) – again, I do not invite the Panel to look at it, they are familiar 
E
with this document now – sets out Dr Southall’s position, and broadly, just to summarise it, 
the grounds are that the correspondence related to a background of child protection concerns 
and issues, in other words a broad policy approach was being applied to these two patients.
Fair? 
A 
That seems to be the thrust of the letter, yes. 
Q 
So on the one hand a very broad policy, protocol if you like, unwritten but 
F
nonetheless a broad policy, but you would go for a slightly different approach and that is to 
examine each individual letter for the purpose of deciding whether it should go in the main 
file? 
A 
I do not think that was a different approach.  I simply was asked to look at each item 
and say whether in my view it was or was not a medical record, so I was doing no more than 
I was asked to do. 
G
Q 
We have agreed that they are medical records.  What it boils down to is where they 
are to be located. 
A Right. 
Q 
I think your position is, and I am quoting really from your evidence and from your 
report, you say that simply because there are child protection issues raised does not justify 
separate filing? 
H
T.A.  REED 
Day 5 -  4
 & CO. 

---

A
A 
Well, I went slightly further than that.  I did say that the fact that child protection 
concerns had been raised does not justify withholding items from a patient’s medical records, 
but I went further and said that if there were child protection concerns, then it was 
particularly important that that material was placed in the patient records. 
Q 
Well, you did, and I am going to look at that in a minute, but you also in your second 
report, and I am referring to paragraph 69, really raised the question of whether one should be 
B
applying a sort of percentage sliding scale when you look at each of the individual documents 
to determine how much is child protection and how much is not.  Do you want to turn that 
up? 
A 
Yes.  I have it here. 
Q 
It is C3, tab 7(b) at page 32 (sic).  Do you have the reference to the sliding scale? 
A I 
do. 
C
Q 
Can you just read it out. 
A 
Yes.  It starts really at paragraph 68, which says: 
 
“The letter from Hempsons dated 24 January 2006 says that these letters related to 
child protection issues, and that therefore there was no obligation to file the 
documents in the medical records. 
D
 
I do have some difficulty with this.  As I see it, Hempsons are saying in their 24 
January 2006 letter (and if I have misunderstood then I apologise and no doubt they 
will correct my error) that any letter that is in any way related to child protection 
matters need not be filed in the medical records.  I find it difficult to go along with 
this.  What percentage of a letter has to concern child protection matters for it to no 
longer need to be filed in the patient records?  Supposing that 95% of a letter concerns 
E
diagnosis and treatment, but 5% contains a child protection concern, should that cause 
the letter to be removed from the medical records?  To put it another way, at what 
point does a letter between Dr A and Dr B about a patient cease to be ‘clinical’ and 
become ‘non-clinical’ or ‘child protection’?  I find it impossible to answer the 
question.”
Q 
Right.  If you are happy, can we just pause there.  In the body of that observation you 
F
are using, or employing an assumption, that the letter in question is, and I quote, “removed 
from the medical records”.  I am not suggesting for a moment that this correspondence is 
being removed from the medical records.  I am accepting it is still part of the medical records, 
but filed in a different place.  I draw attention to this because there may be a fundamental 
misunderstanding of what is being said.  That observation, I suggest, illustrates the 
philosophical difference between Professor Southall and yourself, does it not? 
A 
Well, I cannot speak for Professor Southall, but you have made a point. 
G
Q 
Against what I have called the fault line between you on this approach, I suggest that 
it would be helpful, would it not, for us to be able to make judgements as to the extent to 
which you may be right or justified in your view, or Professor Southall right or justified in his 
view, by looking at a number of background facts in relation to these two cases?  Would that 
be a helpful approach in your opinion? 
A 
I cannot say because I am not quite sure what direction we are going in. 
H
T.A.  REED 
Day 5 -  5
 & CO. 

---

A
Q 
Well, let us wait and see. First of all, it would appear that this was a practice policy, 
protocol, call it what you like, which was adopted and followed by Dr Southall’s team at 
Brompton and at Staffordshire, was it not? 
A 
As far as I can see, yes. 
Q 
In relation to Child H, the actual care and treatment of him had ceased at the 
Brompton Hospital by 17 March 1990.  Were you aware of that? 
B
A 
I do not have the dates in front of me, but I am perfectly willing to accept that. 
Q 
So in other words, when we look at the material in relation to Child H in Appendix 
One, in other words the correspondence, all that correspondence relates to the period after the 
discharge of this patient? 
A 
Can you just give me the date again? 
C
Q 
Yes, of course, 17 March 1990. 
A Right. 
Q 
I just make this observation, that the correspondence that I accept are medical records, 
and which relate to this question for the Panel, it postdates that date. 
A I 
follow. 
D
Q 
I just want you to assume for the purposes of this discussion, as we can see, that that 
is self-evidently the case; secondly, that he was never treated at the Brompton again, and that 
it was unlikely that he would be treated at the Brompton or Stoke again. 
MR TYSON:   I do not want my learned friend, and I am sure my learned friend would not 
want to make a bad point, but this child was treated in Wales about a year later under Dr 
Southall’s care, and he was responsible for dealing with that admission. 
E
MR COONAN:  I am well aware of that, but my question was on the basis that he was not 
treated at the Brompton or Stoke again, all right? 
A I 
understand. 
Q 
Thirdly, and we will hear more evidence about this but the Panel already has some 
evidence in the letter addressed to Dr Dinwiddie dated 22 March 1990, that the mother made 
F
it clear that she did not want Dr Southall to be involved in the care of this child again.  The 
next point I would ask you to consider is that of course both these centres were tertiary 
centres.  Now, in relation to Child H, against the background of those facts, do you think it is 
relevant or not relevant in terms of Dr Southall adopting and applying the policy which is set 
out in the Hempsons letter? 
A 
I do not think it is relevant. 
G
Q Right. 
A 
Would it be helpful to explain why? 
Q 
Yes, do by all means.  I ask you these questions so that the Panel can see exactly 
where, by the time the case has ended, exactly where the positions are on both sides. 
A 
The point that was being made in the question, or one of the points, was that at a 
certain date the patient ceased to be treated at a hospital.  Now, no implications or inferences 
H
were drawn from that, but somebody listening to that might infer that that effectively was the 
T.A.  REED 
Day 5 -  6
 & CO. 

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A
end of the matter, and that therefore, after that point, because the child was not going to 
return to that hospital, it really did not matter what ended up in his medical records or not.  
Now, that has not been said and that point has not been made, but what I had in mind when 
I was listening to that was that of course there are many things that can happen in relation to a 
child after he or she has been discharged form hospital, even if that child’s mother has said, 
“I am never going to come back here again”, there are nevertheless reasons why people may 
need access to that child’s medical records.  There are therefore reasons why those records 
B
need to retain their integrity and must be complete, even though the child will never enter the 
doors of that hospital again. 
Q 
I follow the point.  Ultimately, you are raising there, within that answer, ultimately 
questions of accessibility and integrity, and we will come on to that later. 
A Fine. 
C
Q 
That is a fundamental issue which informs your approach to this, does it not? 
A 
Well, it informed my answer to the question. 
Q 
It has nonetheless loomed very large in the process of your analysis of the case? 
A 
I was not sure what implications you wanted to draw from the fact that the child had 
never been treated again at the hospital, and that is really why I just made that point. 
D
Q 
Well, let us just move on to Child D, so again dealing now simply with the 
correspondence for the purposes of these patients.  This child ceased being treated in 
December 1994 at Stoke.  He was never treated at Brompton.  I do not know whether you 
were aware of that? 
A 
I do not think I have related Child D to the Brompton, have I? 
Q 
No, no, I am just setting the scene to help the Panel. 
E
A 
That was my understanding, that Child D was dealt with at Great Ormond Street and 
at other district general hospitals around Greater London. 
Q 
His treatment at Stoke finished in December 1994.  The next factor, again if you look, 
please, at Appendix One, all the correspondence that falls for consideration for the purposes 
of this today postdate December 1994, yes? 
A 
I have not checked it, but I accept that you are accurate. 
F
Q 
Well, if I am wrong somebody will correct me.  He was never treated at Stoke again.  
If it be the case that it would be unlikely he would ever be treated at Stoke again, not least 
because of geography and the fact that Stoke is a tertiary centre, are those factors not of some 
relevance in informing Professor Southall’s blanket policy for filing separately that 
correspondence? 
A 
Well, my answer is not.  My answer is that there is an absolute need for a patient’s 
G
hospital medical records to be intact. 
Q 
I am not sure how much you read into the medical notes of each of these two patients, 
so if it is a question you cannot help me with, then please say.  The care and treatment of both 
Child H and Child D, by the time they have been discharged, had in effect elided into child 
protection concerns. 
A 
Well, I think they are different in a sort of fundamental way, and again this is me 
H
speaking from memory, but if I recall correctly the difference between the two cases is that in 
T.A.  REED 
Day 5 -  7
 & CO. 

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A
one of them, in Child H, child protection issues had actually been raised by the referring 
hospital, which was Great Ormond Street (I think they had referred to the topic in their letter 
of referral), whereas with Child D those concerns were mainly raised once the child had come 
to stay.  So I see them slightly differently. 
Q 
Well, insofar as there is that difference, I am prepared to accept that for the purpose of 
the question, but the thrust of the question was that by the time of the discharge of each child 
B
the case had, whatever the history had been, there were in fact child protection concerns in 
place?
A 
That is correct. 
Q 
The next factor concerns the correspondence itself.  From your understanding of the 
examination of the correspondence and the situation at the relevant time, that is post 
discharge in both cases, these letters were not sent or received, it would appear, by 
C
Professor Southall, and that includes receiving the third party correspondence, or copies of it, 
in his capacity as a treating clinician in either case. 
A 
Was that a question or a statement? 
Q Yes. 
A 
I do not think I would agree with that.  It seems to me that he was wearing two hats; 
one was that he had been a treating clinician and one was that he had child protection 
D
concerns.  It is hard to separate those two things out.  If you have a patient in your unit, and 
while the child is with you you acquire child protection concerns, and the child is discharged, 
you do not cease to be a clinician; your involvement was as a clinician and you had child 
protection concerns.  So I would not unpick the two roles quite so easily. 
Q 
Professor David, you might have a little difficulty with that concept but do you accept 
that there is a contrary view, that a clinician in a tertiary centre, who has cared for and treated 
E
a child, that the care and treatment of that child at that stage, as far as he is concerned, is 
complete, if correspondence is then received in his capacity wearing his hat as someone 
concerned in child protection issues, there is a difference is there not? 
A 
I do not agree.  If I could pick up the words that you used?  You talked about 
somebody caring and treating and I think if a paediatrician has concerns about a child who 
has been discharged then that paediatrician is still wearing their caring hat; they care about 
the child, they have concerns about the child. I do not see that changing the minute the child 
F
walks through the door of the hospital and says good-bye. 
Q 
Do you accept that that might not be a universally shared view amongst your 
brethren? 
A 
I cannot claim as to what other people’s views are, I can only give you my opinion 
about that. 
G
Q 
Whatever may be the correct way of looking at that issue, what I am going to call the 
primary treating clinicians – you may jib a bit at my expression but I hope it is sufficient for 
the present purposes – that we see involved with these two patients would clearly have kept 
copies of the originals of their correspondence and the receipt of material in their own 
hospital notes, would they not? 
A 
If we leave out the term “primary treating” because I think that anybody that has 
treated the child is a treating clinician.  But if the question is, for example, would the doctors 
H
T.A.  REED 
Day 5 -  8
 & CO. 

---

A
at Great Ormond Street have retained correspondence in the child’s records at Great Ormond 
Street then the answer is yes, I hope so. 
Q 
The same applies obviously to material which we see – and I am not going to go 
through the laborious exercise with you of looking at this, it is evident the Panel will have 
spotted it – that many of this individual correspondence is of course copied to other 
clinicians, GPs certainly.  So when I used the word “primary” what I meant by that was the 
B
treating clinician who is in effect initiating or sending the correspondence from A to B, so 
both A and B would keep copies in their notes. 
A 
I am a little confused.  We are talking about Great Ormond Street as an example.  We 
have Professor Strobel, who clearly had concerns of his own about child D.  Are we saying 
that he should have stopped filing materials in the Great Ormond Street records once he had 
child protection concerns?  Sorry, is there a double standard or … 
C
Q 
No, I am not suggesting that; I am not suggesting that at all.  Sorry, you have 
misunderstood the question.  It was really a question in the nature of an observation, that if a 
doctor at Great Ormond Street, who is actually actively treating the child, sends a letter to the 
GP or the social services, both Professor Strobel would keep a copy in his main file and the 
recipients would keep the original or a copy in their file. 
A 
I would hope all originators and recipients would keep copies of letters in the patient’s 
records.
D
Q 
And the same applies if there is correspondence going directly to social services, they 
would file in in their filing system. 
A 
I actually do not know how social services operate their filing systems. 
Q 
Thus far I have just been examining with you the factual backdrop to both these two 
case and the factors that might or might not have affected the way in which Professor 
E
Southall’s policy was applied.  Can I come to the question of accessibility?  Obviously, 
whatever the policy was, if the material is filed in the medical notes but not in the main file – 
and I am using that expression because I do not want the idea to get abroad that these are not 
medical records – this part of the correspondence is filed as part of the medical records but 
simply not in the main file.  Obviously if those documents filed out with the main file are not 
accessible to clinicians who need to know then there is a problem, and you would have strong 
objections to such a system. 
F
A 
I have difficulty with the proposition of the question.  It may be that I am being over 
simplistic and I am happy to be corrected, but my understanding of the term “hospital 
medical records”, which is what we are concerned with, is that that is a file, a bundle of 
papers – there may be many volumes but it is one volume – that is the patient’s medical 
records, that is the hospital medical records.  So I struggle with the concept that there is 
something else, another bundle of papers somewhere else, wherever they are stored, that is 
being labelled the hospital medical records because, as I understand it, there is only one thing 
G
that is the hospital medical records and that is the original records.  When you ask to see the 
child’s medical records that is what you get.  So I have got a bit stuck with the proposition of 
the question. 
Q 
If you are approaching this on the basis that when we talk about hospital medical 
records that all that does exist and should exist are either one, two, three or four, however 
many buff folders, I suggest that that is a far too narrow approach because – and I will come 
H
to it in more detail – hospital medical records is a much broader concept and includes 
T.A.  REED 
Day 5 -  9
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A
material stored in other sites, in computers, laboratories, other clinics, where there are no 
records of that information kept in the buff folders.  Do you agree? 
A 
I am not sure there is very much between us on this.  It is a point I have made in my 
report that it is a fact that information about patients can end up in all sorts of places.  There 
is no disagreement about that, but ultimately I think – and the point  
I make is very simple – it is about what is a medical record?  I think what this discussion is 
about – and you have used the word – is accessibility, and I accept that. 
B
Q 
Absolutely.  This material is medical records, they are filed out with the buff folders 
and the big question is whether they should be accessible. 
A 
The big question is whether they should be in the patient’s medical records or not. 
Q 
I have dealt with that point and I am now dealing with accessibility.  You would say 
that it is vitally important that wherever hospital records are stored or filed – for example, 
laboratory results, pathology department results – wherever they may be located you have to 
C
have accessibility. 
A 
The vital thing about pathology reports – and the Path Lab may keep their own 
records – those data are of absolutely no use to the patient unless a copy of that laboratory 
report is in the patient’s medical records.  So you are right, there may well be records of a 
laboratory result in the Path Lab, but the key thing is that the report of the test must be in the 
patient’s medical records. 
D
Q 
Professor David, the ultimate reasoning for where you locate something has to be 
whether it is accessible or not, surely? 
A 
Clearly accessibility is one reason why the integrity of medical records is so 
important. 
Q 
I entirely accept that, there is nothing between us on that.  If it be the case – the Panel 
will have to receive evidence in due course – that the medical and nursing staff were fully 
E
aware of the existence not only of the SC files but what was in them, and could get into the 
files, knew where they were, and so far as the relevant health professionals are concerned, 
that meets the test of accessibility, does it not? 
A 
You are assuming in that question that the only reason for having medical records is 
for the purposes of other people looking after the child in that hospital, and of course one of 
the issues, particularly in child protection cases, is that the medical records get used for other 
reasons that go outside the hospital.  So the fact that a nurse on the ward knows that there are 
F
some other papers hidden away somewhere does not really help us. 
Q 
Professor David, I was dealing with nurses and health professionals as a separate 
category of people, an important category of people who were involved in the care of the 
child.  In that sense my suggestion was that it deals with the problems which might be caused 
to the health and safety of the child if there was no accessibility. 
A 
I do not think there is any disagreement that at the time such a child was in hospital 
G
I am quite willing to accept that the nursing staff on the ward were well aware that there were 
other materials stored somewhere else.  I do not think there is any disagreement about that; 
I personally think it is just not the point. 
Q 
We will have to see the extent to which that other concern that you have ends up 
being met by the evidence, but your concern in that respect is noted.  One of the practical 
reasons, I suggest, for adopting this policy, as we see it was adopted, by Professor Southall, 
H
was that it is possible for him – particularly him because he was a consultant – to take a view 
T.A.  REED 
Day 5 -  10
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A
and advise the Trust in respect of documents which are readily available when requests for 
disclosure come into the Trust.  You know that that commonly occurs, does it not? 
A It 
does. 
Q 
If we can flesh that out.  A request for disclosure simply out of curiosity by a patient 
or the possibility of legal action or a complaint, it might raise a question whether there might 
or might not be an objection by the Trust to the disclosure, at least at first, to the entirety of 
B
the documentation. 
A 
That is absolutely correct. 
Q 
Again, all that would be subject to any relevant legal rules applicable at the relevant 
time. 
A 
I am sure you are right. 
C
Q 
So purely from an administrative and practical standpoint it is material relating to 
child protection – and I am using that in a broad sense – if child protection is filed separately 
that allows the doctor, the consultant to take a good look at the matter in the round, so that he 
can determine what advice, if any, he should give to the Trust on disclosure. 
A 
I disagree with that proposition. 
Q 
One has to look, when one is examining the weight to be attached to that proposition, 
D
to particularly the legal position, I suggest, particularly prior to the Data Protection Act 1998; 
do you agree? 
A 
I am not an expert in the Data Protection Act or when it applied but I am happy to 
accept whatever you say about it. 
Q 
It is just an observation I think worth making that the Data Protection Act, although 
receiving the Royal Assent in 1998, of course in effect postdates all this correspondence. 
E
A 
Yes, I think the relevant legislation is different.  I am not sure that this has much to do 
with the Data Protection Act.  The legislation that I am conscious of – and again I really 
know very little about it – is concerned with patients’ access to records and disclosure of 
records, and those are the regulations that I am thinking of, and it is under those regulations 
that we consultants get asked by our Trust if it is all right to disclose copies of a patient’s 
medical records either to the family or to solicitors.   
I think that is the controlling legislation. 
F
Q 
I do not dispute that but I was just taking the Data Protection Act as a factor which 
now governs the topic of disclosure in a way in which it did not do prior to 1998. 
A 
I am not sure it is relevant to the issue of consultants being asked because you are 
saying that it would have been helpful to Professor Southall to have these files available to 
him so that when the Trust go to him and say, “Would it be all right with you for us to make 
copies of these records and disclose them?” you are saying it would be very handy for him to 
G
be able to refer to his own files in order to answer that question, and what I am saying is that 
I do not think it has much to do with the Data Protection Act, I think it is to do with the 
legislation that controls disclosure of records. 
Q 
Professor David, I do not dispute that but I am simply saying that there is an extra 
feature post-1998.  All of what you say, I do not dispute that, and I think we agree that the 
consultant is, in those circumstances, very frequently asked for a view as to whether there 
H
should be disclosure fully, or at least to a part.  So I think we agree about that. 
T.A.  REED 
Day 5 -  11
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A
A 
The only thing that I am uncertain about is the relevance of the Data Protection Act, 
simply because this is a very frequent request that us consultants face, and no doubt when 
I go back to Manchester, having been here for three days, it is quite likely that there will be a 
set of records waiting for me with that request, and I just do not recall the Data Protection Act 
being invoked when I am being asked for my comments, but I may have missed it. 
Q 
I am not emphasising the Data Protection Act, I am using it as a milestone in the 
B
development of these matters.  Can I just deal with this question of tampering?  Both in your 
report and your evidence yesterday you used this phrase – and I make this absolutely clear, 
that nobody on this side of the room is seeking to condone tampering with medical records or 
seeking to justify the tampering of medical records.  Everyone accepts on this side that 
medical records are inviolate and they are sacrosanct and that principle does not need any 
limitation.  But what I am going to briefly examine with you is the way in which you use that 
expression.  I suggest to you that what we have here is not a case of tampering at all; what 
C
one has here is filing in a different place – and we have been through that – but they are all 
securely kept; none of them, it would appear, have been lost; none of them, it would appear, 
have been damaged; none of them spirited away; and, depending on the evidence, all are 
available for access.  I am not following, therefore, the basis for you saying that the medical 
records have been tampered with. 
A 
Would you like me to comment? 
D
Q Please. 
A 
I think it is a very fair question.  I have not brought a dictionary with me to explore 
the meaning of the word “tampering”, but it may be helpful for me to clarify as to what I do 
not intend it to mean? 
Q Right. 
A 
I do not think there is any evidence of any deliberate intent to mislead or damage or 
E
cause harm.  I use the word “tampering” simply because it is a word that is used quite 
frequently when reference is made in circulars that we get about the integrity of medical 
records being lost, and I accept that some of those cases will concern deliberate interference 
with a medical record, a doctor deliberately taking out a set of notes because he or she does 
not want someone to see what he has written.  Clearly nothing like that is involved here.  Or 
it might be used where a doctor – I suppose Dr Shipman is the most famous example – 
created his own false medical records.  There is no evidence of anything like that.  So I think 
F
the question is very fair.  Tampering is not a word that I normally use, but I meant it as a 
word that is used to describe a process that adversely affects the integrity of medical records, 
and I guess the justification for a fairly strong word is ultimately what I think everybody 
agrees, which is the sacrosanct nature of medical records.  I hope that helps clarify where 
I am coming from? 
Q 
I understand and that is certainly helpful to me, at least to a degree.  But the argument 
G
against it is somewhat circular because if, as I say, the documents are available, are 
accessible, are safe and not damaged or lost or any other actions that we have discussed, 
again it is hard to see, is it not, how the documents, the medical records are not sacrosanct? 
A 
I agree it is a circular argument but, with respect, I feel that it was not me who made it 
circular.  The truth is that medical records need to be intact because they need to be 
accessible.  You have asked me to make an assumption in that question, which is that they 
were accessible. 
H
T.A.  REED 
Day 5 -  12
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A
Q 
I have, but I said “assume” that. 
A 
I cannot assume that.  The whole problem is that there are items that were not in the 
medical records and that means that they are not accessible.  They may have been accessible 
to the nurses looking after the child, but to somebody outside the hospital requesting copies 
of the records, they would not have been provided. 
Q 
That is a matter of evidence but I am just asking you, for the purposes of the 
B
discussion, the principle that if the system set up here was accessible – whether or not it is 
just to professionals – that the people in the hospital knew about it and could have got the 
material if necessary, how the system worked in practice may be another matter we have to 
examine, but if the principle was one of accessibility, what I say to you – and I do have to put 
this to you – is that there is no basis for saying that these medical records were no longer 
sacrosanct or that the integrity had been interfered with.  It is a simple point. 
A 
It is not a simple point.  You are asking me to consider a hypothetical position and 
C
then going back to fact.  I am quite happy to accept a hypothetical argument, but you cannot 
then relate it to the facts. 
Q 
I am putting this purely on the basis of the hypothesis that there was accessibility.  If 
there was then any suggestion of tampering or reduction in integrity falls by the wayside. 
A 
I can see the point.  I think the basic point is that a patient’s medical records should be 
complete and should be intact.  I would not be happy for somebody to say, “Well, that is OK.  
D
Actually if they are stored somewhere else and they are available then it does not really 
matter”.  I do not go along with that. 
Q 
You have set out your position, as you say; that is your opinion.  Just to complete this 
section, you referred yesterday to advice commonly given by medical defence organisations 
on the subject of medical records.  In effect you used the word “tampering” in that context as 
well.  Again, I do not dispute that the medical defence organisations have said that, indeed for 
E
the very reasons you have said; that is, to guard against doctors deliberately tampering in the 
ways you have described, with medical records.  It is a very serious matter.  But just for the 
purposes of this part of the discussion, the medical defence organisations’ advice has never 
had occasion to deal with precisely this issue, has it? 
A 
I cannot answer for the medical defence organisations and I have absolutely no idea 
what they have been called upon to consider. 
F
Q 
If I can just move on to the next topic, I think we have drawn, as it were, I hope 
helpfully for the Panel through you, where the arguments lie on both sides here.  This is not 
intended to be in any way offensive, but the Panel should be alert, should they not, in 
approaching this issue, to guard against too prescriptive or too rigid an approach to topics like 
this? 
A 
I am not sure I am in a position to advise the Panel on how they should approach this. 
G
Q 
There ought to be, ought there not, your advice and assistance to the Panel ought 
really to reflect to a significant extent the realities of professional life as paediatricians when 
dealing with topics like this. 
A 
I can only repeat, I do not bring special advice to the Panel.  I hope that I bring with 
me experience of working with the NHS. 
Q 
Again, I do not want this to be offensive, but to be somewhat excessively pedagogic 
H
would be excessive, would it not? 
T.A.  REED 
Day 5 -  13
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A
A 
I am not quite sure what you mean. 
Q 
A rather excessive teaching approach to an analysis of this issue, which I suggest is a 
simple, practical one. 
A 
All I can really do is reflect my own medical upbringing, if I can call it that, and the 
various things that get drummed into one during one’s career.  One of them is that the one 
thing you must not touch or interfere with, or do anything to harm the integrity of is the 
B
patient’s medical records.  I mean, there are lots of facets there.  It is kind of, not exactly one 
of the Ten Commandments, but one of the things that really – I have received many messages 
of that sort and I am really doing no more than reflecting that prevailing approach.  If the 
Panel disagrees or feels that is excessive, that is up to them. 
Q 
Leaving aside the Panel’s view, do you accept that there is room for a different view 
in your approach to this issue? 
C
A 
I certainly accept that there may be different approaches and different opinions on 
many topics. 
Q 
Right.  These matters, as we can see from Appendix One, the spread of 
correspondence, which is what we are dealing with, is from about 1989 to about 1998 – that 
is the last dated letter.  It is fair, is it not -- and one makes a judgment as to whether or not 
this is a system that should have been adopted -- to bear in mind that there has been, over this 
D
period of time, a climate change in the approach to the entire subject of management of 
records and the sharing of information and so on.  Do you agree? 
A 
Yes and no. 
Q 
What is the yes? 
A 
I am sure there have been many many changes. 
E
Q The 
no? 
A 
The basic need for medical records to be intact is the sort of given that is the theme 
that has always been there and I do not think that has ever changed. 
Q 
I agree, so ultimately it may well be that the question arises whether, on the facts of 
this case, the records as a whole were intact and the integrity was preserved, ultimately.  Do 
you agree? 
F
A 
I am not sure what the ultimate issue is.  I guess that is really for the Panel. 
Q 
Again I am just picking out a couple of passages from your report.  If we need to look 
at them then do so, but the Panel read your reports in detail.  As to the yes part of the question 
I put to you, you referred – I will give the Panel the reference – in your first report, at 
paragraph 345 to, as you expressed it, the general situation of certainly some aspects of the 
approach to records being now vastly more complex than it was. 
G
A 
We never used to have the Caldecott guidance for a start. 
Q 
That, as you very fairly pointed out, is a concept, or an innovation – call it what you 
like – which comes in right at the end of the period with which we are concerned in this case. 
A 
It may have come in after, I am not quite sure. 
Q 
That is a fair point, but it is a sort of book end for the period, is it not? 
H
A 
It is something new. 
T.A.  REED 
Day 5 -  14
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A
Q 
Again, I think in paragraph 353 in your first report, you highlighted what you have 
described as “new thinking”. 
A 
Yes, “the” new thinking. 
Q 
One must not lose sight of the fact that, quite apart from the unchanging proposition 
that you have highlighted about the fact that records are sacrosanct and should be intact, the 
B
way that one goes about managing records and having records communicating with each 
other and the ability of practitioners to communicate with each other via records has 
undergone something of a change. 
A 
I am not sure that has undergone much of a change.  I think the Caldecott guidelines 
and all these new things are really concerning access to records rather than to the way you 
file them away.  I am not sure that that has really changed.  I think the main change in 
relation to the storage and filing of records is the computer.  That is the main change. 
C
Q 
Very often in cases it is helpful to draw upon either national or local guidance dealing 
with the management of issues arising in a particular area.  I think you very fairly indicated 
that you had carried out something of a review of this and there was no national or, it would 
appear, direct local guidance which informs this issue. 
A 
I could not find any.  There are one or two references, actually – I hope you are not 
going to ask me what they are – one or two protocols that do refer to the need for materials to 
D
be stored in the records and things, but there is very little guidance.  I think there is one local 
protocol that refers to that.  There are one or two references as to where things should be 
stored.
Q 
It certainly does not deal with this particular issue, does it? 
A 
Not the matter of keeping certain things away from the main hospital records.  I have 
not seen that discussed anywhere. 
E
Q 
Again, in so far as national guidance has developed in relation to the issue of child 
protection and the area of fabricated or induced illness, and the approach of paediatricians 
and the way they go about dealing with records in that context, one only gets any degree of 
national guidance in the year 2000 FII.  Is that right? 
A 
I am not sure what you are referring to actually. 
F
Q 
I am referring to the Department of Health publication 2000 FII, and also the 
publication by the Royal College published in 2002. 
A Right, 
OK. 
Q 
You have also, so the Panel are aware, referred to a Department of Health circular 
1999 which appears in your report.  For the purpose of the questions, I just draw attention to 
the fact that there has been a development in the thinking and analysis of general matters 
G
relating to child protection and the way in which you handle records but it comes after this 
period.  Is that a fact? 
A 
I would have to look at the documents in some detail, but there has been a great deal 
of new thinking about child protection matters and how you handle them.  There is no 
question about that.  What I cannot remember is how the two documents, the Department of 
Health 2000 report and the Royal College guidance 2002, exactly what they say about 
medical records.  So I cannot, off the top of my head, say whether there is something new 
H
that they have to say about medical records that was not already a given or common sense. 
T.A.  REED 
Day 5 -  15
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A
Q 
I am not suggesting that those publications actually focused on this particular issue, 
but certainly, as occurs in many areas, the Royal College or Department of Health or other 
agency, feels the need to provide guidance on issues precisely because practice would have 
been at best patchy or variable throughout the country up until that moment. 
A 
There are a number of reasons for issuing guidance. 
B
Q 
You do not dispute the proposition I put to you. 
A No. 
Q 
You agree that it is in a sense perhaps ironic that in the case of Stoke, where Professor 
Southall was, there had in fact been the promulgation of two policies by the end of this period 
of the correspondence.  The Panel were aware of that.  There were the security guidelines 
published in March 1995, which I think you have seen.  Is that right? 
C
A 
I cannot remember offhand. 
Q 
It is C3, Tab 7(v). 
A 
What is the actual document? 
Q It 
is 
called 
Security Guidelines.
A 
No, I mean where do I refer to it in my report. 
D
Q 
I was just asking whether you had seen it. 
A 
If I refer to it in my report, then I have. 
Q 
I cannot recall whether there is specific reference to it. My learned friend says 88.5 in 
the second report.  It is a short policy. 
A 
I am not sure what you would like me to do.  I would need to dig out what reference 
E
I have got to this document.  I can see it in front of me. 
Q 
Do want to look at the passage in your report?  It is 88.5. 
A 
That is what I was looking for. 
Q 
Just for my purposes, I simply wanted to point out through you that during the period 
of this correspondence that we are focusing on, Stoke, and for these purposes I will include 
F
Professor Southall, had gone into print and attempted to deal with aspects of record keeping.
First of all, we have this single document, the Security Guidelines.  Then, if you turn the tab 
in C3, you see the Child Protection Policy Procedures, which the Panel were given yesterday 
as a substitute for yet another Stoke policy, which is available if you need to look at it.  I do 
not think it helps any of us, one way or the other, to deal with the present issue.  But this 
document is dated – bottom right hand corner – January 1997.  Again I just highlight that.  In 
the document we see the date in the bottom right hand corner.  Obviously in due course the 
G
Panel will be invited to consider that document and read through it.  Just to point out one 
matter, Professor David, if you go to page 20, bottom left hand corner, you will see that under 
“Background” at 1.1 there is a reference to the trust policy for clinical record keeping, policy 
number 10.  That was the policy you referred to yesterday in your evidence when you 
remarked that you had not been able to obtain that. 
A 
I think that is right.  Do you have that? 
H
T.A.  REED 
Day 5 -  16
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A
Q 
No.  The trust has not been able to help.  Again, I just wanted to highlight the fact that 
we have those two documents which fall within the period of the correspondence we are 
looking at.  I have one further point to deal with and then I have finished this document.  In 
the course of your evidence you referred to inquiries and such like which have highlighted 
difficulties arising from body A and body B not communicating information and individuals 
not communicating information.  You mentioned that yesterday. 
A 
I mentioned that potential problem. 
B
Q 
In fact that did happen in a number of inquiries, did it not? 
A 
It has been a thread.  If one looks at inquiries into fatal cases of child abuse, that is a 
recurring theme. 
Q 
Indeed so.  I think the Climbie Inquiry, Lord Laming’s inquiry in 1999, had a lot to 
say about the need for keeping unitary records. 
C
A 
I cannot remember what Laming said on this point, I have to admit. 
Q 
Again, I will just keep this very short, but he did have something to say about the 
need for keeping unitary records; in other words, almost the precise thing that you are talking 
about.  But those recommendation have not been published to the professions and nor have 
they been accepted. 
A 
I am not sure that is right.  The Laming recommendations have been very widely 
D
disseminated and there have been Department of Health circulars instructing all trusts to 
make sure – there were numerous recommendations that he made – that they were all 
followed. 
Q 
But not in terms of dealing with this particular issue. 
A 
I cannot remember what the individual issues were, but they are regularly referred to. 
E
MR COONAN:  The wider matters, of course, I am not disputing.  They were, if I may say 
so, very helpful and very good recommendations.  Madam, that was the point I wanted to 
deal with and that may be a convenient moment. 
THE CHAIRMAN:  We will adjourn then for 15 minutes. 
(The Panel adjourned for a short time)
F
MR COONAN:  Professor David, can we just move on, please, to talk about a separate topic 
now briefly.  I am referring to the letter from Dr Southall to Dr Dinwiddie dated 22 March 
1990, and you will find that at C2 2(i). 
A 
I am not quite there.  Right. 
Q 
I see what you are doing.  It is not in Appendix One. 
G
A 
That is what I was searching for. 
Q 
I though you might be.  No, it is not in Appendix One.  This is a letter which was in 
the main hospital file. 
A 
Thank you very much. 
Q 
So I am dealing now with a freestanding topic. 
H
A Right. 
T.A.  REED 
Day 5 -  17
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A
Q 
So we are not dealing with special cases files now.  Now, yesterday, towards the end 
of your evidence yesterday afternoon, you were asked some questions based upon this 
document, and I just want to explore one or two aspects of that, if I may.  I am going to ask 
you, please, to address it on the basis of – forgive me if it is a hypothetical basis, but you 
were asked a number of questions on a hypothetical basis yesterday by Mr Tyson, and it is 
not a criticism, but it is the only way you can do it because you have not heard all of the 
B
evidence yet – so if it be the case that Dr Southall had child protection concerns and wished 
to alert a paediatrician in Gwent about this, and about the existence of a tracheostomy, then - 
and I am going to ask you, please, for the purposes of this question to leave aside for the 
moment that there was no covering letter, to leave aside for the moment that, on the face of it, 
it appears it was sent to an unidentified consultant, so those are matters which will have to be 
addressed in the evidence, so take those out of the equation – do you accept that if he did 
have those concerns (child protection, tracheostomy, the fact that the child might be admitted 
C
to this local hospital at some stage), that sending a letter in those terms was justified? 
A 
There is not a problem with a paediatrician sharing his concerns of a child protection 
nature with another paediatrician who might have contact with that child.  One might go 
further than that and might say you would have a duty to do that. 
Q 
Again, if I may just flesh that out a little.  In those circumstances, he would have no 
duty of care to the parents? 
D
A 
The duty would be to the child, absolutely correct. 
Q 
In other words, not only no duty of care to the parents, but no duty of confidence 
owed to the parents? 
A 
No need to obtain their consent. 
Q 
No need to obtain their consent. 
E
A Absolutely. 
Q 
Or, alternatively, if you look at it another way, insofar as there may have been a duty 
of confidence owed to the parents, a paediatrician in those circumstances would be justified 
in breaching it? 
A 
That is absolutely right. 
F
Q 
As you have said, the paramount duty is owed to the child? 
A Correct. 
Q 
As I have said, and again I close this part by just a comment that the precise 
circumstances in which the letter came to be penned awaits the evidence.  Professor David, 
can I just turn briefly, please, to the question of the computer material.  I think you will need 
C10 for this.  There are two aspects of this, and it really arises out of the evidence you gave 
G
yesterday rather than anything in your report, which the Panel has got and which we all have.
So can I just take the two points quite separately.  The first point concerns page 3 of C10.
Sorry, before we get to the detail, can I just ask you a general question?  What I think you 
said yesterday was that each one of these documents, and you used the word “documents”, in 
C10 are first of all medical records, and, secondly, they (that is the documents) should have 
been found in the medical records. 
A Correct. 
H
T.A.  REED 
Day 5 -  18
 & CO. 

---

A
Q 
Now, again I do not want to be over-pedantic about this, but, first of all, strictly it is 
the data in the computer which forms, first of all, part of the hospital medical records, 
because it may not be printed off. 
A 
I was referring to the printed copy before me. 
Q 
Yes, but our printed copy, we have heard evidence as to the circumstances in which it 
came to be printed off. 
B
A 
I accept that, but I was simply dealing with the bits of paper that were put before me. 
Q 
Let us just see, however, just with your assistance if we can just deal with the 
technical side of this.  If the data that we see in these documents is stored in a computer, then 
you would agree, I think, that that data should be viewed as part of the hospital medical 
records.
A 
Yes, I would. 
C
Q 
As and when the data is printed off by somebody, all right, the print off becomes 
again part of the hospital medical records? 
A Yes. 
Q 
 So again, and this may be self-evident, the document only becomes part of the 
hospital medical records when somebody thinks to print it? 
D
A 
It does not exist until it is printed. 
Q 
It does not exist.  Now, with that background, again let us look at the example that 
Mr Tyson took you to.  You said that the document on page 3 should be in the main hospital 
records following what is called the letter signed by Dr Jawad.  You were taken to that, 
Professor David, and it is C3, tab 7(d)(i) – do you have that? 
A 
Well, I know what you are referring to, but my views on this letter did not depend on 
E
that.
Q 
Well, I am just wanting to try and tease out really the basis of your answer, because 
I have not checked the exact transcripts and I am relying on my manuscript note from 
yesterday, and my note and my recollection was to the effect that you appear to be saying that 
the document at page 3 should have been with the medical records following the Jawad letter. 
A 
No.  To use your word, you have elided too thin. 
F
Q 
That is why I wanted to explore this. 
A 
My view on this item on page 3, and the rest are all the same, is that this appears to be 
a summary relating to a child being admitted to hospital to have some observations done.  
The observations were done, the results of those are recorded here, recommendations, follow 
up, clinical impression, and I would call this a discharge summary, and I would have 
expected this to have been placed in the records and sent to the referring hospital and sent to 
G
the GP.  Now, my expectations are derived from first principles.  They have absolutely 
nothing to do with the document that you are talking about.  The document that you are 
talking about used the words “computer printout” and I was assuming that that reference was 
to these kinds of materials. 
Q 
It is just that it may be that your answer was on the platform of a question to you by 
Mr Tyson.  It is not a criticism, but I want just to flesh out what you meant.  So in other 
H
T.A.  REED 
Day 5 -  19
 & CO. 

---

A
words, your answer in relation to page 3 of C10 is wholly irrespective in the context of the 
Jawad letter. 
A 
That is correct. 
Q 
Just pointing out in passing, of course, the Jawad letter is dated after the discharge on 
page 3. 
A 
I did not place any reliance on that and I was not even sure, when there was a 
B
reference to computer summaries or computer printouts, that this is what it was I was getting, 
but this is what that letter refers to and no more. 
Q 
Very good.  That clarifies it for me.  The next letter in the document bundle is at page 
13.
A 
Page 30 of? 
C
Q 
13 of C10. 
A 
Is that my report? 
Q 
No, no, the thin bundle. 
A 
Sorry.  C10, is that what this is called? 
Q 
It is called C10. 
D
A Thank 
you. 
Q 
The other larger one is C9, I do not know whether that is marked either. 
A 
Well, I have marked it now, so--- 
Q 
Again, Mr Tyson took you to this document, and you said, and again it is based on my 
recollection and on my manuscript note of yesterday, that the document was a medical record 
E
and it should be filed in the main hospital notes, again making reference to the Jawad letter. 
A 
Well, the same comments apply.  My opinions on this, where it should have been, are 
not derived from the Jawad letter, they are derived from first principles. 
Q 
Very helpful, not least I was going to observe of course that the Jawad letter related to 
a completely different hospital. 
F
MR TYSON:   Well--- 
MR COONAN:   Anyway, you have clarified the point for me.  It was suggested that it 
should be included in the main hospital records, and I do not know whether the implication 
lying behind that, that in fact it was not, but if there was an implication that it was not, can we 
look at C2 5--- 
A 
I think I might need some help here.   
G
Q C2 
5(iii). 
A 
Thank you very much. 
Q 
As I say, I do not know whether the implication that was being sought to draw was 
that it was not in the main hospital records, but this document at C2 5(iii) is an extract from 
the main hospital records. 
H
A Is 
it? 
T.A.  REED 
Day 5 -  20
 & CO. 

---

A
Q 
That is what we are told.  So it follows, does it not, that the document on page 13 of 
C10 is in fact in the hospital records? 
A 
If that is correct, that follows. 
MR COONAN:   Professor David, thank you very much indeed.  That is all I ask. 
B
Re-examined by MR TYSON
Q 
You were asked about five items that were not, as it were, clinical correspondence, 
and in particular you were asked about the manuscript entry written by Dr Samuels in relation 
to Child H, which we see at page 20, so it is C7, page 20. 
A Right. 
C
Q 
You may recall you were given five items that ideally should have been in the main 
file, and then we came to, as it were, the fifth and a half, if I can put it this way, where it was 
suggested to you by Mr Coonan that this, whether or not it is a clinical entry it was suggested, 
may depend upon the purpose for which it was created.  Can I ask you, is that a valid test as 
to whether or not this is a clinical entry, i.e. does it or does it not depend on the purpose for 
which it was created? 
A 
(Pause)  It is quite a difficult question, which is why I am pausing.  If one is making 
D
clinical notes about a patient, then the purpose is simply to record statements or record facts 
or record opinions about that patient, and the purpose is quite simply to make notes about the 
patient, and that is the primary purpose.  Why I paused is that I suppose I could conceive of 
an alternative circumstance in which somebody might write something down, but basically 
writing medical records is for the purpose of writing medical records.. 
Q 
The evidence will be, as I anticipate, that this is a note, amongst other things, of a 
E
consultation of the parents with Dr Samuels shortly before they left the Brompton Hospital in 
the middle of March 1990.  If, amongst other things, it is a record of a consultation with the 
parents does that assist? 
A 
It is a straightforward note of events that is part of the child’s records. 
Q 
A proposition was put to you that the SC files were part of the medical records, albeit 
filed in a different place.  Before you heard that proposition being put to you today, had that 
F
been your understanding of the SC files? 
A 
No, that was a novel suggestion. 
Q 
From your recollection was that novel suggestion put forward in the explanation that 
Professor Southall gave of the purpose behind the SC files? 
A No. 
G
Q 
Could you look at C2, section 6, which is the Hempsons’ letter?  The page number 
I would ask you to look at is page 12. 
A 
I have it. 
Q 
We see at the bottom of the page two possible explanations as to why Professor 
Southall used special cases files.  And dealing with the second one you see it says: 
H
“To store confidential documents relating to child protection issues.” 
T.A.  REED 
Day 5 -  21
 & CO. 

---

A
Going back to the paragraph before we see: 
“Professor Southall was informed in his discussions with social services, the lead 
agency for child protection, that these documents were not to be placed in the hospital 
medical records.  It therefore became Professor Southall’s practice to keep 
documentation relating to child protection issues in special case files.” 
B
On your reading on that matter does that indicate that these special cases files in relation to 
child protection were part of the medical records of this child? 
A 
No, but I think what is more relevant is item one at the bottom of the page, where it 
says:
“Thus, Professor Southall used special case files in two situations: 
C
To keep documentation relating to the specialised monitoring of children that 
he was undertaking.  In our submission these documents were not part of the 
usual medical records …” 
That is the key point.  The earlier thing that you were referring to, about documentation 
relating to child protection issues, that really refers to child protection case conference 
D
minutes, and they usually come with a warning saying that they should not be put in medical 
records.  As I indicate in my report, I personally disregard that, but I think most of my 
colleagues do not disregard that; so to be perfectly legitimate and not file a child protection 
case conference minutes in the child’s medical records, and I do not that that really gives any 
authority about the filing of medical records. 
Q 
The basic point to this Professor David, in anywhere of your reading of this letter 
E
from Hempsons does it indicate that the special cases files are part of the child’s hospital 
medical records? 
A 
It is the reverse of that; this sentence says that these were not part of the usual medical 
records.
Q 
Is it your understanding from your knowledge of this case that the parents of child A, 
child D and child H have made extensive requests for copies of their children’s medical 
F
records, out of which the SC files have not, until very, very much later been produced. 
A 
I do not actually have any information about that topic. 
Q 
On a hypothesis, that these parents that I have mentioned, had been seeing their 
child’s hospital records and when they had achieved it those hospital records did not include 
the SC files, do you have any comments on that in relation to this novel suggestion that they 
are part of the hospital records? 
G
A 
It is a hypothetical situation and the answer is that it would drive a coach and horses 
through the argument that these were actually part of the child’s records. 
Q 
In two cases you have indicated in your reports that you have been instructed by the 
parents to look at the medical records, to give the parents certain advice in the past. 
A 
The cases I was referring to, I was not instructed by the parents.  I am sorry, are you 
referring to two of these cases? 
H
T.A.  REED 
Day 5 -  22
 & CO. 

---

A
Q 
Yes, I am referring to the fact that as you gave evidence yesterday that you have been 
involved in two of these cases in a separate capacity. 
A 
I am sorry, I was on the wrong track.  You are correct; we are talking about case D 
and case H. 
Q 
When you were involved in your separate professional capacity in those two cases 
were you given a copy of the child’s medical records? 
B
A I 
was. 
Q 
Did the copy of the child’s medical records that you produced include the SC files? 
A 
As far as case H is concerned we have to rely on my memory, but I have no 
recollection of seeing an SC file.  I say that partly because I had never heard of SC files until 
I was asked to report on these seven cases.  It was a new concept to me. Child D is different 
in that with child D I was potentially working on that case in parallel to working on that case 
C
for this, for the purposes of these proceedings.  Of course, I have been provided with the SC 
file by Field Fisher Waterhouse.  What  
I cannot say from memory is whether I had been provided with the SC file by the solicitors 
who were instructing me in the parallel matter. 
Q 
You also said in evidence that there have been a number of cases in litigation where 
you and Dr Southall have been both involved. 
D
A 
There are not many but there are a few. 
Q 
In those cases had the existence of the SC files ever come into play? 
A 
No, not as far as I can remember.  I have no recollection of ever having heard of SC 
files until I was instructed to report on these seven cases. 
Q 
You were asked a separate matter in relation to child H and the same point was put in 
E
relation to child D, that the matters in Appendix One came into existence after the particular 
child was an inpatient at the relevant hospital, and you indicated that for reasons of integrity 
it was important that these matters remained in the child’s medical records even though the 
child would never go there again.  My simple question in re-examination is, why is it 
important, even though the child may never go there again, that these matters remain in that 
child’s medical records? 
A 
I think for the reasons that those records may be needed, for example, in legal 
F
proceedings, such as care proceedings, which would concern the removal of the child and 
other children from the family, or criminal proceedings. 
Q 
You were asked questions about a clinical correspondence in child D’s case that was 
going between, for instance, Professor Southall and Professor Strobel of Great Ormond 
Street.  Just looking at Appendix One, 1(a), the letter from the Professor, would it surprise 
you that that letter can be found in the Great Ormond Street files in the main Great Ormond 
G
Street files? 
A 
No, it would not surprise me. 
Q 
Indeed, would you expect it? 
A 
If it had been sent there, yes. 
H
T.A.  REED 
Day 5 -  23
 & CO. 

---

A
Q 
I am sorry, I think I have asked you the wrong question.  1(a) was a letter from 
Professor Warner.  Would you be surprised to know that that is in Professor Warner’s own 
hospital medical records file? 
A 
I would be amazed if it was not. 
Q 
Ditto 1(b), the letter from Professor Strobel of Great Ormond Street, would you be 
surprised to hear that that is filed in the parallel Great Ormond Street children’s medical 
B
records? 
A 
Not at all. 
Q 
Just dealing with some examples from 2, at 2(a) the letter from Professor Strobel to 
the GP.  Would you be surprised to know that that is in Professor Strobel’s Great Ormond 
Street medical records? 
A No. 
C
Q 
You were asked under the general heading of “accessibility”, about the fact that whilst 
the child was an in-patient, the nurse may well have known that there were other papers 
relating to the child and it was suggested to you that the fact that the nursing staff on the 
ward, as it were, at the time was a useful matter.  Your answer was, “I do not disagree but it 
is not the point”. 
A Exactly. 
D
Q 
What is the point? 
A 
The point is that subsequently, if the mother of that child faces a murder trial and 
everybody depends on the medical records of the case to get expert reports, and if those 
medical records are missing all sorts of documents, then that whole trial is corrupted. 
Q 
You gave evidence in chief that if there was a temporary separation of files during the 
E
in-patient period, immediately the in-patient period ended they should be re-merged.  Is there 
anything as a result of cross-examination that makes you go back on that main point? 
A No. 
Q 
It was suggested to you that a good reason for holding SC files was for the practical 
reason that if there was a subsequent request for access to those files, the use of an SC file 
would assist the clinician to decide on whether or not to disclose material.  Is that a good 
F
enough reason for keeping these kinds of files? 
A 
It is completely incorrect.  Indeed, it would be most unwise to rely on what amounts 
to a partial set of records in order to advise the trust as to whether it is appropriate to disclose 
the entire records.  The only way you can do that is to see the hospital records for the child 
and that is exactly what happens.  You get a letter from the trust saying, “We have been asked 
to supply a copy of this child’s medical records for the purposes of litigation, do you, as the 
treating consultant agree?  Is there anything that we should not supply because it would be 
G
harmful to the child?”  That is the question.  There is only one way that you can answer that 
question, and that is to see the hospital records and see everything that is in them and answer 
either “Yes, it is fine to supply these”, or “No, there is a piece of paper in here that really 
should not be disclosed because it could be harmful to the child”.  The only way you can 
answer that question is by seeing the hospital records.  You could not answer that question by 
seeing a subset of those records that you have kept for other reasons. 
H
T.A.  REED 
Day 5 -  24
 & CO. 

---

A
Q 
You were asked about various protocols and you indicated that there were no general 
protocols that assisted as to whether child protection matters should be filed deliberately in 
separate files.  You indicated that there may be some assistance in the North Staffs’ own 
documentation.  Can I ask you to look at C3, Section 7, subsection (d)(vi)?  Can I also take 
you to page 20 of Appendix Two?  You see under the general heading “Recording 
Observations during Child Protection Procedures”, under 2 on page 20, 
B
“Guidelines for documentation in situations where to inform parents could jeopardise 
the child’s safety”? 
A Yes. 
Q 
Do you see some guidance under 2.1 that, 
C
“Where there are concerns regarding Child Protection issues and a decision has been 
made in the interests of the child’s safety not to inform parents”, 
the bullet point on the top of page 21 says, 
“record concerns on a separate sheet of paper which should be stored with the medical 
notes in a separate folder and must be signed and dated (Note: these should not be 
D
kept by the bedside)”. 
Does that or does it not indicate that even if there are child protection concerns, the matter 
should still be part of the medical records. 
A 
That appears to be the message unless the medical records are being kept at the end of 
the bed. 
E
MR COONAN:  I hope I made it clear that I accept that these documents are part of the 
medical records.  My learned friend predicates these questions on the assumption that they 
are not.  I would invite my learned friend to use the terminology “the main file”, because if 
this matter has to be looked at elsewhere later, the terminology needs to be clear. 
MR TYSON:  I have difficulty in adopting my learned friend’s stance because it is one that 
has only come to the attention of anybody in this case in the last hour, that SC files are part of 
F
the hospital records. 
MR COONAN:  I am not going to rise to the bait. 
MR TYSON:  Professor David, if one was to apply the test, if it is child protection it must be 
kept separate from the document produced by Hempsons to which you have just drawn the 
Panel’s attention, if that was the test, could you look please at C2(i), which is the unnamed 
G
paediatrician letter, if I can put it that way?  This is the letter which is the subject matter of 
heads of charge 8, which is being dealt with separately.  This is a letter, if I can put it this 
way, would you agree that as well as clinical matters, it also includes child protection 
matters? 
A 
That clearly is the case. 
H
T.A.  REED 
Day 5 -  25
 & CO. 

---

A
Q 
Can you see any consistency in the stance being put forward by Professor Southall 
that letters relating to child protection matters should be in the SC file when, as we know, this 
particular letter was in the child’s main hospital records. 
A 
It is not consistent. 
Q 
I will not burden you or others with other examples, but can take my witnesses to 
them as required.  It was suggested to you in relation to that letter that a letter in those terms, 
B
provided they were covered by a suitable covering letter or whatever, in sending information 
to other clinicians about child protection concerns, you do not need to obtain consent, and 
you agreed with that. 
A 
Yes.  It was a hypothetical discussion. 
Q 
Yes, a hypothetical discussion.  Again a hypothetical discussion that in cases of child 
protection you were justified in breaching confidences. 
C
A Correct. 
Q 
In a particular case where it is claimed that there was consent for such a letter, do 
those hypothetical considerations apply? 
A No. 
Q 
Just one last sweeping question in re-examination and that is this: in respect of any or 
D
all of the matters that were put to you in cross-examination, have you any reason to go back 
on any of the propositions that you put in either of your two reports or when you were giving 
evidence in chief? 
A No. 
MR TYSON:  Thank you very much. 
E
THE CHAIRMAN:  Professor David, the next thing would be for the Panel to put its 
questions to you.  What I would like to do is take a short break to give the Panel time to 
consider any questions it might wish to put.  Another 15 minutes would be sufficient for that, 
and we appear to have plenty of time in hand.  We will come back in 10 to 15 minutes and I 
remind you about not discussing the case at this time. 
(The Panel adjourned for a short time)
F
THE CHAIRMAN:   The Panel is now ready to ask questions, so I will go round and see who 
is indicating. 
Questioned by THE PANEL
MR SIMANOWITZ:  Good morning, Professor.  If I may, I would like to start with 
G
something you said right towards the end of your evidence, in fact under
re-examination, and then I will move to a more chronological system.  You were talking 
about one of the reasons given by Professor Southall for keeping separate files was if 
requested to give advice the documents would be more easily accessible, and I think what 
you said was that it would be unwise to rely on a partial record to advise the Trust as to 
whether to disclose.  I wonder whether it is possible for you to give an example of what 
would happen if you relied on a partial record? 
H
T.A.  REED 
Day 5 -  26
 & CO. 

---

A
A 
Well, basically, the Trust is asking the consultant the simple question “Is it all right 
for us to provide a photocopy of the set of medical records and send it off to the solicitors that 
have asked for it?”  That is the question one is being asked, and, as I understand it, the only 
reason that anybody can object to that at the hospital end is if somebody feels that there is 
information in there that, if it were disclosed, could harm the child.  The only way you can 
answer that question, “Is there any information in the hospital records which are about to be 
photocopied which might harm the child?”, there is only one way you can answer that 
B
question, and that is to see the hospital records.  You cannot answer that question by looking 
at a subset of those records, or what ought there to be. 
Q 
In other words, you are suggesting where there is a request to disclose the entire 
hospital records? 
A 
It is always entirely – well, not always, but in a child protection context one is asked 
to supply the entire medical records, absolutely every piece of paper, and you cannot answer 
C
the question unless you can see them. 
Q 
I understand.  Thank you.  If I could return now to your report at C3, and if you look 
at page 241. 
MR TYSON:   This is the first report. 
D
MR SIMANOWITZ:  Page 241, paragraph 392.  Have you got that? 
A 
It starts on the previous page, yes. 
Q 
This is the second paragraph on page 241, and you are talking about accessibility, and 
at the end you say: 
 
“A system may be needed which alerts staff to the fact that other information is 
E
available”.
I just wonder whether that “may” is correct, or whether it is “must”, because you seem to be 
suggesting that there could be other records and in some circumstances there does not have to 
be a note to alert the staff if there are those others. 
A 
Right.  I simply copied a chunk of text from the Royal College guidelines, well the 
Working Party report in 2002, so I am merely quoting their words.  I suppose the question is 
F
could one improve on their wording--- 
Q 
In other words, do you consider that “may” is sufficient, or would you think that there 
was always a reason for alerting the rest of the staff that there are other records? 
A 
It is very hard.  I think it would depend on the circumstances.  There is obvious logic 
to the question that you are putting, but I would need to think carefully and reflect on what 
the possible variations might be.  Obviously, it is vital, for all the reasons that I have given, 
G
that if anybody in the team has child protection concerns it is vital that those are in the 
medical records so that if anybody else deals with those medical records they can see that 
people have been worried, if the child gets readmitted, it is obviously essential. 
Q 
It was because you used the word “vital” on a number of occasions that it seemed to 
me that “may” was inappropriate. 
A 
It is self-evident that it is vital. 
H
T.A.  REED 
Day 5 -  27
 & CO. 

---

A
Q 
Thank you.  Page 242, paragraph 396, in paragraph 1 you refer to accident and 
emergency departments keeping their records separate, and you say nowadays it is common 
to put a photocopy in the records, but it did not used to be the case. 
A 
That is correct. 
Q 
Is there not a parallel then with the case we have here, that records in the past were 
kept separate without any indication that they were? 
B
A 
I do not think it is a parallel, but it is an example, and all these are examples of where 
one might find information about a child somewhere other than the main records, and it is 
self-evidently undesirable if that information is not available in the main records.  I do not 
really see this as a parallel because you are comparing arrangements in an A&E department 
with a systematic process of setting up separate records which should be in the main records.  
This is different, at the point when A&E departments were first established and people had 
not thought through where the records ought to be.  The issues in this case concern 
C
correspondence between doctors at Great Ormond Street and doctors at Stoke on Trent, and 
that medical records that ought to have been kept in the main medical records.  So I see that 
as being a bit different. 
Q 
It is not clear to me why it is different because are they not part of the medical records 
if you are using that term? 
A 
Well, they are not part of the main records, and clearly they are part of the hospital’s 
D
accumulated records, but the problem of course is that they are not available, and if 
somebody, in the old days we are referring to, asked for a child’s hospital records, they might 
not get the A&E department records because somebody did not trouble to provide a 
photocopy of them. 
Q 
Those might be very important records. 
A They 
might 
be. 
E
Q 
When you are talking about the “old days” what period are you talking about?  Is it 
similar to the beginning of the facts in this case? 
A 
It is very hard to say.  Originally, and if I think back to our own accident and 
emergency department, which has been the only paediatric one in the North-West, originally 
there were not separate records, but there might have been an attendance card, but where the 
child got to see the physicians, then the main hospital records would be made up.  Then later 
F
on the A&E department became a sort of autonomous article, and then they had their own 
record system, and then further down the stream it was appreciated that that had to marry up 
with the child’s main records, but I could not put timeframes as to at what point people 
realised that you really had to have a system to make sure that when a child was seen in the 
A&E department, that a copy of that went into the child’s main records. 
Q 
Turning to your second report, page 29, paragraph 68, referring to the Hempsons 
G
letter, I just want to know would you regard it as satisfactory is photocopies were placed in 
the file or the medical records file? 
A 
The correct procedure is that originals should be placed in the child’s main records, 
and if one is going to have a copy somewhere else, then it should be a copy somewhere else, 
but the main issue really is not having any copy in the main records.  So the correct answer is 
that the original should be in the main records, and if somebody wants to set up another file, 
that should have a copy, but I do not think there are going to be any serious consequences, or 
H
it is hard to think of many situations where there would be a serious problem if actually what 
T.A.  REED 
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A
was in the patient’s records was a copy and the consultant took the original home with him.  
So long as there was a copy in the main records, that is the main thing. 
Q 
Whereas you think that if there was nothing in there, there could be serious 
consequences? 
A 
That is the point. 
B
MR SIMANOWITZ:  Thank you. 
THE CHAIRMAN:   Dr Sarkar, who is a medical member. 
DR SARKAR:  Good afternoon, Professor.  You said in the report that you are involved in a 
number of child protection cases, or you have been. 
A Yes. 
C
Q 
Would those cases have involved your attending strategy meetings? 
A Yes. 
Q 
Would there be any paper record of those strategy meetings kept and sent to you? 
A Yes. 
D
Q 
Where ordinarily would you file those? 
A 
If that was a patient I was looking after, I would put those in the patient’s records. 
Q 
If it was a case where you were not looking after the child, where would you have 
kept them? 
A 
It would be unlikely that I would be invited to a strategy meeting.  Strategy meetings 
are, for the benefit of colleagues who might not be familiar with the concept, are held where 
E
one has concerns of a child protection sort but one does not want to share those with the 
family to start with;  what you want to do is to share them with other professionals, so you 
might meet up with social services, with the GP, with the health visitor, other people 
involved, but it would not be a child protection case conference.  Is that clear? 
Q 
Partly.  Thank you for clarifying what a strategy meeting is.  Now, our questions are 
not really questions, it is seeking clarification on your testimony, on the paperwork that 
F
already there is.  I would like to take you to a hypothetical situation where you, as an expert 
in, say, cystic fibrosis, have been invited to comment on a suspected child abuse case in 
Hampshire.  You have no direct clinical responsibility for that child.  Your colleagues in 
Hampshire are very grateful for your involvement and seek your input.  They hold a strategy 
meeting, not a case conference at that stage, minutes are kept, detailed minutes, and at the end 
of it they send you a copy saying, “Professor, just make sure that we got it right, and if we 
have, keep it”.  In that hypothetical situation where would you file this paperwork, or would 
G
you have destroyed it? 
A 
It is a hypothetical question, because I am not involved in that way, in that I do not 
usually get called in to advise on other people’s strategy meetings.  If it is a patient in 
Hampshire, then the way I would be involved is if care proceedings had been initiated and the 
court has directed that various experts should be involved and one of those is me, then that is 
how I become involved.  To answer your hypothetical question, I would have to find 
somewhere to put those.  I would have no medical records for that patient.  The child would 
H
not be under my care.  So I would have to find somewhere to put them. 
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Day 5 -  29
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A
Q 
Continuing in the hypothetical vein, would you, rather than shred the paperwork, have 
created a file which you would not call an SC file but some other file? 
A 
If that happened, I suppose I would have a plastic folder that I would put somewhere 
and wait and see if it is needed, or if my involvement is needed, and if, after a period of time, 
it is clear that I am not involved and I am not required, then my usual practice, not in exactly 
that situation, but my usual practice, when I want to get rid of bits of paper, is to ask for 
B
permission to shred whatever papers I hold, because I have got nowhere to store things like 
that.  So that would be my procedure when I want to dispose of papers in a matter, which I do 
because I cannot hold on to them forever, then I ask for permission, and I always give the 
opportunity to the person I am writing to saying, “If you want me to return the papers to you 
so that you can store them, of course that is fine”. 
Q 
Thank you.  The next question takes you to page 240, paragraph 392, which is your 
C
Royal College of Paediatrics and Child Health, February 2002.  Do you agree with this 
guidance in general? 
A 
I would not disagree with it. 
Q 
So it might be lawful to keep separate files if the keeper of the document finds that it 
is of such nature that it needs to be kept separate from the main bulk of medical reports? 
A 
I could not really comment on the lawfulness of it; it says here it is lawful, and I do 
D
not know the answer to that. 
Q 
But if it says lawful you would agree, or not? 
A 
I would read that and say, I do not really know about that, I do not know who says it 
is lawful.  There is no reference to any law that says it is lawful.  It would clearly run counter 
from my practice, which is to not keep separate records, and that has been discussed in my 
report, that the only time that one would keep something separate is when the records are at 
E
the end of the bed; but otherwise, generally, one keeps them separate.  My guess is that this 
sentence refers to the situation of an inpatient unit where it is there practice – and there are 
one or two units where this happens – for the medical records to be freely available to the 
parents, to be by the bed or at the end of the bed and it is self-evident that under that situation 
if you do not want the parents to know that you have child protection concerns you cannot 
leave those lying about, they have to be put somewhere out.  So, I do not know about lawful, 
but it is commonsense. 
F
Q 
My next clarification deals with a piece of paper which has not been addressed. It 
appears in the list of Appendix One as child H, item 2.  It has been troubling me.  You said in 
your testimony that you considered that part of the medical record. 
A Yes. 
Q 
I think Dr Southall’s team did not comment either way. 
G
A 
I think it was flagged up by Mr Coonan as being an uncertain area that was yet to be 
clarified, that was how I understood it. 
Q 
You thought that it would have been an ordinary medical record? 
A I 
did. 
Q 
I am not going to be hypothetical about this because you said that you do some legal 
H
work, but is it your practice to have, what I call it, a crib sheet summarising points from 
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A
which you would then dictate a report?  I do not know if you dictate or type yourself, but 
people who dictate might find it useful to have a summary sheet with salient points, and if 
you do that would that be part of the medical report, even if the patient was yours? 
A 
First of all, my own practice is to type everything myself, I have nobody to do it for 
me, if it is in this kind of situation.  If it is clinical, if I am looking after a patient there are 
medical secretaries to type things, but if I am preparing a report like the reports that you have 
before you, they have all been typed by me. 
B
Q 
So you really cannot give an example from your own practice.  So hence 
I have to move to the hypothetical realm again.  So a doctor acting as an expert, as doctors 
sometimes do on their own patients, have been asked by the court to provide a report, and for 
the purpose of providing the report, other than furiously going through page after page the 
doctor decides to make a bullet point summary of the whole case, from which he will then 
expand his dictation.  He writes it down, does not put a date on it, but of necessity puts the 
C
patient’s name or initial.  Will that be a medical record and then ought to be filed in the 
patient’s main bulk of medical file? 
A 
It is a hypothetical question.  It would not be my practice.  You are talking about a 
doctor who has clinical care but who has been asked to prepare a legal report nevertheless? 
Q 
It does happen. 
A 
It is very hard to answer because I do not prepare summaries in this way and  
D
I would not use that approach, but I could conceive of the possibility that somebody might, 
and if one was preparing a note or whatever materials one was preparing – it might be the 
first draft of a report, that would not form part of the medical records, and I have clarified that 
in my reports already. 
Q 
Thank you, I was just going there.  If the information in that crib sheet, sketch book, 
whatever you want to call it, or the first draft, contained therein is then subsequently 
E
produced in another written document, which is circulated and available in the main clinical 
note, as this particular piece of paper was, would you say that it probably does not make 
sense to file that piece of paper in the medical records as well? 
A 
If I understand the question correctly – and I want to make sure I understand it – we 
are saying that I am hypothetically preparing a report and I have made some notes for the 
purposes of my report, but then I think we are saying that at some stage  
I then send those notes to another clinician.  That really is hypothetical because  
F
I cannot think of a reason why an expert would send a draft or a note of their notes that they 
are using to prepare a report to someone else, unless one had permission and requested to 
discuss with another expert matters relating to the case.  But normally one would not do that 
until one had finished writing a report.  So I think the hypothesis is really completely out with 
my experience. 
Q 
Let us take this manuscript entry by MS, whom I understood at that time was  
G
Dr Southall’s junior.  If the information contained in that manuscript three days later, six days 
later finds its way into a clinical document, a letter written to a consultant, copied widely, 
would there be any prima facie need for that piece of paper to be filed in the patient’s medical 
record? 
A 
If it has been sent to other doctors who are involved then it is clearly part of the 
medical correspondence and is clearly part of the child’s medical records. 
H
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A
Q 
The letter is, but the piece of paper? 
A 
Anything that was sent with it. 
Q 
But the piece of paper was not sent, I am asking you --- 
A 
I am sorry; I thought you said that a piece of paper was sent with the letter. 
Q 
No, the piece of paper was relied on in writing the letter, the letter was sent to four 
B
different doctors.  Would there be any need for that piece of paper to be filed in the patient’s 
medical record? 
A 
It would depend on why that piece of paper was created.  But if the hypothesis is that 
these were notes that I had made for the purposes of writing a medico-legal report, I do not 
see how I would rely on those if I was writing to another colleague;
I would rely on the medical records.  I feel I am not being terribly helpful here. 
C
Q 
No, it is okay; you tried.  You talk about consent in your report.  Could you, for the 
benefit of the Panel, myself included, give us what are the components of a valid consent? 
A 
Can you refer me to the bit of the report we are talking about? 
MR TYSON:  If I can assist, as a matter of information the issue of consent and valid consent 
came up in relation to child H, about which Professor David had written a separate report, but 
that report is not before the Panel, at the request of my learned friend. 
D
DR SARKAR:  That is correct, I apologise.  It is not actually in the body of the report but in 
your testimony you said there are issues about consent if a letter was sent about somebody, 
and you said that in certain circumstances consent is not only not required, you would bypass 
consent requirements if it is in the interests of the child.  If there is a suspicion of 
maltreatment or abuse and a professional is writing to another professional alerting that 
professional that there might be concerns – not necessarily proven concerns – would that be 
E
sufficient to bypass parental consent? 
A It 
would. 
THE CHAIRMAN:  Mr McFarlane is a medical member. 
MR McFARLANE:  Good afternoon, Professor.  I have a number of questions.  I am quoting 
verbatim from your evidence when you started and you said that medical records were the 
F
only way that healthcare providers are aware of medical history.  Is that your belief? 
A 
There may be other ways that people involved in the care of a child might obtain 
information – they might talk to each other – but ultimately the repository of information 
about a patient is in the medical records. 
Q 
I see where you were getting from because also you can obtain aspects of the history 
by taking a history from the carers and the parents and you can also get aspects of medical 
G
history from examination, so operation scars, an appendectomy scar is an appendectomy scar 
and you do not necessarily need to rely on the notes there.  You are obviously extremely 
experienced and you have been working in hospitals for 30 years at least and looking at 
notes.  From your own experience how often do – for instance you have discussed X-ray 
reports and Path reports – X-ray reports and pathological reports get misfiled in the wrong 
notes? 
A It 
happens. 
H
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A
Q 
Would you say that it happens often? 
A 
No, not often, but it definitely happens. 
Q 
Certainly in my own cases if I see something that is clearly misfiled I take it out of the 
notes and make arrangements to get it filed in the correct notes, and
I presume you would do something similar. 
A 
I believe that one of my reports actually mentions that. 
B
Q 
But from the case in point, whilst this report has been misfiled, as it were, it is not in 
the original record where it is meant to be. 
A Correct. 
Q 
So it have happened that a document was produced, two copies, one was put in the SC 
file, and the other one, which was intended to go to the main file, had become misfiled. 
C
A Absolutely. 
Q 
So this could have occurred in these cases? 
A Yes. 
Q 
I must admit that I have been involved in some child protection – not a great deal and 
it was over ten years ago – and I am the holder of a Diploma in Community Child Health, 
D
which looks at this in particular.  From my own experience I find that the actual size of the 
folders of these particular children tend to get very large very quickly.  Would you say that is 
true? 
A 
It varies but some of them are very large and if you look at the documentation in these 
cases they are large. 
Q 
So if you look at the actual records themselves you find that information within the 
E
files is quite often repeated.  You will have documents and aspects of diagnosis or separate 
episodes, or what have you, and these are copied within the documents within the folders, so 
there is quite a lot of repetition of information within the actual files themselves. 
A 
Maybe.  You may have the same document filed more than once. 
Q 
Yes.  So one area we have in terms of the actual data that is kept on these SC files, is 
it not likely that the data is going to be filed somewhere else within the child’s main record? 
F
A 
I cannot say what is likely or not.  It depends on what it is.  If it is an original item, 
then it may be it is not available anywhere else. 
Q 
I see.  From the point of view of the computer records – if you want to look at C10 – 
even if you just look at the very first page, you will find that in there you have got details of 
the patient’s name, the patient’s parent’s name, the patient’s address and details of their 
general practitioner and phone number and what have you.  All these things are likely to be 
G
replicated elsewhere in the child’s file, are they not? 
A 
The name and address, certainly, yes. 
Q 
But in actual fact most of the data on this document will be replicated elsewhere and 
I would imagine that even the aspect of the multiple allergies and the low body temperature, 
in fact we have got direct evidence that those particular terms were used in the actual records 
themselves and were available within the actual records.  So the data here, which was kept on 
H
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A
a computer, there is no harm done by this data here being kept on a computer because it was 
available in the main file, is there? 
A 
I am not sure that I would agree with that.  Obviously some of the information is 
going to be on almost every page of the medical records; for example, the child’s name, date 
of birth and address is probably present on every single letter that has ever been written about 
the child.  So that is absolutely correct.  But there will be other things that are unique and, if 
you like, the unique thing about this document is that it is either a discharge summary, 
B
summarising the situation, giving the diagnosis at the end, or it is a summary of the 
investigation that is done.  That is actually something that might not be duplicated elsewhere. 
Q 
If we take this particular record into consideration, have you been asked to look for 
evidence that any of the information on here was unique? 
A 
No, I have not.  I am not sure that that was really the task that I was set, which was to 
answer the simple question: are these medical records or not?  Whether the records had 
C
information that was or was not unique and could or could not be found somewhere else was 
not an issue really that I addressed. 
Q 
When you were talking about other departments of the hospital which tend to keep 
their own separate notes – again I have to advise that one of the jobs that I do currently is a 
very specialist job working within a hospital setting in Scotland, and we do keep our own 
files within our department; they are accessible but we do keep our own files and we get 
D
referrals; we respond to them and we send out our findings.  You did give a list of certain 
circumstances and what have you whereby it was considered to be acceptable for various 
units to keep their own files. Are you aware that one of the major defence organisations in its 
guidance to doctors does specifically say that child protection notes should be kept separate 
from the main record? 
A 
Could we turn to the page where I deal with this, first of all? 
E
Q Yes, 
please 
do. 
A 
Could you remind me of the bit you are referring to?  It is in my original report, is it? 
MR TYSON:  It is page 242, paragraph 395. 
MR McFARLANE:  Thank you very much. 
A 
I think the question was that I had said it was “acceptable” for these separate records 
F
to be kept.  I do not think that is actually what I said.  What I was doing was to list a number 
of possibilities where records are sometimes kept separately. I do not know about the 
defence organisation recommendations that you are referring to.  In my general dredging of 
regulations I tried to get what information I could.  I certainly went to the website of the 
Medical Protection Society and the Medical Defence Union – this is all from memory I have 
to say – and I do not recall the medical Defence Union having very much but I remember the 
Medical Protection Society had quite a lot of documents about records and record keeping.  
G
I am afraid I cannot remember what they said.  I did try to be extremely faithful and rigorous 
in reproducing everything that I could find. If I had found something that had a bearing, I 
would have quoted it, so I am not sure what is being referred to 
Q 
Maybe I was asking you a little bit on the periphery of that.  Certainly, genitourinary 
medicine clinics keep their own files, and they are usually kept very much separate from 
other files.  Is that not the case? 
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A
A 
I am not an expert in genitourinary medicine and I have no knowledge of how they 
run their affairs. 
Q 
Looking at the records that were made regarding the recordings of respiration that 
have been alluded to, was this particular technique of recording respirations an accepted 
technique or was this an experimental technique? 
A 
What do you mean by “recording respirations”?  Do you mean measuring oxygen 
B
saturation and respiratory rate, and things like that? 
Q Yes. 
A 
That is an accepted technique. 
Q 
That is very useful, thank you.  The other thing that struck me as very interesting was 
the large distances that people seem to be referred.  We had someone in Elsham who was 
C
referred down to Southampton and also up to Stoke.  Is this usual in child protection cases? 
A 
It depends on what sort of expertise is being sought.  I would say that in most cases 
there would be resources available relatively nearby, but there are some difficult cases where 
assistance is sought from elsewhere because there is some particular expertise that one can 
only get at a distance.  That is a feature of working in tertiary units, that one does get referrals 
from well outside one’s area if one has got a particular interest or expertise in some area. 
D
Q 
Very good.  From the point of view of the letter, a copy of which was sent to an 
unspecified paediatrician, certainly from my own practice, when I practised as a locum and 
say if I had been referring somebody for a surgical referral and I do not know who it is, 
I would put down, “The General Surgeon”.  So far as I know every letter has been seen and 
opened and the patient has received an out-patient appointment.  When I was working in 
surgical specialities I was often referred patients and it just said, “The general surgeon” or 
“The orthopaedic surgeon”.  Have you, as a paediatrician, ever had a referral to, “The 
E
paediatrician” at whatever hospital you were working at? 
A 
Certainly.  But the context is quite different.  For example, we get referrals from 
general practitioners, a patient with asthma and that letter is likely to be written, “Dear 
Doctor”.  It is sent to the paediatric department of the hospital and it is done for a very good 
reason, that the GP who is making the referral would like that patient to be seen by the 
consultant who has the shortest waiting list, so he does not necessarily want to put a name.  
That is standard practice.  I think one has to bear in mind that in the context of child 
F
protection one would not want to be so relaxed about where letters went.  That really is a 
situation where good communication is really important and if you were referring a patient 
with child protection concerns in mind, you would want to target that letter pretty carefully.
So it is a different context. 
Q 
I take your point on that, however, obviously Professor Southall may have been 
wanting to cover every base here because as we can see, with that particular child there were 
G
some aspects of dysfunctionality within the family.  He was aware that they lived on the 
border between one particular hospital and another and it could have been likely that the 
parents presented at either hospital.  Given that there is usually some appreciable delay 
between dictating a letter and actually having it back for signature and subsequent sending 
out, if he was not terribly sure of whichever doctor he was referring to, he could have just 
dictated that at the bottom and subsequently found out somebody and put a “with 
compliments” slip in, and that could be done manually a week later. 
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A
A 
As a hypothetical quite clearly that is possible.  It is not something I would do but if 
the secretary was involved in that, then they would usually add in the details for the copy that 
goes in the hospital records as well. 
DR SARKAR:  Also quite often they may just have locum consultants at a small hospital and 
there may have been some information on that.  As I say, this is speculative.  Can I say thank 
you very much indeed.  You have been most helpful. 
B
MRS LLOYD:  Good afternoon, Professor David.  Going back to C3, Tab 7, paragraph 392 
of your report, one of my colleagues asked you a question about the paragraph you quoted 
from the Royal College.  I just wanted to ask you in relation to systems being needed to alert 
other staff as to whether there is other information available, whether you have any personal 
experience of such systems in place? 
A 
No, because the units where I have worked have not split records up in that way and 
C
I have never personally worked in a unit where records were available at the end of the bed or 
at the bedside.  In all the hospitals where I have worked, they were kept in the ward 
manager’s office or what we used to call the ward sister’s office, so the issue of having 
separate documentation did not arise. 
Q 
The only other question I have is that, in your reference on page 242 on the other 
departments and services that are likely to hold their own records because they are all a 
D
speciality in themselves – for example, occupational therapy, physiotherapy – in most cases 
would not the clinician be initiating the involvement of these services and would there 
therefore be some indication in the main record that other departments and services were 
involved? 
A 
That is exactly right with the exception of the A&E department where there probably 
would not be that flow chart.  You are quite right otherwise. 
E
Q 
So in a case where special monitoring is being done, in the case of Professor Southall, 
there would not be any particular indication, as this is perhaps not widespread activity, in the 
file to indicate this. 
A 
I presume there would be something in that if the child is admitted for the purposes of 
monitoring, then one of the things that should happen is that one of the doctors in the team – 
usually a junior doctor such as a senior house officer or possibly a registrar – would take a 
history, (it is called “clerking”), where they would admit the child, write down the basic plan 
F
and that process would include mention under the plan of action that monitoring would take 
place and some details of that would be provided.  So there would be reference to that in what 
we call the “clerking in” notes, when the child was admitted to hospital.  If other tests were 
planned, there would be reference to those as well. 
Q 
Would it state who was doing the special monitoring? 
A 
Not necessarily.  I mean, if we take out special monitoring, there might be a plan for 
G
the child to have a CT scan of the head. One would not say who was going to do that.  You 
would know it would be done in the X-ray department.  Similarly with the monitoring, you 
have got multiple people involved.  You have got the nurses involved at the clinical end, 
because they have got to connect the child up to the various monitors, and you have got 
somebody who has got to keep these activity charts where you record how the patient is and 
whether they have got any symptoms, and then this lot, plus the recordings that are made, are 
then handed over to somebody else who analyses the data.  So you have got lots of people 
H
involved.
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A
Q 
What I was trying to establish is whether you could clarify whether it was possible to 
trace, an audit trail if you like, to other records that were being kept with regards to the 
monitoring?
A 
I am not sure about an audit trail.  I mean, if you have got a note that investigations 
are being done, then I suppose one can then go to the place where they are being done to see 
what records there are. 
B
Q 
Perhaps audit trail is the wrong word.  What I am trying to say is if it is established by 
the medical record that the physiotherapy department is involved and somebody wanted 
information – a clinician or another member of the hospital staff – wanted information about 
the physio’s input, could go there, and what I am trying to gauge is whether, by the clerking 
in and everything that is being down which would be in the medical record, would another 
clinician know that they could find other recorded information by special monitoring in the 
C
sense of a special case file? 
A 
It is hard to know what other people would know.  If we take your physiotherapy 
example, if your hypothetical child is admitted to hospital and one of the things you say is 
“Refer this child to the physiotherapist”, and then the physiotherapist will see the child, they 
will make their own notes which they will keep within the physiotherapy department, but 
they will usually write in the hospital records, saying, “Date, seen by physiotherapist, signs of 
left hemiplagia.  Recommend the following”, so there would be something to show that the 
D
physiotherapist has got his or her hands on the case, and I think it would be evident that if one 
wanted to know more, one could go to the physiotherapist and say, “Could you dig out your 
records?” 
MRS LLOYD:  Thank you very much. 
THE CHAIRMAN:   Mr Simanowitz has got a supplementary question. 
E
MR SIMANOWITZ:  Sorry, I did not ask these questions before.  One of them is a question 
of clarification, and I am not sure whether you are the right person to answer this, but it is 
something that is troubling me and perhaps you can help.  In C10, if you look at document 3, 
and there are others, these purport to be letters but they are not addressed to anyone.  You 
will see letter 3 says “Dear [blank]”.  In that situation would that be part of the medical 
records? 
F
A Yes. 
Q 
Would you file that even though it is not addressed to anyone? 
A 
It does not matter whether it is addressed to anybody, it is clearly a summary of the 
case.
Q 
Is it not incomplete? 
G
A 
Well, it might or might not be.  I mean, I am not a great expert on computer systems, 
but one way that they operate is that you have data of names and addresses in one file and 
then you have your letter in another file, and then you have a process called merging, where 
you put the two together, then you print the thing out to produce a report.  If you go back to 
the computer and look at the data, it will not be merged unless you tell it to merge it, so you 
might have gone to the computer, looked up the records for Child H, but it would not have 
the merged name of the GP.  So it is still a summary of the case. 
H
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Day 5 -  37
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A
Q 
So this could have been printed out without having given the instruction to press the 
button to merge, in other words? 
A 
I think that is probably what happened.  I mean, I was not there, but my understanding 
is that these were printed out separately.  We have been shown one by Mr Coonan this 
morning that was in the patient’s medical records, but I think these were specially printed out 
as a result of a visit to the hospital. 
B
Q Thank 
you. 
A 
So I think it is understandable as to why some of those details were not there. 
Q 
That is helpful.  I understand the position.  The last question relates to disclosure of 
documents and the practice, and you have got long experience of this.  Is it right that certainly 
in the old days consultants would keep separate records for their own purposes and often in 
litigation those records would not surface because they had been kept separate, not 
C
necessarily deliberately, but they had been keep separate and were therefore not known 
about? 
A 
I have never come across that. 
MR SIMANOWITZ:  Thank you. 
THE CHAIRMAN:   It now falls to me to round up the Panel’s questioning.  I am a lay 
D
member.  I would just like to go back to, if you could help me with, because I am a lay 
member, the whole business of records of patients so that I can just be very clear on this.  Is 
there any difference between the term “hospital medical record”, does that mean something 
special as compared with, say, the term “medical record” in general? 
A 
Yes.  I mean your hospital records relate to when you went to hospital and were 
treated for a, b and c.  There will also be, for all of us, a general practitioner’s set of medical 
records.  So the word “hospital” means that it is records that relate to a patient’s attendance at 
E
a hospital, but there will be other medical records, particularly the GP will have medical 
records on everybody. 
Q 
If a patient has been seen at more than one hospital, do those notes get brought 
together? 
A 
No.  Each hospital will have its own records.  So if you have been lucky or unlucky 
enough to be treated at four different hospitals, each of those four hospitals will have a 
F
separate set of records for you.  The only time that they would be merged is if those hospitals 
were all part of the same Trust, but apart from that they will be separate. 
Q 
You have pointed out in your report other types of medical information that might be 
retained by different specialties for one reason or another, and indeed Mr McFarlane 
suggested others, so any individual patient, in some sense there might be medical information 
about them in many, many different places? 
G
A That 
is 
true. 
Q 
Is there any system in place that makes any effort to try and link those so that if the 
patient shows up in one place, suppose a completely different place from any of those, is 
there any kind of way of finding out where information about that patient is located? 
A 
The answer is there is now, in that there is a direction that there should not be separate 
records in separate departments, and what I described as a situation that could happen is quite 
H
clearly now frowned upon, and the Department of Health has given directions that this should 
T.A.  REED 
Day 5 -  38
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A
not happen, and Trusts up and down the country are now making a lot of effort to stop 
separate records being kept, so that in the future there will not be separate physiotherapy 
department records, there will not be separate genetics department records, they will all be in 
the main hospital records.  So there is a system, but it has not been fully implemented yet. 
Q 
Perhaps in the context of this case we heard that the SC files that are in contention 
originated in 1980.  Was there a different philosophy at that time? 
B
A 
Well, my answer to that would be “No”, that the philosophy has always been that 
basic bits of medical records, like correspondence from one consultant to another, should 
always be placed in the main records. 
Q 
By “the main records” you mean--- 
A 
I mean the main hospital records. 
C
Q 
You mean a hospital doctor should be placing everything in relation to a patient that 
she or he is seeing at the hospital where they work in this one entity? 
A 
That is exactly right.  The fact that there was a physiotherapy department that kept its 
own records really does not have any bearing on that. 
Q 
The acknowledgement is that in practice that has not always been the case because--- 
A 
No, I do not think that is true.  The acknowledgement is the arrangements have been 
D
standard, that if you have got correspondence between consultants they were stored in the 
patient’s hospital records.  What I am saying in my report at paragraph 395 is that if you go to 
a hospital, until now you will be able to find information about patients scattered in different 
places like the physiotherapy department, like the path lab, like the EEG department, and that 
does not have any bearing on where you file correspondence between consultants. 
Q 
Thank you.  That helps very much on that point.  Two other separate matters.  If you 
E
could look at the Hempsons’ letter.  This is C2 6(c).  I think it may have been in re-
examination you were referred to the two reasons that were given as to why Professor 
Southall used special case files in two situations. 
A 
Page 12.   
Q 
That is the one, yes.  You commented on one being, where it says: 
F
 
“To keep documentation relating to the specialised monitoring of children ….. In our 
submission these documents were not part of the usual medical records…” 
Now, am I right in thinking that originally when you did your report, you were looking at a 
number of documents that do not now feature in our Appendix One? 
A Correct. 
G
Q 
Are you able to comment on whether this category 1 refers to documents that were in 
an older version of Appendix One, and do any that fall into that category, do they feature in 
our present Appendix One? 
A 
No, I do not think they do. 
Q 
They do not?  They are not in our present Appendix One? 
A 
I do not think so. 
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Day 5 -  39
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A
Q 
So in fact the documents that might fall into that category of not being part of the 
usual medical record in Dr Southall’s submission are now featuring in our Appendix One? 
A 
That is what I understand. 
Q 
So that does not really apply to our consideration? 
A I 
follow. 
B
Q 
Is that fair in your view? 
A 
Well, it is not quite right.  The things that have been taken out, as it were, were charts 
that were kept when children were being monitored and observations were being made about 
their state and their symptoms, and whether any events happened.  That has all been taken 
out.  What is left, if you like, is the Appendix Two documents, which are the summaries of 
those investigations. 
C
MR COONAN:   Well, madam, I think there may be a limit, with respect, as to how the 
Professor can deal with this, because one would have to ask the maker or Professor Southall 
what was intended by the words that were used in that letter and the basis on which they were 
used.
THE CHAIRMAN:   I was just seeking clarification on, I think, some answer that Professor 
David gave, I think, in answer to a question in re-examination, when he referred to that, and it 
D
was not clear to me whether he still thought that that referred to any documents that were 
under our consideration, but I think he has answered it now. 
MR TYSON:   As the drafter of Appendix One and Two and the heads, I can give 
information by way of illustration that you will note in the second report of the Professor at 
D, in relation to each and every child, for instance at C3 7(b), page 14, there is a discussion at 
the beginning of paragraph 28 on infant activity level, do you see that, and that discussion 
E
goes on and you will note in respect of that that the professor says that in certain 
circumstances, keeping those in a separate file could be valid.  We see that at paragraph 32.  
If you look at your initial heads of charge in your yellows, you will see, for instance, under 
Child A there were other matters in the original Appendix One under 2 to 5, and under Child 
A there were originally four other matters originally in the appendix bundle but not now, is 
due to the fact that you have the original appendix bundle, then you have got the second 
report from the professor because he said that it could be valid, we took them out.  So 
F
Appendix One has what we say are invalid matters.  I hope you understand the point.  
Appendix One is a working document that contains all the matters that we say were invalidly 
in the SC files. 
THE CHAIRMAN:  I think basically I was seeking to clarify that comments or criticisms 
about this reason one really stem from documents that are no longer in Appendix One.  Is that 
not the case? 
G
MR TYSON:  No. 
THE CHAIRMAN:  One final question is, you were asked about the use of the word, 
“tampering”, and we took the opportunity in the break, we had to consider the meaning of 
tampering.  I just wanted to be clear that we were understanding this the same way, because 
obviously we want to see a word that is in a head of charge as having the same meaning.  As I 
H
had understood, it seems to be reflected in various definitions that we have to mean to 
T.A.  REED 
Day 5 -  40
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A
interfere in a harmful manner;  to engage in improper or secret dealings as in to “tamper” 
with a jury;  to play around with, alter or falsify, usually secretively or dishonestly, to 
interfere without authority so as to cause damage.  All those definitions seem to imply a level 
of perhaps either intent or dishonesty or whatever which I think you said you did not intend 
in your use of the word. 
A 
That is absolutely correct. 
B
Q 
But we have in the heads of charge something that says it amounts to tampering with, 
so I wanted to be quite clear whether the Panel’s view of the word “tampering” was the same 
as your view when we were perhaps looking at the evidence in your report in connection with 
this head of charge? 
A 
I accept that there are obviously many different definitions of the word, and some of 
them imply intent and quite clearly that is not what I am saying.  I suppose my summary of it 
is just two words, and that is damaged integrity – the integrity of the medical records has 
C
been damaged – and I use the word tampering simply because it is a word that appears in the 
context of medical records when that has happened.
I accept that many examples are where somebody has intended something quite dishonest, 
and that is not the case, but it is damaged integrity of the medical records is my use, if you 
like, of that record. 
Q 
I think that perhaps the distinction is that tampering in its most usual word would be 
D
to do something to something that exists, to alter it, whereas I think that you are saying, as 
I read what you said in your report again, that to fail to put something in that in your view 
ought to be there amounted to tampering because, as in the words you are now using, it 
damaged the integrity.  Would that be a correct way of interpreting how you have used the 
word? 
A 
Yes.  I have not gone anywhere near the factual matters as to who did what and 
whether something got taken out or whether it was never put there in the first place; I have 
E
not attempted to go near that. 
THE CHAIRMAN:  I seem to have provoked yet another question here.  That completes my 
questions anyway, Professor David. 
MR SIMONOWITZ:  This does follow one of the questions the Chair asked you.  You were 
talking about separate departments and if there was correspondence it would go into the 
F
medical records.  I suspect it could arise that, say, a consultant in one genetics department 
wrote to a consultant in another genetics department and got a reply.  Where would that 
correspondence go? 
A 
I think that would all go in the medical records.  I do not think that genetics 
departments keep separate medical records, what they keep are separate records of genetic 
investigations and things like that. 
G
Q 
Perhaps I selected the wrong separate entity.  You have listed a whole number, are 
there any of those? 
A 
Really what I was saying is that I do not think they have any bearing on the central 
issue of where would you expect to find correspondence between two consultant 
paediatricians, and the answer is that you would expect to find that in the main hospital 
records.  The fact that the physiotherapy department has its own little records does not really 
have any bearing on that. 
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A
DR SARKAR:  This follows on from what my colleague Mrs Lloyd was asking.  If we accept 
that there are separate departments, divisions in the hospital who tend to keep their own 
records, in the main hospital record one would expect to find some clue as to the existence of 
those records, I understand.  So if the handwritten note said, “Refer to physio” that would be 
a clue.  By examining the notes of, say, child H and child D, would an ordinary person like 
me be able to ascertain that there exists a bunch of different notes which were called secret 
files, SC files, whatever? Was there any indication because you might have examined the 
B
entire medical records of child H and child D? 
A 
I do not think there would be specific reference.  I think a local person on the unit, as 
has been pointed out, for example a nurse working on the unit, would know that when a child 
has been monitored there will be a separate repository of information about that.  But I do not 
think that anybody from outside the hospital who was not absolutely familiar with those local 
arrangements would know that, unless there was a specific entry that says there are other 
records in this case.  I am speaking from memory but I do not recall entries of that sort. 
C
Q 
In some cases in psychiatry it sometimes has a sticker on the buff files, “Other notes 
may be available” or something of that nature, but in your examination of the notes of these 
two children, D and H, you did not find anything like that, like a flag directing to the 
existence of separate case notes. 
A 
I have no recollection of it and, to my recollection, I had never heard of special case 
files or SC files until I was instructed to report in these cases. 
D
THE CHAIRMAN:  Before Professor David stands down are there going to be further 
questions from counsel?  Can I enquire, if there are, whether there are many? 
MR COONAN:  I have none at the moment. 
MR TYSON:  I have about six or seven. 
E
THE CHAIRMAN:  So that might take a little while. 
MR TYSON:  I am conscious of the time and it would be better if they were not dealt with 
now as they may take some time into your lunch break. 
THE CHAIRMAN:  In that case we will take a lunch break now and the final questions will 
F
be after lunch.  You are still on oath, Professor David.  If we reassemble at two, please. 
(Luncheon adjournment)
Further re-examined by MR TYSON
MR TYSON:  Professor David, I have some questions arising out of questions put by the 
G
Panel.  You were asked questions by various Panellists including, in particular, 
Dr Simanowitz, about your first report, which we see at 7(a), page 242, paragraph 391.  There 
are a number of questions arising out of the Panel questions on this.  Do you understand 
Appendix One and heads of charge 10 to 12, to be dealing with paediatric records as opposed 
to A&E records, other department records and the like. 
A Yes. 
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A
Q 
In relation to the paediatric part of the hospital medical records, again is it your 
experience that if you were wanting to access, say the A&E department notes, that there 
would be any problem in asking, for instance, for the A&E department notes? 
A No. 
Q 
Is it your experience that any of these departments that you have listed in paragraph 
295 would have parallel files? 
B
A 
What is your definition of a “parallel” file? 
Q 
A file such as an SC file going, as it were, alongside the main file. 
A 
No, I have not come across that. 
Q 
You were asked by Dr Sarkar in this context whether one could, by looking at the 
notes, discern the existence of a separate file relating to these children being made, for 
C
instance, in relation to Child H?  Were you involved in a different professional capacity in 
looking at the files of Child H in the past? 
A Yes. 
Q 
Did you, having looked at all the notes there given, discern the existence of an SC file 
in the background? 
A 
I have got no recollection of ever having heard of an SC file until this present case. 
D
Q 
Can you see any reason at all for having – I am going to break this down into parts – 
clinical correspondence between consultant paediatricians anywhere but in the child’s 
hospital medical records? 
A 
No.  I can see no objection to an extra copy being somewhere else. 
Q 
That leads me to my second question.  Can you see any reason at all why original 
E
clinical correspondence should be kept in a separate file? 
A 
Original documents should be in the main hospital records. 
Q 
You were asked various questions by Dr Sarkar about the manuscript clinical note 
which we see in C2 at Tab (h). 
A 
Is this the page 20 document? 
F
Q 
Yes.  It was suggested by Dr Sarkar that it may be some form of crib sheet prior to the 
preparation of a report. Do you recall those questions? 
A Yes. 
Q 
Can I ask you to look at what Dr Southall says about that particular document, which 
we see in the same bundle, C2, at Tab 6?  It is the last (c) tab, page 19, which I think is the 
last document in the whole of C2. 
G
A 
I have page 19. 
Q 
Do we see what Professor Southall himself says about that, that this document looks 
like an original?  He says, 
“It is a note made by Dr Samuels.  I think it is the note made by Dr Samuels on 16 
March 1990 when he reviewed Child H prior to discharge”. 
H
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A
A Yes. 
Q 
Do you see the reference there where it says, “See page 60 of the Brompton Hospital 
notes”? 
A Yes. 
Q 
Again, in the same bundle please, can you turn back to (e), the first document in that 
B
bundle?  Is this page 60 of the nursing notes to which Professor Southall made reference in 
his explanatory document that we have just looked at? 
A 
I am sorry, was that a question? 
Q Yes. 
A 
Could you repeat it? 
C
Q 
I want you to look at the first document in the bundle and the last document in the 
bundle.  Turning to the last document in the bundle, page 19, you will see it says, “See page 
60 Brompton Hospital nursing records”. 
A Right. 
Q 
Going to the first document in the bundle we see that that is page 60. 
A Indeed. 
D
Q 
If I have to prove it I will, but can you take it from me that these are the nursing notes 
there referred to? 
A OK. 
Q 
Do you see on the nursing Cardex note for 16 March 1990, it records that the child 
slept well, etc., and records that the overnight monitoring continued then, 
E
“pm Up and about all care given by parents s/b Dr Samuels.  To go home with PCO2 
monitor”.
A Yes. 
MR TYSON:  As it shows in those notes, the child was seen at that time by Dr Samuels.  
Does that assist you as to whether or not this document on page 20 that we have been 
F
looking at was a clinical record of that clinical visit or whether it was a crib sheet for a 
possible report? 
MR COONAN:  I am sorry, I object to this.  True it is that this line of questioning was 
opened by Dr Sarkar, but this is a matter that must wait for the evidence to be given.  
Otherwise this becomes a wholly speculative exercise. 
G
MR TYSON:  He is allowed to give his impression, which is what he was asked for by Dr 
Sarkar, and it arises directly from a question posed by the Panel so I am entitled to ask the 
question that I do.  The weight of the answer is, of course, a matter for the Panel to consider, 
but he is entitled to give his view on the question that he was asked by Dr Sarkar.  Such 
weight that the Panel give to his answer is another matter, but he is entitled to answer the 
question.
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A
MR COONAN:  Madam, it is entirely a matter for you whether you think this is a profitable 
line asking an expert to decide the status of a document when he has not heard the evidence. 
THE CHAIRMAN:  Mr Tyson, I have been wondering myself about the line of questioning, 
if I can put it that way, as to whether this witness had knowledge in order to answer this 
particular question. 
B
MR TYSON:  He can answer as best he can.  What value you put on his answer is a matter 
for your evaluation, but it does not stop me asking the question, bearing in mind it is a direct 
area about which he was asked by Dr Sarkar. 
THE CHAIRMAN:  Perhaps it would help if you could reiterate the question.  There was 
quite a long preamble to it. 
C
MR TYSON:  I had to show him the documentation.  I have shown you the explanation given 
by Hempsons, and I have shown you the nursing record there referred to in the nursing 
Cardex.  Does that assist you in answering the question that you were asked by Dr Sarkar, as 
to whether this document was a “crib sheet”, to use his own words, to help him dictate a 
report.
MR COONAN:  I do object to this.  I am sorry, but Dr Sarkar’s question, as I understand it, 
D
was put on a hypothetical basis.  He was not asserting as a fact that it was a crib sheet.  He 
was asking whether, if it was, what one might expect to happen.  That, as I understand it, was 
the question.  If it had been a direct suggestion, then I accept that my learned friend would be 
entitled to ask the professor in re-examination.  But there are limits because it is becoming a 
speculative exercise. 
MR TYSON:  I can only deal with the question that was asked.  I am entitled to ask questions 
E
arising out of Panel questions.  That must go without saying.  If a hypothetical question – I do 
not necessarily accept it was hypothetical – but let us assume for the sake of my learned 
friend that it was a hypothetical that was asked, whether this could be a crib sheet, I am 
entitled, having shown the professor what Professor Southall has to say about it and what the 
nursing Cardex says about it, to ask him whether it assists him in answering the question he 
was asked by Dr Sarkar. 
F
THE CHAIRMAN:  Some concerns remain, especially as there is a difference between you.
I am going to ask the Legal Assessor for his advice on that. 
THE LEGAL ASSESSOR:  Dr Sarkar’s question was based on a hypothesis.  To extend the 
hypothesis into the field of speculation, which you may think – it is entirely a matter for you 
– is the effect of Mr Tyson’s question, the Panel may find to be wholly unhelpful.  Indeed, 
speculation based on hypothesis you may feel would lead you to a conclusion that this is not 
G
a question which should properly be put, but it is of course entirely a matter for you. 
THE CHAIRMAN:  You heard the advice, Mr Tyson. 
MR TYSON:  Of course I accept it, madam, and will move on.  You were asked by 
Mr McFarlane, I think it was, about the unnamed paediatrician letter in relation to Child H.
Mr McFarlane was putting to you various examples of when he in his practice might say, 
H
“copy to general surgeon”.  You answered that the context of this letter is quite different.
T.A.  REED 
Day 5 -  45
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A
I was wondering whether you could explain further as to why the context of this letter in 
these circumstances is quite different. 
A 
I was trying to explain, I think the analogy was given in relation to general surgery 
and a referral to an unnamed surgeon.  I was simply saying that that really is a completely 
different situation from a child where one has child protection concerns, where the need for 
really clear communication is quite clear and not disagreed by anybody.  I was saying that we 
get referrals – I get referrals or see referral letters – that are written, “Dear doctor”, because it 
B
is quite clearly immaterial which of the consultants end up seeing the patient and there may 
even be an advantage in not putting the name on because the patient may get seen quicker 
that way.  But that is really nothing to do with the need to communicate very carefully and 
very precisely when one is dealing with a child protection case.  I think they are really quite 
different scenarios. 
Q 
Can we just look at that letter for a moment?  It is in C2, Tab (i), about the fourth or 
C
fifth letter in.  Can I ask you to look at page 24, please?  Can I ask you to look at the bottom 
sentence and the top paragraph, where it says, 
“We also feel that it is vital that Child H has his overall care managed by a local 
paediatrician”. 
Is this letter an effective or appropriate way of informing an unnamed consultant 
D
paediatrician to deal with the management of his overall care? 
A 
I would say no, only if it was part of a referral process that included a specific letter of 
referral. 
Q 
Second question, if it was a letter seeking to alert the unnamed consultant 
paediatrician about child care concerns, again is it, on its own, an appropriate or effective 
means of passing on those concerns? 
E
A 
It is not. 
MR TYSON:  That finally completes your evidence.  Thank you very much. 
THE CHAIRMAN:  Thank you professor.  You are now released from oath and may stand 
down.
F
(The witness withdrew)
MR TYSON:  Madam, as far as where we go from here, I would ask you to rise for a short 
time so that my learned friend can have a discussion which may or may not require your 
determination.  If I can indicate what the nature of the discussion is, it is that I will seek to 
call evidence from three of my clients, Mrs A, Mrs H and Mrs D as to the difficulties that 
they encountered in seeking to unearth the SC file.  I also seek to call evidence from the Head 
G
of Administration at the Royal Brompton as to his knowledge, or, as he will put it, lack of it, 
of SC files when it was his responsibility to hand over documents which were requested.  At 
present, as I understand it, my learned friend is seeking that that evidence cannot come in--- 
MR COONAN:   My learned friend really does not represent the current position.  I think we 
would be grateful if my learned friend did not embark upon his understanding of the position 
until we have talked.  It is far better to do it that way.  My learned friend knows full well, 
H
because we have agreed that we should have a short chat, and then we can get on with the 
T.A.  REED 
Day 5 -  46
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A
next piece of business, but to spend time telling you about what the issues are going to be 
between us at this moment probably does not help you. 
THE CHAIRMAN:   I will take it that Mr Tyson was just in the interests of being helpful to 
the Panel so as not to leave us in a complete state of mystery, but we understand that your 
chat is to do with whether certain witnesses should or should not be called and where--- 
B
MR COONAN:   Or to the extent of their evidence. 
THE CHAIRMAN:   Yes.  So you are asking for a short adjournment? 
MR TYSON:   That is exactly right, madam.  I was not having a dig at my learned friend, 
I was just trying really to tell you what we wanted to have a chat about. 
C
THE CHAIRMAN:   Perhaps what might be of even more interest to the Panel might be is if 
when you say “short” whether you are talking about five minutes or an hour? 
MR COONAN:   Oh no.  Madam, I have done the reading.  There are a number of queries 
I have got.  I am sure that we can sort this out.  You want an indication from me now, can 
I say no more than 20 minutes. 
D
THE CHAIRMAN:   Thank you.  We will not hold you to it, but thank you for the indication, 
and we will retire downstairs until you tell us you are ready. 
MR COONAN:   Thank you.  If we hit a problem of any sort, could we get a message to you 
through the usual channels? 
THE CHAIRMAN:   Yes.  I will ask members of the Panel to make sure we stay available in 
E
the members’ room. 
MR COONAN:   Thank you very much. 
(The Panel adjourned for a short time)
MR TYSON:   Madam, I am extremely grateful for giving us the time.  It has in fact saved a 
F
considerable amount of time, as a result of which we will not have to have a determination by 
the Panel this afternoon, and my learned friend has indicated, and I now indicate to you, that 
I can give to you, the Panel, evidence of the individual patients’ attempts to find their SC 
files, and attempts by the administrator of the Brompton Hospital, also dealing with his 
knowledge or otherwise of SC files.  Accordingly, it is my intention to call this afternoon 
Mrs A - and again I am grateful to my learned friend, and I have to say there has been 
considerable cooperation behind the scenes in making this case be effective, and I am grateful 
G
for that and I publicly acknowledge it - I call Mrs A, and my learned friend has indicated that 
for a lot of what she has to say I can lead her through her witness statement, as I take you to 
various documentation of her attempts or otherwise to discover matters relating to her son’s 
medical records.  To that end, can I ask you, please, to go to C2 at section (a), which you may 
not have even an (a), and I am going to ask you to put in some material under (a) and we will 
get the dividers to you.  (Document handed)
H
THE CHAIRMAN:   After which number tab is this? 
T.A.  REED 
Day 5 -  47
 & CO. 

---

A
MR TYSON:   This is going to be under 3, immediately under number 3, and I have also got 
some tabs for you to put in.  (Same handed)
THE CHAIRMAN:   Mr Tyson, while this is being circulated, can I say that I think you had 
originally indicated you would be calling your witnesses after Professor David next week.
You say you have a witness here this afternoon. 
B
MR TYSON:   Yes. 
THE CHAIRMAN:   Given that the Panel started early this morning, we were not really 
wishing to sit later than around four-thirty to quarter-to five, but obviously we would not 
wish to recall a witness for a few minutes on Monday.  You have no idea of course how long 
this witness might take at this stage. 
C
MR TYSON:   Madam, can I just indicate two matters in relation to that.  I mean, one is 
pushing on a Friday at an open door as far as I am personally concerned because I do not live 
in London, and so of course on Fridays I am rather anxious to be elsewhere, but my learned 
friend has indicated that (a) I can lead this witness, and (b) that he wants to review his 
position after this woman has given her evidence in-chief and it may be that he has no 
questions in cross-examination.  So we are hoping that this is going to be a short witness that 
D
can be slotted in.  That is the hope. 
THE CHAIRMAN:   That is a helpful indication. 
MR COONAN:   I think the plan was, and I entirely agree with Mr Tyson, that at the end of 
her evidence, taken much more shortly than would otherwise be the case, if I could have two 
or three minutes literally and I could make a decision, and if there is no cross-examination 
E
then I for one would be hopeful that we could conclude her evidence today. 
MR TYSON:   I call Mrs A. 
MRS A, Sworn
Examined by MR TYSON
F
(Following introductions by the Chairman)
MR TYSON:   Mrs A, we are going to call you Mrs A during these proceedings. 
A Fine. 
Q 
I was wondering if, on a bit of paper, which hopefully is in front of you, you could 
write your name and address down. 
G
A 
Just on here?  (Indicated)
Q Yes. 
A 
Okay.  (Witness wrote down her name and address)
Q 
I wonder if that could be shown to Panel members so they can put your real name to 
the files.  (Paper shown to Panel members)  Mrs A, I am going to ask you some questions 
H
about your son, and in particular I am going to take you to some documents, and in particular 
T.A.  REED 
Day 5 -  48
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---

A
I am going to take you to some documents which show how he arrived up at the Brompton 
Hospital.
A Yes. 
Q 
Then I am going to take you to some documents that refer to after he went to the 
Royal Brompton and what happened thereafter. 
A Okay. 
B
Q 
Then I am going to take you to some documents to show your attempts to trace his 
medical records. 
A Sure. 
Q 
First of all, can I ask you, please, there should be a bundle in front of you at C2, 
section 3, tab (d), and, Mrs A, this is a letter – have you seen this before? 
C
A 
Since we have had the SC file, yes, not previous to that.  The SC file came to us 
fourteen months ago from Field Fisher Waterhouse--- 
Q 
This is a letter dated January 1987, and it refers to your child, who we are going to 
call Child A. 
A Yes. 
D
Q 
You can see that, in January 1987, Great Ormond Street referred your child to the 
Brompton Hospital, and we can see that at the top of that letter (it is a letter from Great 
Ormond Street Hospital to Brompton Hospital) it refers to a child there mentioned.  Since that 
time, have you changed your name from, as it were, “C” to “A”? 
A 
Yes, that is right. 
Q 
We can see that your child was referred by Great Ormond Street.  In the first 
E
paragraph:
 
“He came to see us for a third opinion about his episodes of unexplained pallor, 
hypotonia, shallow breathing and small pupils.” 
A Yes. 
F
Q 
So you see that this letter set out at that time your child was about five months old? 
A 
Yes, he would be, yes. 
Q 
We can see the letter goes on to refer to the fact that he was admitted to a hospital in 
Cornwall.
A 
That was the first hospital. 
G
Q 
Yes.  Then the next paragraph deals with his admission to a hospital in Hampshire. 
A Yes. 
Q 
It sets out, on the bottom paragraph, his past medical history, and then, going over the 
page, various investigations that were dealt with at Great Ormond Street Hospital. 
A Yes. 
H
T.A.  REED 
Day 5 -  49
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A
Q 
On the last page we see that there is a description by Great Ormond Street that your 
child has: 
 
“…had numerous episodes while on the ward most of which were very mild in that he 
was easily rousable when the ward staff arrived.  All attacks occurred when his 
parents were in the room apart from one which occurred within ten minutes of them 
leaving the cubicle.  None occurred at night.  We witnessed one severe episode during 
B
which his pupils were very constricted (a feature of even his mildest episodes) and he 
was unresponsive to pain, with shallow respiration.  His parents commented that the 
Pethco he had prior to the CT ….. made him look similar and on that basis we 
attempted to reverse an attack with naloxone which we did convincingly on one 
occasion.  In view of the negative toxicology screen from Guy’s the significance of 
this observation remains unclear.” 
C
So that was the letter that brought you and your child to the Brompton Hospital? 
A 
That is right, yes. 
Q 
If you go to the next tab, which is (e), we see the notes there of your child being 
admitted, and we see the Brompton’s doctors’ handwritten notes, and if we look at the bottom 
left hand corner of the first page we see that your child was admitted on 10 January 1987 to 
the Rose Ward. 
D
A 
Rose Gallery, that is right. 
Q 
If we carry on through the pages – and the Panel has been through all these pages 
before – I need to take you to one matter, and that is on a page which has 13 on the bottom of 
it.  Do you see that there is a section at the bottom that says “From conference 4 February 
87”? 
A Yes. 
E
Q 
Do you now know but did not then know that a strategy meeting was held about your 
child to which you were not invited on that day? 
A 
We knew nothing of any of the meetings. 
Q 
Was there another meeting, turning over the page, on 13 February 1987, a second 
conference, where a decision was made at that conference where you were not there, as we 
F
can see, and that was to make your child a ward of court? 
A 
Yes.  Can I explain something here?  Yes, this is Friday 13 February, the second case 
conference and we were told on the ward that we were to go to a diagnostic meeting and 
Southall came and met us on the ward and took us down to this meeting, which actually 
turned out to be a case conference, and my husband and  
I were expecting to see doctors and expecting to have a final diagnosis for our son because 
the MMR scan had been completed and we did not know the results of the MMR scan.  So 
G
when we walked in we thought we were going to have a medical meeting and the reports on 
that scan and in fact we walked in and it was a room full of solicitors and social services and 
we were served with wardship documents instead, which was a bit of a shock, as you can 
imagine. 
Q 
Is that recorded on this page where it says: 
H
“Parents very upset and angry by court order.  (Had no warning).” 
T.A.  REED 
Day 5 -  50
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A
A 
I was absolutely devastated; we had absolutely no inkling at all that that was about to 
take place.  In fact just a mere few days before this conference it is mentioned in the notes 
that our son was to be sent home and TTOs had been prepared for us to go home.  Then they 
were to carry out this brain scan.  So we expected to get the report of a brain scan and we 
were supposed to be told how to care for child A at home and instead of that we walk in and 
we are told that there had never been anything wrong with our son, that our son had always 
been perfectly normal, that we were never to use the word “episode” ever again, that he had 
B
never had any episodes – this is Southall talking now to me – we were never to refer to 
episodes again, we were never to discuss them with anybody, we were never, ever to research 
them, our child had always been perfectly normal. 
Q 
Thank you for that.  I need to now channel you down one path in particular and that is 
the subsequent path after this.  Your child was warded and were your first solicitors Hodge 
Jones and Allen. 
C
A 
Of Camden Town, yes.  It is very difficult to find a solicitor on a Friday afternoon in 
London, I can assure you, but we were desperate. We did not want to lose child A into care, 
obviously.
Q 
Amongst the instructions that you gave those solicitors did you ask them to obtain all 
your medical records? 
A 
Because the medical record would have shown and it shows here today that our son 
D
was not normal, so we asked them for the medical records and we also asked them to prepare 
psychiatric reports. 
Q 
Did you obtain from Hodge Jones and Allen child A’s medical records? 
A No. 
Q 
In particular, did you obtain them from the Brompton Hospital? 
E
A 
Certainly not, no. 
Q 
Did there come a time when you had a second set of solicitors called Graham and 
Graham. 
A That 
is 
right. 
Q 
Did you ask them to get all of your child’s medical records? 
F
A 
Yes, because obviously child A was under an interim care order by this time so we 
needed the medical records to exhibit them in the High Court. 
Q 
Did you get them via that firm of solicitors? 
A No. 
Q 
Did there come a time when you started acting for yourself? 
G
A 
Yes, very shortly afterwards, August 1987, when we took over the case ourselves, 
yes.
THE CHAIRMAN:  Mrs A, you may not be aware of the fact but for the purposes of this 
hearing we are referring to your son as child A.  I do not think there is anybody in the public 
gallery reporting but if there is no name should be reported. 
H
T.A.  REED 
Day 5 -  51
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---

A
MR TYSON:  Can I take you to C2 at section (a).  Is this a letter written by you and your 
husband dated 26 August 1987? 
A 
That is right.  My husband by that time was acting as the family barrister, so, yes, he 
drafted it and I signed it.
Q 
Can I take you to the first paragraph of that? 
B
“This is to inform you that we, the parents, will be representing ourselves in the High 
Court of Justice in London …” -- 
in the case that you there mention -- 
“… to decide our son’s future under a wardship.  In preparing our defence we wish to 
pursue medical notes held by the Brompton Hospital and we believe we have a legal 
C
right to them.  (See enclosed notice).” 
Was that a letter written to the Brompton Hospital on that date? 
A That 
is 
right. 
Q 
As a result of that letter did you get any medical records relating to your child? 
A 
No, we did not and there was a legal argument about whether under the wardship we 
D
were entitled to them, and I think there is a letter that states, no, you can only have them if 
you pursue litigation. 
Q 
So you did not get them there? 
A 
No.  Am I allowed to point out one thing in this letter, which is very important, which 
is we also requested a copy of the report made after the MMR scan performed on child A on 
10 February, because that scan was used to take out the wardship proceedings, and we only 
E
saw that scan report 14 months ago for the first time.  The original medical record held in the 
SC files all these years.  And had we had the MMR scan report at the time we certainly would 
have exhibited it in the High Court wardship proceedings as evidence, because there are 
discrepancies in there.  There is enough in that MMR scan report to require a second opinion 
from a neurologist and it has been denied us all these years. 
Q 
So you make your request in 1987 for a copy of the MMR or MRI scan. 
F
A Yes. 
Q 
There may be in front of you something that we call the heads of charge on the yellow 
pages in front of you.  Can you look at Appendix One, and under your name and the SC file 
numbers there is mention of an MRI report of 11 February.  Is that the report you were 
specifically asking for on 26 August 1987? 
A 
Yes.  That MRI report was absolutely crucial for the defence in the wardship case, 
G
and also for our son’s ongoing health, of course, naturally. 
Q 
Did there come a time when, in January 1998, when you decided to pursue possible 
litigation in respect of the matters that had occurred? 
A 
Yes.  Can I explain why I had to go down the litigation route? 
Q 
I do not think we need at the moment. 
H
T.A.  REED 
Day 5 -  52
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---

A
A 
It is only to say it was the only way to get hold of the medical record.  It had been 
made quite clear to us by the solicitors from the Brompton that it is the only way you can 
legally get hold of your son’s medical record.  We tried every other route.  It was not about 
money, it was not about finance, it was about finding the truth about our son’s medical 
record.  So I just want to say that because there has always been a slur that we want to make 
money out of our child and that is not the case, it was simply about getting to the detail. 
B
Q 
Initially in order to help you did you instruct a firm of solicitors in Manchester called 
Pannone Blackburn? 
A Yes. 
Q 
The Panel will not have the document that I am referring Mrs A to now.  Is this a  
letter written by you and your husband to your solicitors in January 1988 and does it enclose 
the documents which you had had to date? 
C
A Absolutely, 
yes. 
Q 
Does it include, amongst other things, under four medical notes from the hospital in 
Cornwall, where you were? 
A 
We had all the notes from Cornwall and they were helpful. 
Q 
In paragraph 5 does it indicate you had the wardship papers? 
D
A Yes. 
Q 
By that time, in January 1988, did you have the Brompton records? 
A 
No.  It would have been number one on the list. 
Q 
Did Pannone Blackburn pass you over to other solicitors? 
A 
Yes, they were Foot and Bowden in Plymouth. 
E
Q 
Did they obtain any records from the Brompton? 
A No. 
Q 
Did you move home and end up in a town on the south coast? 
A Yes. 
F
Q 
Did you then instruct a firm of solicitors called Donne Mileham and Haddock? 
A 
That is right, Mr Allen. 
Q 
Did they, on your instructions seek to get some records? 
A 
They tried.  In March 1991 Mr Allen wrote to the Brompton administrator,  
Dr Braithwaite, and I think there was a memo sent to Southall and to Valerie Moeri about it. 
G
Q 
Can I ask you to look at another file, which we know as C5, which is your SC file? 
Could you look please at page 32 in that document?  Is that a letter written on your behalf by 
your solicitors, Donne Mileham & Haddock, to the administrator of the Brompton Hospital? 
A Yes. 
Q 
It sets out the nature of your claim in the first few paragraphs, then at the bottom of 
that first page, 
H
T.A.  REED 
Day 5 -  53
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A
“We believe that you are likely to have or have had in your possession, custody or 
power the following documents relevant to issues arising or likely to arise out of the 
above mentioned claim: Baby A’s medical and nursing notes during his stay at your 
hospital”.
A Yes. 
B
Q 
Indeed this letter goes on to demand disclosure of those documents. 
A Yes. 
Q 
Did you enclose with that letter at page 34 your authority seeking to have those 
documents? 
A Yes. 
C
Q 
Are you aware that, as a result of that document, Professor Southall was personally 
requested to provide the documents? 
A 
Yes.  Dr Branthwaite sent a memo to Dr Southall and to Valerie Moeri.  It was copied 
to Valerie Moeri who is the principal social worker at the Brompton. 
Q 
Can you recall the date of that, or the month that it took place? 
A 
I think it was about April 1991, shortly afterwards at any rate. 
D
Q 
Forgive me madam I have a copy of this document and I know it is in the SC file, but 
I cannot find the page. 
A 
I know it is in the SC file but I cannot remember the page number. 
Q 
I understand it is page 31.  Is that, as we see, a letter from Dr Branthwaite asking Dr 
Southall whether he would agree with disclosure of the notes? 
E
A That 
is 
right. 
Q 
Was there a reply to that letter at page 24, I think it is, from Dr Southall?  Do you see 
that on page 24? 
A. 
“I am sorry it has taken so long”, that one? 
Q Yes. 
F
A Yes. 
Q He 
says, 
“I have now had a chance to look at the report and would like to draw your attention 
to a medical report on 17 February 1989 which I wrote on Baby A, which really 
summarises the problem.  I have no reservations at all about releasing these notes to 
G
the solicitor acting for Mr and Mrs A”. 
A 
Yes, but he was referring to a report he prepared for the wardship case which said that 
Child A had always been normal.  He swore that in the High Court, -- perjury I think. 
Q 
Were you also subsequently to become aware of a memo written about this time, 
before Professor Southall got personally involved, which we find at page 25? 
H
A 
Yes.  That was the memo I was referring to. 
T.A.  REED 
Day 5 -  54
 & CO. 

---

A
Q 
We see who it is copied into. 
A 
Yes, Valerie Moeri, the social worker. 
Q 
And on the right it is copied into -- 
A 
Yes, it has gone to the SC notes and it has gone to David Southall and Martin Samuels 
who also appears to have notes on us which we have not yet seen. 
B
Q 
Does it say, from the Director of Legal Services, 
“I attach a copy of a letter received from the family’s solicitor dated 19 
March…Please ensure that the case notes are preserved in their entirety pending 
completion of this matter and please also notify the medical and other staff involved 
that the family is likely to institute legal proceedings for damages arising from 
C
professional negligence suffered by them”. 
A Yes. 
Q 
As a result of that, did you get any records from the Brompton? 
A 
No, we did not.  We got nothing at all at that stage, no. 
D
Q 
Did there come a time when you instructed another firm of solicitors, Messrs Holden 
& Co, and did you send to them a list of the documents that you had had by 1993? 
A Yes. 
Q 
Can I ask you please to go back to C2, Tab (a) and look at a document with (b) on the 
top of it? 
A Yes. 
E
Q 
Is this a list of the documents that you had had by 1993 when you instructed these 
solicitors Holden & Co? 
A 
That is right, yes. 
Q 
Looking through it, does it set out documents from the hospital in Cornwall and the 
documents from the hospital in Hampshire, but does not set out there any reference to the 
F
notes from the Royal Brompton? 
A 
No, there is no record of anything coming from the Brompton at that time, no. 
Q 
Did there come a time in the course of searching for documents when the solicitors 
acting for the Royal Brompton swore an affidavit relating to medical reports? 
A 
Yes, I think it was Melanie Jane Minter, solicitor from Norton Rose for the Brompton, 
who swore an affidavit. 
G
Q 
Can you look please at the next page after the one we have been looking at, which has 
a little (c) on the top. 
A 
I have that. 
Q 
Was that affidavit sworn, as we can see, in January 1999 by Melanie Jane Minter and 
does she say in paragraph 1 that she is a solicitor employed by Norton Rose, and were those 
H
the solicitors for the Royal Brompton? 
T.A.  REED 
Day 5 -  55
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A
A 
Yes, they were. 
Q 
She had conduct on behalf of the defendants because by that time, going back to the 
first page, we see your husband as the second plaintiff, Child A as the first plaintiff and you 
were the third plaintiff. 
A Yes. 
B
Q 
You were suing the Royal Brompton. 
A Yes. 
Q 
Turning to paragraph 3, do we see that that solicitor says, 
“I refer now to the three categories of documents sought from the defendants as 
referred to in the Plaintiffs’ Originating Summons.  As to categories (1) and (2) 
C
(Medical and Nursing Notes and a referral letter), the Defendants have no objection to 
the production of this information”. 
A Yes. 
Q 
 As a result of that affidavit, where it was stated that there was no objection to the 
production of medical and nursing notes, did you get some notes from the Royal Brompton? 
D
A 
A few, not many.  That was in April. 
Q In 
1993? 
A Yes, 
1993. 
Q 
Pausing there, did there come a time, which we will come to later, when you got some 
more? 
E
A Eventually, 
yes. 
Q 
So you got some in 1993, and by 1994 did you move to another firm of solicitors 
called Thomson, Snell & Passmore, and did those solicitors identify a number of different 
documents? 
A 
Diana Kettle, she was very thorough and she identified an enormous number of 
missing documents, yes. 
F
Q 
Turning over the page after this affidavit, can you see a document headed (d) on the 
top? 
A Yes. 
Q 
Is that a letter written by your solicitors Thomson Snell and Passmore, on 15 
December 1994 to Norton Rose, solicitors for the Royal Brompton, seeking further medical 
G
records? 
A 
Yes, those are the outstanding things she was asking for, including the MRI scan 
report.
Q 
We see that it reads in the second paragraph: 
H
T.A.  REED 
Day 5 -  56
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A
“We note that you kindly disclosed the medical notes and records held by the Royal 
Brompton … early in 1993.  However, upon looking through those notes there are still 
various items outstanding, and we would like to see the following.” 
And at number 2, as you rightly point out, they wanted a report describing the MRI scan and 
the scan itself. 
A Absolutely. 
B
Q 
At number 8 were they asking for copies of all tapes showing multi channel 
recordings? 
A Yes. 
Q 
And the Panel heard evidence that these multi channel recordings are made as a result 
of various monitors being attached to your child, to various parts of his body? 
C
A 
Yes, it was about the cardio respiratory monitoring that was done on child A in the 
Brompton. 
Q 
As a result of that letter did your solicitors get the letter at (e) on 22 December 1994, 
and if I take you to the second paragraph of that letter: 
“With regard to the further documents to which reference is made … we confirm that 
D
we have no further records relating to this matter, but we have asked our client to 
carry out a thorough search for the apparently missing documents and we will revert 
to you … as soon as we can.” 
A Yes. 
Q 
Turning over the page to (f) in February 1995, did further records emerge as a result 
of the second search done on behalf of Norton Rose, and do we see a letter dated 1 February 
E
1995:
“We refer to your letters of 15 December and 30 January.  We apologise for the delay 
in responding and confirm that we have carried out a further review of the original 
medical records held by our client and we enclosed copies of the following.” 
That is the report of the CT scan and the various matters there set out.  Then under 6: 
F
“We also enclose the original images from the magnetic resonance scans.” 
A 
That is right.  There is quite a list and then the original X-ray scans were sent to our 
solicitor and then we had to return them. 
Q 
Did you get the images of the MRI scan; did you get the report of the MRI scan? 
A 
No, we did not. 
G
Q 
Did your solicitors chase matters, as we can see at (g) in March 1995? 
A Yes. 
Q 
And in particular dealt with the issue of the multi channel recordings? 
A 
Yes.  We did finally get those. 
H
T.A.  REED 
Day 5 -  57
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---

A
Q 
Then over the page your solicitors were carrying out more chasing for more 
documents and was there a letter in March 1995 from Norton Rose for the Brompton, saying:   
“We look forward to the MRI scans being returned as soon as possible.  In the 
meantime we have asked our client to investigate whether further records exist.” 
A Yes. 
B
Q 
Was there a letter in March from your solicitors, at (i): 
“We are grateful to you for assurance in respect of the further records, but take this 
opportunity to advise that we do require an affidavit to be sworn by the secretary or 
other appropriate officer at the Royal Brompton in the event that no further records 
can be found.  Please could this affidavit explain what steps have been taken to trace 
the records and why it is that they cannot be found.” 
C
A Yes. 
Q 
Was there a chaser to that on 2 May by your solicitors at (j) saying:
“We write with reference to your letter dated 20 March 1995 in which you indicated 
that an affidavit would be forthcoming if further records could not be found.  If your 
clients have been able to find further records, then we would be grateful if you could 
D
disclose them to us.  However, if nothing can be found we would now like to receive 
the affidavit.” 
A Yes. 
Q 
Was a letter written in reply to that in June 1995, at (k): 
“We refer to your letter … and apologise for the delay in replying. 
E
Our client has still been unable to locate any further records.  However, our client has 
managed to contact Professor David Southall himself.” 
Pausing there, for a moment, were you aware that by this time Professor Southall was no 
longer at the Brompton but was elsewhere? 
A 
Yes, I knew he was at the North Staffordshire Hospital. 
F
Q 
It goes on: 
“It appears that Professor Southall is indeed holding six multi channel physiological 
recordings made of your client in the Department of Paediatrics at the University of 
Keele, North Staffordshire Hospital.  We are informed that the recordings involve 
physiological signals that exist on multi channel tape.  Professor Southall has 
informed our client that because of problems with storage it has not been possible to 
G
retain paper copies …  However, he is willing to release the physiological tape 
recordings to you, which can then be transcribed.” 
A 
Yes, we did get those actually.   
Q 
So was that the first time or was there another time when you realised that records 
relating to your child had actually been taken by Professor Southall to the University of 
Keele?
H
T.A.  REED 
Day 5 -  58
 & CO. 

---

A
A 
Of course, what on earth were they doing there?  You would not have dreamt it, 
would you, really? 
Q 
Was there a reply to that letter on 20 June at (l), a letter from your solicitors, thanking 
them for the letter: 
“We agree that it would be most sensible if we were sent the original tape recordings 
B
so that we can determine whether or not we should obtain paper copies of those 
records.
As regards the affidavit, provided we receive the tape recordings from you and they 
appear to be complete, we will not be requiring an affidavit in respect of the multi 
channel recordings.  However, our expert has indicated to us by telephone that he 
thinks there may be other records missing and we will wait to hear further from him in 
C
case it transpires that we should be making further enquiries of you.” 
A Yes. 
Q 
In relation to this was there a further letter from the solicitors of the Royal Brompton 
on 25 July 1995, saying: 
“Further to our previous correspondence we enclose the six original recordings. 
D
With regard to point number 1 in your letter of 5 July we confirm that our client has 
no further records.  In fact the entries dated 16 and 29 January are on the same sheet 
of paper …” 
It deals with that, and then does it go on to say: 
E
“Enquiries of the Medical Records Department to determine whether, for some 
reason, a temporary medical record was created at the time have confirmed that there 
is none.” 
A That 
is 
right. 
Q They 
add: 
F
“As a precaution our client is raising the point with Professor Southall but we do not 
anticipate that any further records will be forthcoming.” 
Yes, they were wrong there, though. 
Q 
Then in October 1995 we have a letter from Norton Rose from the Royal Brompton, 
at (n): 
G
“We refer to your letter of 5 July and are now in a position to provide further 
information.” 
It then deals with the status of Dr Samuels and Dr Warner, and the last paragraph says: 
“Finally, please find enclosed further records relating to the treatment and care of 
[your child] at the Royal Brompton, which our client has just received from Professor 
H
Southall who had taken them with him to North Staffordshire Hospital.” 
T.A.  REED 
Day 5 -  59
 & CO. 

---

A
A 
Yes, we were quite astonished.  Quite a paper trail. 
Q 
Do you recall at that stage what further records you then got? 
A 
I think they were nursing records, medical records from the Brompton. 
Q 
Did they include the report of the MRI scan? 
A 
No.  The first time we saw the MRI report was when we got hold of the SC file 
B
fourteen months ago. 
Q 
I will come to that in a moment. 
A Sorry. 
Q 
Can I now ask you, please, to go away from that file, which shows the paper chase of 
your various solicitors searching for Brompton Hospital, and take you back to your SC file, 
C
which is C5.  Can we see what, as it were, was going on at the hospital end rather than at the 
solicitor end, if I can put it that way. 
A Yes. 
Q 
Can I ask you, please, to look at page 10, and is that a letter of 22 March from the 
Director of Administration, Mr Chapman, at the Brompton to Professor Southall at the North 
Staffordshire Hospital? 
D
A 
It is, yes.  He tried very hard to get the records. 
MR TYSON:   Pausing there, madam, you will be hearing evidence from Mr Chapman next 
week.  (To the witness)  Does that letter dated 22 March 1995 inform Professor Southall that 
he was informed in 1991 that you, as it were, and your husband “…were contemplating legal 
proceedings again Royal Brompton Hospital alleging ….. negligence in his treatment and 
care in 1987”? 
E
A That 
is 
right. 
Q 
“You gave consent to disclose the medical records to his solicitors in April 1991 and 
Norton Rose were instructed to represent the Hospital.  You also wrote a medical 
report, a copy of which I enclose.  On their advice, disclosure of the medical records 
was resisted since the solicitors acting for [Child A] did not specify the nature of 
allegations relating to his treatment which would justify pre-action discovery of the 
F
records.
 
For more than two years it was contended that insufficient information had been given 
by the solicitors acting for Mr and Mrs [A] to comply with legal rules relating to the 
disclosure of medical records.  Furthermore, the proceedings became complicated 
with parallel action being pursued against the Royal Borough [there mentioned] and 
the Hospital [there mentioned].  Mr and Mrs [A] also decided to instruct another firm 
G
of solicitors in February 1993 about disclosure of the medical records relating to the 
treatment of their son.  In April 1993, the medical records were disclosed. 
 
In December 1994 I was informed that another firm of solicitors had been instructed 
by Mr and Mrs [A] and the copied medical records has been passed to them.  They are 
now seeking copies of recordings made on 10 January, 16 January and 20 January 
1987 of the breathing patterns, oxygen saturation and heart rate patterns taken of 
H
[Child A]. 
T.A.  REED 
Day 5 -  60
 & CO. 

---

A
 
The medical records contain only reports of the recordings and I enclose copies.
I have been informed that you may have some records in your possession at the 
University of Keele relating to the treatment and care of certain children in Royal 
Brompton Hospital.  If you have the recordings requested by the solicitors acting for 
[Child A] in your possession, would you please send them to me.” 
B
Going to page 5 in your SC file, does Professor Southall write back to Mr Chapman, saying: 
 
“Thank you very much for your letter ….. 
 
I have looked through the records and identified 6 multichannel physiological 
recordings that we performed on [Child A].  These recordings involve physiological 
signals and because of storage, we destroy the paper version and retain only the taped 
C
version.
 
In order to produce paper versions it would take us many hours of quite hard work as 
well as using a lot of resources.” 
Then he goes on to say what he has to say about the multichannel recordings, do you see 
that?
D
A Yes. 
Q 
Then also further letters from Mr Chapman to Professor Southall.  The first one we 
pick up is on page 4, which is a letter of 19 July 1995 to Professor Southall from Mr 
Chapman: 
 
“…I have received further correspondence from the Solicitors who act for [Child A] 
E
….. following his treatment and care at Royal Brompton Hospital ….. They have 
asked for an explanation of two matters and I will be grateful for your assistance”. 
The first matter relates to a gap in the medical case notes, do you see that, between 16 and 29 
January? 
A Yes. 
F
Q 
There is an assurance there that: 
 
“The Medical Records Department has informed me that no temporary records were 
created for [the child] between those dates and I would therefore be grateful for 
confirmation that no other records between the two dates exist.  Alternatively, if you 
should be in possession of any medical notes which were written between those dates, 
could you please send copies to me.” 
G
Was there also a request as to the status of Dr Warner? 
A 
Yes.  Those medical notes we are talking about between 16 and 29 January, we got 
most of those about two years ago. 
Q 
That would be 2003? 
A Yes. 
H
T.A.  REED 
Day 5 -  61
 & CO. 

---

A
Q 
There was a further letter written at page 6 in August 1995 by Mr Chapman to 
Professor Southall, thanking him for sending the recordings, and indicated: 
 
“There are now further matters on which I will be grateful for your help.  You will 
recall that I wrote to you on 19th July about the observation by the solicitors that there 
is no entry in his medical notes between 16th and 29th January ….. I enclose a copy of 
the respective pages from which you will see that Dr Martin Samuels has signed both 
B
entries.  The solicitors have asked if any notes are missing but I have not found any 
additional documents in Royal Brompton Hospital.  I write therefore to ask if you 
have any separate notes in relation to the treatment of [Child A] at Royal Brompton 
Hospital in your possession.  The nursing records indicate that certain events took 
place during the intervening period.  For example, [the child] was transferred to 
Westminster Children’s Hospital on 20th January returning on 21st January.  You saw 
the parents that day and they subsequently demanded his transfer to the Hospital for 
C
Sick Children at Great Ormond Street.  On 23rd January Dr Samuels spoke to the 
parents.  Dr Samuels also appeared to have spoken to the parents again on 27th
January.  None of these events are recorded in the medical notes. 
 
The second matter concerns the reference by Dr Samuels on 29th January, when after 
discussion with you, no further need was felt to perform either cardio-respiratory
monitoring or video (which I presume is video surveillance).” 
D
A 
Yes.  Can I just say that that was a research protocol used by Southall at the time 
I was – the protocol was not actually in place until July of that year, but nevertheless he went 
ahead and did the covert video surveillance on me in that period of time, but he said he had 
never carried out--- 
Q 
Can I just stop you there, please, Mrs A, because that is not a matter currently before 
E
the Panel. 
A 
---video surveillance, but the record shows he did carry out video surveillance. 
Q 
Please, that is not, and I have to emphasise for the sake of the transcript, a matter that 
is before this Panel.  Dealing with the questions that he there asked, was there a yet further 
letter from Mr Chapman to Professor Southall, which we see at--- 
A 
Can I just go back to the medical notes, the previous letter of 7 August 95, which is 
F
page 6, where we are talking about medical notes missing between 16 and 29 January.  The 
reason those medical notes were absolutely crucial is it showed, just a matter of days before 
Southall swore on oath that [my son] was normal, that there were very clear records, for 
example a paediatric registrar clearly stating that [my son] was nowhere near normal;  in fact, 
he had very clear pathological, neurological symptoms, and he was given facial oxygen on 
one occasion when he cyanosed.  That is not a normal baby in my book. 
G
Q 
We have now reached 1995, seeing the attempts by your solicitors to obtain the notes 
and the piecemeal giving of notes by the Brompton Hospital through their solicitors after 
getting further notes from--- 
A 
Sorry, I missed the page reference. 
Q 
No, I am not giving you a page reference. 
A Sorry. 
H
T.A.  REED 
Day 5 -  62
 & CO. 

---

A
Q 
I am asking probably an overlong question:  we have now reached 1995. 
A Yes. 
Q 
In 1995 did you know of the existence of something called a special cases or SC file? 
A 
No.  When did I first hear about the SC file?  It came to us fourteen months ago.  It 
must have been, I suppose, two years ago. 
B
Q 
That is 2004. 
A 
It would be approximately then when I contacted the North Staffordshire Hospital, 
yes.
Q 
Let us take that in stages.  You first heard of the existence of an SC file.  Did you hear 
of that through any legal source or was it through another source? 
A 
No, it was through a journalist. 
C
Q 
Before you had that conversation with the journalist, and we cannot hear about the 
nature of that conversation -- 
A 
It was by e-mail, it was not a conversation. 
Q 
Before hearing from that journalist, did you know there was anything called an SC 
file? 
D
A 
I had never heard of SC files before.  In fact I laughed and said, “Don’t be silly.
I have not got one of those”. 
Q 
As a result of the information that you learnt from this journalist in 2004, did you 
contact anybody or an organisation? 
A 
Yes, I rang the administrator of the North Staffordshire Hospital.  I sincerely did not 
believe that there would be anything there, simply because we had never been to the North 
E
Staffordshire Hospital.  Our son had never been a patient there so you would never dream 
that there would be records there.  But I thought I had better check this out anyway so I rang 
and had a sensible conversation with the administrator.  She said she would check.  She rang 
me back and said, “No, there isn’t anything”.  I said, “Would you mind checking one more 
time and be absolutely certain”.  She said, “Let me have your original address and Child A as 
a baby”.  She went back and did indeed then find the SC file, much to my astonishment. 
F
Q 
When there came a time when you were able to see the SC file, did it contain material 
that you had not seen before or had not been provided with before, despite all the endless 
requests for documentation by your solicitors over time? 
A 
An enormous amount of documentation.  I mean, two-thirds, I would say, of that file 
we had never seen before.  It was quite extraordinary, and it certainly answered some 
questions for us. 
G
Q 
In particular, did you see in that file for the first time, the scan report?  Could you go 
to page 131 in the SC file, which is C5? 
A 
This is the scan report, yes. 
Q 
We have seen in the correspondence that you requested this in August 1987.  Before 
you saw this SC file, some time after 2004, is that the first time that you saw that document? 
A 
That is right.  Can I explain the importance of the second file.  I must just explain in 
H
history at that time, Baby A was one of the earliest babies to go through the MMR scanner 
T.A.  REED 
Day 5 -  63
 & CO. 

---

A
and we had to sign a special consent for that.  What interests me is the second paragraph 
where it says, 
“The cerebellum is less myelinated but this should be within normal limits at this 
age”.
Now bear in mind that this document was never read by a neurologist, it was simply being 
B
reported on by a radiologist.  Had we had this document at the time we would certainly have 
questioned that.  No radiologist at that time could have said that the cerebellum was within 
normal limits because they did not have enough brain scans on file to be able to say that.  So 
had we had this piece of paper we would certainly have gone for a second opinion, and 
I believe that is why it has been held secret all this time. 
MR TYSON:  Just wait there a moment.   
C
MR COONAN:  I have no questions, thank you. 
Questioned by THE PANEL
DR SARKAR:  Good evening.  Just one clarification.  In C5, Tab A, can I take you to page 
57?  It is the sworn statement made by yourself among others.  Can I ask you to go to 
D
paragraph 5, please? 
A Yes, 
certainly. 
Q 
There it says, 
“The scan referred to by Dr Southall was conducted, with our reluctant consent and 
on the basis that Baby A might still have an undetected brain problem, on 11/2/87 and 
E
results given to us on 13/2/87”. 
A 
It was minutes before the wardship papers were served on us. 
Q 
It says “results given to us”, does that mean the results were conveyed to you 
verbally? 
A 
Yes, verbally.  It happened in a sequence.  Southall said, “The brain scan was 
F
perfectly normal.  There is nothing wrong with your child.  Here are the wardship papers”, 
exactly as I have said it now. 
Q 
The first time you actually saw the paper that contained that report was when? 
A 
It was 14 months ago. 
MR McFARLANE:  Good afternoon, Mrs A.  You have described in pretty graphic detail 
G
what happened when you thought you were going to a diagnostic meeting but it was not so. 
A Yes. 
Q 
I can understand that you felt completely gobsmacked, for want of a better word.  Did 
you ask Professor Southall why such an action had been taken? 
A 
We asked lots of questions.  You have to understand the sheer terror you feel when 
you are faced with a room full of solicitors and social workers who are telling you that your 
H
child might be taken away.  So yes, we did argue. 
T.A.  REED 
Day 5 -  64
 & CO. 

---

A
It was bizarre in the extreme because David Southall was saying, “You must accept your 
child has always been normal”.  I said, “Don’t be ridiculous, how can he be normal when he 
was given phenabarbitone in the first hospital for epilepsy?”  For example, I do not think 
doctors give out phenabarbitone to normal babies so surely there has to be something wrong 
with him.  Then he said, “That is nothing to do with it.  The child is perfectly normal”.  I said, 
“But the medical records shows that Child A was clearly unwell, plus numerous 
B
paediatricians, registrars and house officers had seen and witnessed Child A’s episodes”.  All 
that had been written in the medical notes. 
As we were speaking the social workers were coming in and saying, “I am afraid you need 
help, Mrs A, you cannot see your child as normal.  There is clearly something very wrong 
here.  You must accept what Dr Southall is saying.  There is nothing wrong with your child”.  
Then we began to get very very frightened because there was no logical reasoning going on 
C
here at all.  Everybody knew in the hospitals we had been in, all the other doctors knew that 
there was something seriously wrong with child A yet we were being faced with this barrage 
of people telling us, “You have to accept that your son is normal”. 
So there was this kind of collective madness taking over, that is how I feel about it.  Then the 
penny began to drop, “If they really think our son is normal, then really the tone is that there 
is something wrong with us”.  We had already sussed that the psychiatric angle was creeping 
D
in, and then Susan Reece, a social worker, came in and said, “We are trying to get you a place 
at the Castle Hospital family unit”, which is a psychiatric unit where they assess families and 
babies together, family therapy.  We thought, “Oh my God, they think we are mad”.  Then 
you start to back off.  I mean we were really angry initially, then you are in shock and fear.
Then you calm down and think, “These people hold all the power here.  We are going to have 
to be ever so careful”. 
E
First I would not accept the wardship papers because I was not going to accept them.  I was 
hanging on very very tightly to my chair so my hand would not have to take those papers.
Finally I accepted the papers.  I am sorry, I have lost track of the question. 
THE CHAIRMAN:  Possibly we should check with Mr McFarlane that you have answered 
his question. 
A 
It was the most bizarre situation, that is all I can say, and it was no clearer by the end 
F
of the meeting than at the beginning, really. 
THE CHAIRMAN:  Has your question been answered, Mr McFarlane? 
MR McFARLANE:  Nearly, I have just one more question. 
THE CHAIRMAN:  If you could focus on the actual question. 
G
A Sure. 
MR McFARLANE:  You have been most helpful in what you have said thus far.  Looking 
purely at the explanations offered to you by Professor Southall and Professor Southall alone, 
was he able to explain to you why he was saying the things he was, or was he perhaps being 
brief or aloof? 
A 
There was absolutely no explanation, absolutely none, none whatsoever.  In fact we 
H
were told from that point on that we were literally never to discuss the matter again, never to 
T.A.  REED 
Day 5 -  65
 & CO. 

---

A
use the word “episode” again.  We were never to talk about it, never research about it.  We 
had to accept that Child A was perfectly normal.  From that time on, because we were so 
terrified of losing Child A, we had to play the game and pretend that he was normal, knowing 
that he was not.  Of course we knew that he was not, I mean the medical record would show 
that he was not.  But we had to pretend for the safety of our baby and to hold on to him that 
he was normal.  So we were in a most bizarre situation. 
B
MR McFARLANE:  Thank you very much. 
THE CHAIRMAN:  It is possible either counsel might have questions arising from the 
answers you have just given. 
MR COONAN:  I have no further questions. 
C
MR TYSON:  No, thank you. 
THE CHAIRMAN:  In that case that completes your evidence. 
A 
Thank you for listening.  I am grateful. 
THE CHAIRMAN:  You are released from your oath and may stand down. 
D
(The witness withdrew)
MR TYSON:  Madam, you will be relieved to know that I have no further witnesses today 
and we will start on Monday morning with Mrs H.  Towards the end of the day I anticipate 
being able to call Mrs D and I will possibly be asking on Tuesday to interpose the solicitor, 
Mrs Parry, relating to child M, depending on how far and what state we have reached with 
Mrs D.  Thereafter, after Mrs H, Mrs D and Miss Parry, then my last witness will be the 
E
director of administration.  So I anticipate being able to close my case either late Tuesday or 
early Wednesday, if that helps on the housekeeping. 
THE CHAIRMAN:  Thank you, that is helpful.  We will adjourn now until 9.30 on Monday 
morning.
(The Panel adjourned until 9.30 a.m. on Monday 20 November 2006)
F
G
H
T.A.  REED 
Day 5 -  66
 & CO. 

---

GENERAL MEDICAL COUNCIL
FITNESS TO PRACTISE PANEL (PROFESSIONAL CONDUCT)
Monday 20 November 2006
44 Hallam Street, London, W1W 6JJ
Chairman:   
  
Dr Jacqueline Mitton 
Panel Members:
Mrs Leora Lloyd 
Mr Alexander McFarlane 
Dr Sameer Sarkar 
Mr Arnold Simanowitz 
Legal Assessor:   
Mr Robin Hay 
CASE OF: 
SOUTHALL, David Patrick 
(DAY SIX)
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 JOLLIFE 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
MRS H, Sworn 
 Examined 
by 
MR 
TYSON 
    1 
 
Cross-examined by MR COONAN   
 
          34 
 
Re-examined by MR TYSON  
 
 
          46 
 
Questioned by THE PANEL   
 
 
          46 
 
Further re-examined by MR TYSON  
 
          56 
MRS D, Sworn 
 
Examined by MR TYSON 
 
 
 
         57 

---

A
THE CHAIRMAN:  Good morning, everyone.   
MR TYSON:  Good morning, madam.  So far as the delay this morning is concerned, it was 
caused by my side and I apologise.  I am going to call Mrs H, but before then perhaps I can 
do some housekeeping, and I am grateful to my learned friend that further documents are now 
going to be permitted to be added to the bundle.  Can I ask you, please, to look at C2 and 
B
insert into C2 a new section (k). 
THE CHAIRMAN:  I take it that this is in the section at the front, a continuation of 2 rather 
than behind any of the other tabs. 
MR TYSON:  Yes.  It should follow 2(j).  (Document handed)
C
The second bit of housekeeping is that I would ask you to look at 2(o), which should contain 
a letter dated 3 April 1990 from a consultant paediatrician, Dr Weaver, and I would ask that 
you put the document you are about to receive in front of that.  It is a letter from the same 
paediatrician.  One is to the parents and the one you are about to receive is to Dr Southall.
(Document handed) 
Can I now call Mrs H.  I also indicate that my learned friend kindly informed me that I can 
D
lead Mrs H in a number of these matters by way of background.  This witness deals with 
Heads of Charge 7 and 9 and is also involved in Appendix One and Appendix Two. 
MRS H, Sworn
Examined by MR TYSON
(Following introductions by the Chairman)
E
MR TYSON:  Mrs H, there should be a bit of paper and a pen in front of you.  Would you 
please write your full names and address on that piece of paper? 
A 
(The witness wrote on the piece of paper)
THE CHAIRMAN:  Can I take this opportunity, Mrs H, to say that we will refer to your child 
as Child H.  However, it does occasionally happen that names will slip out.  Do not worry if 
F
that happens, but I would like to give a warning to any members of the press who are present 
that names of the families involved here should not be reported even if they inadvertently slip 
out.
MR TYSON:  Mrs H, in the course of your giving evidence I shall ask you to look at two 
bundles of documents.  One is what we have as C1.  Towards the end of that bundle is a 
Section 2.  Section 2 carries on in the next bundle, which is C2, so it is the back of C1 and the 
G
beginning of C2.  I am going to ask some questions about the lead-up to your child coming to 
the Brompton Hospital in 1989, and I am going to do this by way of leading questions, so all 
you need to do is say yes or no or make any odd comment that you want to make.  Was your 
child born on 20 September 1985 by Caesarean section? 
A Yes. 
Q 
Did the child need to be taken to the special care baby unit when he was born because 
H
he was cold and blue? 
T.A.  REED 
Day 6 -  1
 & CO. 

---

A
A 
Only very briefly.  He was returned to me.  As soon as I came out of theatre and 
regained consciousness he was brought to me. 
Q 
Was he a sicky baby when he was born?  Did he used to vomit his food? 
A 
Yes.  He used to have projectile vomiting which got progressively worse really.  By 
“projectile vomiting” I mean when he vomited it would shoot across the room. 
B
Q 
In November 1985 when he was two months old, did he have to have an operation for 
bilateral in-groin hernias? 
A 
Yes, he did. 
Q 
When he came back from the theatre, was there any problem with noisy breathing? 
A 
Yes.  When he was coming back from theatre we did not realise it was him who was 
being brought back because they put the child or baby on the trolley.  You could hear his 
C
breathing coming down the corridor and when they brought him to us we realised it was our 
little boy.  His breathing was very very noisy and in fact from that day on was quite noisy 
really.  We were told later that that was a laryngeal strider. 
Q 
At that time, as a result of what the consultant paediatrician at your local hospital did, 
did that consultant put your child on to an apnoea alarm? 
A 
Not at that moment in time, no. 
D
Q 
But a bit later. 
A Yes. 
Q 
In December 1985, he having been born in September 1985, was your child admitted 
to hospital with failure to thrive? 
A 
He was admitted to hospital because every time we fed him he was being very very 
E
sick.  As I say, he had projectile vomit.  He was not gaining weight properly.  He was not 
exactly skinny but he was not doing as well as he should, so yes he was admitted for failure 
to thrive.  I was breast feeding him and it was very difficult to assess how much feed he was 
actually getting when I was breast feeding him and he was vomiting it back.  So it was 
decided to put him on the bottle so that we could measure his feeds.  Then it was thickened 
with Nestragel to make sure it stayed put in his stomach. 
F
Q 
Did there come a time in February 1986 when your child was about five months old 
when there was an occasion when your husband was feeding him and the child suddenly went 
blue, limp and stopped breathing? 
A 
Yes.  Prior to that we had taken our son, following the in-groin hernia repair, we had 
taken him to the out-patients department and during that appointment they noticed in the 
waiting room that his breathing was very noisy, very irregular.  He would breath very loudly 
and then he would stop, and they were getting very anxious.  We were used to it, but they 
G
were a bit jumpy.  The nurse said to me, “Has he got an apnoea alarm?”  I said no, and she 
said, “I am going to ask Dr Hythe for one”, my apnoea consultant at the Lister.  I said if you 
want to fine, but I am not going to ask for one.  That is how we got the apnoea alarm.  I am 
afraid I have lost track of your question. 
Q 
I was taking you to February 1986 and I understand there was an occasion when your 
husband was feeding the child and he suddenly went blue, limp and stopped breathing. 
H
T.A.  REED 
Day 6 -  2
 & CO. 

---

A
A 
That is right.  My husband was feeding him and he went blue and unconscious.  
I quickly got on the phone and said we are bringing in a child who is not breathing.  As we 
grabbed him – it was a February morning – and I grabbed him off my husband because my 
husband drove, and as we went into the cold air he gasped and started breathing again.  By 
the time we got him to the hospital he appeared perfectly normal and we said we would take 
him home, but Dr Hythe insisted that he stayed in.  He said he would be happier if he did, and 
from that time he had what they call a number of blue attacks.  At one time we were in 
B
supper, came back and they were giving him oxygen to bring him back.  He had gone 
unconscious.
Q 
When the child was admitted on that occasion, was a special kind of tube, called a 
naso-gastric tube, inserted in the child to assist him feeding? 
A 
Yes, it was.  They thought he had something called an oesophagal fistula I think it 
was and they decided they would put a naso-gastric tube in to feed him, and it was decided 
C
that he would be transferred to Great Ormond Street Hospital in London. 
Q 
Once the child reached Great Ormond Street, was there an incident there where the 
child went blue and unconscious, but you were told by the doctor that the EEG was normal? 
A 
Yes.  I think it was shortly after we arrived.  They wondered if our son might have 
epilepsy because I have it and it is in the family.  They decided to take him for an EEG and 
while he was in the EEG department, he went blue unconscious.  The next thing I knew there 
D
were alarm bells ringing and they came in from all over.  He regained consciousness.  They 
took him back to the ward and it was very soon, within an hour or two, that they decided that 
it was not an oesophagal fistula, but that we needed to be on the respiratory ward.  He was 
transferred to 5B in Great Ormond Street under the care of Dr Robert Dinwiddie. 
Q 
So he is admitted first to the gastric ward and then transferred to the respiratory ward 
under Dr Dinwiddie? 
E
A 
I think it was the gastric ward.  We were not there long enough to know really. 
Q 
Did he continue to have blue attacks when he was on that ward and was the child 
being transferred backwards and forwards between the respiratory ward and the respiratory 
intensive care unit next door? 
A 
Yes, he was, and also during that time he was put into – I think it was an oxygen, it 
was not a tank but that kind of thing, because he was too big.  They were doing readings on 
F
him and they were all over the place.  His oxygen levels were dropping, etc., etc., and yes, he 
was back and forth between intensive care and the main ward. 
Q 
Was it decided at that time to do a laryngoscopy or a bronchoscopy on the child? 
A 
Yes, it was. 
Q 
As a result of that were you told that the child had laryngeal stridor? 
G
A 
Yes, we were told he had layrngomalacia and bronchomalacia, which meant when he 
breathed in his voice-box collapsed and crushed his airway and he could not breathe out. 
Q 
Was there a discussion as to whether your child should have a tracheostomy or not? 
A 
Yes, there was.  There was a suggestion from the ENT team that they would do a new 
type of surgery which involved cutting away pieces of his voice-box.  We were not sure 
about that and we consulted Dr Dinwiddie, who was obviously [Child H’s] clinician, well, he 
H
was the one person that our son was under mainly.  So, we asked him what he thought and he 
T.A.  REED 
Day 6 -  3
 & CO. 

---

A
said he thought he should have a tracheostomy because it would bypass his airway and give 
us a quick means of resuscitation should we need it.  It turned out that the surgery the ENT 
team had suggested was very new.  I think they said that when our son --- 
Q 
I am sorry, we need not go down there. 
A 
Sorry.  Anyway, to cut it short, we had the tracheostomy on the advice of Dr 
Dinwiddie, yes.
B
Q 
I think you also just said that one of the advantages was that it would provide a quick 
means of resuscitation? 
A Yes. 
Q 
In March 1986, when the child was aged six months, did he have the tracheostomy 
and were you and your husband taught how to care for it, how to suction it, irrigate it, change 
C
the tube and how to deal with matters if the tube became blocked? 
A 
Yes, we were. 
Q 
Just in about three sentences, for the benefit of lay members of the Panel, tell us what 
a tracheostomy is? 
A 
It is just an opening into the trachea which bypasses, obviously, the nose and mouth, 
so that the child breathes in through the hole in his neck, for want of simple terms. 
D
Q 
Were you also shown how to resuscitate the child via the tracheostomy tube if 
necessary? 
A 
Yes, we were. 
Q 
Were you given oxygen and something called an ambubag in order to do that? 
A 
We were, yes. 
E
Q 
Thereafter, did your child continue to suffer apnoea attacks at any time and there was 
no pattern to them? 
A Yes. 
Q 
Were there occasions when you had to resuscitate Child H and did you do that in, as it 
were, a graduated way? 
F
A 
I think in the time that we had our son at home we probably only had to resuscitate 
him using the ambubag about twice maximum.  Mostly all you had to do to get him out of the 
apnoea really was to disturb him.  It mostly happened when he was asleep, so you had to 
disturb him and then he would come back. 
Q 
As time went on – and we are dealing with the child now up to about two years – did 
he have to be admitted to great Ormond Street because of asthma problems at one time? 
G
A 
Yes.  I took him for an out-patients’ appointment and he had been ill on the train 
going down.  He was admitted to hospital because his breathing was not right and later on he 
was diagnosed as having status asthmaticus and was really quite poorly.  It was the one time  
I left him in hospital and my husband rang me to say they were moving him into intensive 
care.  I do not drive, I could not get back, it was the middle of the night, and it was one of the 
worst nights at that point of my life, because my son was in trouble and I could not be there. 
H
Q 
You are using quite a lot of technical terms, Mrs H. 
T.A.  REED 
Day 6 -  4
 & CO. 

---

A
A Sorry. 
Q 
Do you have a background in nursing at all? 
A 
I am a qualified nurse.  I have not worked for many years, but yes.  Sorry. 
Q 
No, that is fine.  Did there also come a time when your child had to have surgery for 
another inguinal hernia? 
B
A 
Yes, he did.  I cannot remember exactly when.  I think it was around the same time as 
that admission actually. 
Q 
In 1998, by which time the child was aged about two and a half years, did he also 
have a further operation to remove a cyst in his neck? 
A 
Yes, he did. 
C
Q 
Did he also have to have an operation because his stomach became twisted, so he has 
stomach volvulus? 
A 
Yes.  He was being very sick still, as I say, and eventually he was not well.  He went 
into hospital for the thyroglossal cyst.  He became ill – I think this is right anyway – and they 
did various follow-ups.  They had done them previously, but on this occasion it showed that 
he had a twisted stomach, which I think is called a volvulus, so it was decided he needed to 
go to theatre for surgery for that.  While he was in theatre they discovered that he had a 
D
diaphragmatic hernia and they repaired that.  They also discovered that he had severe reflux 
and for that they needed to do what they called a Nissen’s fundoplication and they explained 
to us that they had to untwist his stomach and put a suture over his bottom rib to hold his 
stomach up so it did not twist.  I think that Nissen’s fundoplication is slightly different but
I do not know. 
Q 
So he had a stomach volvulus, a Nissen's fundoplication and a repair of the hernia? 
E
A Diaphragmatic, 
yes. 
Q 
During this admission did he have a number of apnoeic episodes when the child 
stopped breathing? 
A 
Yes, he did.  He was on the ENT ward as it happened for that because he had been 
admitted for the thyroglossal cyst and he was going through a particular bad patch with the 
apnoeas when he went to sleep, and so I deliberately sat at the nurses’ station at night and 
F
they saw to him and he had a quite a few attacks and I think on at least one occasion they had 
to use the ambubag to resuscitate him, to get him breathing again and give him oxygen, etc.  
Q 
Did Dr Dinwiddie come over and see the child because I think the child was now on 
the ENT ward and Dr Dinwiddie was from respiratory.  Is that right? 
A Yes. 
G
Q 
Did Dr Dinwiddie come and examine the child when he was on the ENT ward? 
A 
Yes, he did.  He came over and they called him because our son was having problems 
with apnoeas and it was on that occasion that Dr Dinwiddie told us that [Child H] had 
Ondine’s curse. 
Q Ondine’s 
curse? 
H
T.A.  REED 
Day 6 -  5
 & CO. 

---

A
A 
Which meant that when he went to sleep, your brain tells you to carry on breathing, 
but in our son’s case it did not.  That was the explanation we had at that time and that was the 
diagnosis.
Q 
Can you just look in a bundle please which we have as C2 and look under tab (j)?  
There should be a second letter within tab (j) and do you see that letter of 18 March 1989?  
Do you see that? 
B
A Sorry, 
yes. 
THE CHAIRMAN:  Excuse me one moment.  I think one of the Panel members has a 
problem. 
MR TYSON:  There should be two letters in (j).  Has Mrs Lloyd got nothing in tab (j) or only 
one letter in (j)? 
C
MR COONAN:  We are missing it as well. 
MR TYSON:  Can I ask if anybody has not got the first letter in (j), which is dated 30 March 
1990?  There should be a second letter there of 18 March 1989, which we are just getting 
some copies of now. 
D
THE WITNESS:  I am sorry, what did you say the first letter was, Mr Tyson? 
MR TYSON:  Do not worry, Mrs H.  We are just doing some housekeeping. 
A 
I am sorry, I think I have got a different date, that is all, on the one I have got. 
Q 
Let me ask you at this stage.  Within your bundle (j) have you got two letters, one 
dated 30 March 1990 and the second dated 18 March 1989? 
E
A 
Yes, I have.  Sorry.   
THE CHAIRMAN:  Are additional copies being fetched?   
MR TYSON:  Yes, they are.  (Further copies distributed)
(To the witness)  If we look at the letter dated 16 or 18 March 1989, is this a letter signed by 
F
Dr Dinwiddie of Great Ormond Street Hospital, Consultant Paediatrician, and does it say: 
“To whom it may concern 
RE:  [Child H] … 
This letter is to confirm that [Child H] attended this hospital and that he suffers from 
G
Ondine’s curse (irregular breathing pattern) weakness of the breathing tubes and 
asthma.  He also has tracheostomy (breathing tube inserted into the windpipe to help 
with his chest problems). 
He will certainly benefit from an ultrasonic nebuliser for his treatment.” 
A 
Yes, it does. 
H
T.A.  REED 
Day 6 -  6
 & CO. 

---

A
Q 
Is that a letter that you saw at the time? 
A 
Yes.  It is a letter that was given to me actually because we had recently moved from 
[named town] back to Wales, so it was for that purpose it was given to me. 
Q 
We have had Child H in hospital having all these operations you have told us about, 
including the fundoplication and the hiatus hernia.  We have got to the bit where 
Dr Dinwiddie told you that he came and visited the child on the ward and that the child had 
B
Ondine’s curse.  Was there a discussion between you and Dr Dinwiddie as to what your child 
may need in order to deal with the problems that he had? 
A 
He said he would need a ventilator but it had to be a particular type, a trigger system 
ventilator, which we understood was not available in this country at the time anyway.  So, 
obviously it was not going to be something that appeared overnight, but that was what 
Dr Dinwiddie said that we needed, yes. 
C
Q 
So he needed the ventilator and you said that there was a specific kind of ventilator 
but I think you used the word “trigger”? 
A Yes. 
Q 
If it was a triggered ventilator, how would that work?  What was the triggering 
mechanism? 
A 
The point was that if you put on a normal ventilator, the ventilator breathes for the 
D
child or the person.  What Dr Dinwiddie wanted was a trigger ventilator which meant it 
would rely on our son triggering it.  So, if his oxygen levels dropped for any reason it would 
actually trigger the ventilator, when his oxygen levels rose the ventilator would go off, 
because obviously a child or a person on a ventilator that is just getting breath anyway, the 
child would become dependent upon it. 
Q 
So when there were discussions between you and Dr Dinwiddie about ventilators and 
E
triggered ventilators, did there come a time when you watched a daytime television 
programme where you saw Dr Southall on this programme? 
A 
Yes.  It was one of the early morning programmes that were on in the eighties,
I suppose, and I happened to be watching it and Dr Southall was on there talking about a new 
monitor that rather than telling you when the child stopped breathing, it would tell you when 
the child was about to stop.  We wondered if that would be of any help to [Child H].  It 
sounded like a good idea, it sounded a feasible thing, and the next time we saw Dr Dinwiddie 
F
in Great Ormond Street my husband and I asked him if this ventilator would be any – sorry, 
not ventilator, if this monitor would be any good.  He said that Dr Southall was a friend of his 
and he would contact him and ask him. 
Q 
Do you now understand that Dr Dinwiddie then wrote a letter to Dr Southall in March 
1989? 
A Yes. 
G
Q 
Could you look please at bundle C1 and the first letter under section 2 should be
tab (a).  Did you see this letter at the time or only subsequently when you had access to the 
notes? 
A 
No, actually I remember I did see it at the time.  We were taking our son down to 
something like an ECG monitoring, or something like that, and we were given his records 
and I had a look and I saw this letter and I saw the question of Munchausen’s syndrome by 
H
proxy has been raised. 
T.A.  REED 
Day 6 -  7
 & CO. 

---

A
Q 
We are rushing ahead of ourselves a little bit. 
A Sorry. 
Q 
Did you see the letter at the time it was written? 
A 
No.  Sorry, no, I did not. 
B
Q 
Can we look at it together, please?  We see that it is a letter from Dr Dinwiddie to 
Dr Southall related to your son, who was born in September 1985, and this letter is March 
1989, so he would be about three and a half years at this time.  Does it say: 
“I would be most grateful if you could please see [Child H] at his parents’ request.
He has been having a number of unusual apnoeic attacks particularly associated with 
hypoxaemia and they are very keen to know if any of your new monitoring equipment 
C
would be helpful for him.” 
THE CHAIRMAN:  Mrs H, I wonder if you could keep your voice up.  We do not always 
hear too well at this end of the room.  If you can speak up – it is quite a big room – that 
would be helpful. 
MR TYSON:   That, as you just told us, was as a result of what you had seen on the 
D
television programme. 
A 
Yes, that is right. 
Q It 
says: 
 
“His history is very long and complicated and I think it best to enclose copies of the 
case summaries from his numerous admissions here. 
E
 
We have had him on the ward on a number of occasions for sleep studies and have not 
been able to document serious hypoxia during these episodes although he has 
certainly been pale at times.  He has had various treatments as you will see including 
tracheostomy and more recently Nissen’s fundoplication, but according to his mother 
the apnoeic spells continue.” 
F
Then there is a bit in manuscript which you see: 
 
“The question of Munchausen by proxy has been raised. 
 
He is also asthmatic and has been treated with Salbutamol nebulised on a regular basis 
and previously had Becotide but this has been stopped recently without any obvious 
detrimental effect. 
G
 
I would be very interested if you could see him and arrange the necessary further 
investigations and advise in any other treatment which you think might be helpful in 
this particular situation.” 
So did you then get a call from the Brompton as a result of which your child was admitted in 
September 1989? 
H
A 
Yes, we did. 
T.A.  REED 
Day 6 -  8
 & CO. 

---

A
Q 
On that occasion, how long was Child H there? 
A 
I think it was two nights that he was there and then he was discharged. 
Q 
During those two nights and days he was there, did you meet Dr Southall on any 
occasion? 
A 
Yes.  We were in the ward with our son and Dr Southall came into the ward.  He 
B
introduced himself to us, said who he was, said that he had only ever seen one child with the 
condition that our son had been diagnosed with. I have to say he seemed very charming.  He 
did not spend any more than five minutes with us. 
Q 
Can you recall the condition that he talked about? 
A 
He referred to it as congenital hypoventilation syndrome, which I gather is the same 
as Ondine’s curse. 
C
Q 
Could you look, please, at 2(b), which should be under the next tab from the letter you 
have just been looking at.  The Panel has been taken through this document, but this is the 
clerking record of the doctor who first saw your child when he was admitted, and sets out, as 
you can see, that the history that you gave is that he had had:
“Difficulty in breathing since birth 
D
[Patient] has been unable to breathe well since birth 
-
He was often breathless and intermittently stopped altogether going blue as a 
result.
-
Feeding was difficult because of the breathlessness and was often followed 
by vomiting. 
E
-
At about 5 [weeks] he developed stridor following anaesthesia for Bilateral 
Herniotomy 
-
Parents complained [they] were not taken seriously until at nearly 5 [months] 
he collapsed in a local hospital and was referred to [Great Ormond Street] as 
a case of Tracheo-Oesophageal fistula. 
-
Thereafter his development regressed and it was another ... [year] before he 
could use his limbs. 
F
-
At [Great Ormond Street] he was said to have Laryngomalacea and 
Tracheostomy was done.  A diagnosis of Ondine’s Curse was also suggested. 
-
However his problems occurred when awake as well as when asleep and 
sometimes apnoea can occur more than 40 times a night.  Parents often have 
to bag him with the tracheostomy. 
-
He has been on an apnoea monitor since about 2 [months] ago ... 
-
For the last 8 [months] parents have been having a gruelling time waking up 
G
sometimes ’60 [times]’ in response to the alarm.  They now feel exhausted 
and would like a system that will help the child breathe so that they can relax 
and sleep”. 
It sets out that his development had been delayed, then the child was examined, various 
respiratory matters were dealt with, various other investigations were carried out, and then he 
is admitted for respiratory monitoring.  Then it being a new hand, which I think the Panel has 
H
now become familiar with, which was Dr Samuels’ hand, and he said: 
T.A.  REED 
Day 6 -  9
 & CO. 

---

A
 
“Unusual story ... partial/intermittent hypoventilation syndrome.” 
That is what you told us earlier you had discussed? 
A Yes. 
Q 
Then we see at the bottom there was a plan to “Need to observe respiratory 
B
abnormality … Discharge – re-admit when has problems”.  Do you recall meeting  
Dr Samuels and him saying that you can take the child home? 
A 
Yes, we did. 
Q 
During the time that you were in with your child in September 1989, was there any 
discussion with Dr Southall about any other paediatrician becoming involved in your child’s 
case?
C
A No. 
Q 
When you were in with your child in September 89, was there any discussion with  
Dr Samuels about any other paediatrician being involved in your child’s case? 
A 
No, other than Dr Dinwiddie, of course, who was already my son’s clinician of 
record.
D
Q 
Sorry, I did not hear that, he was your son’s? 
A 
Clinician of record. 
Q 
Clinician of record. 
A 
That is what we were told.  That was the terminology that was used later. 
Q 
Were you happy with Dr Dinwiddie being your child’s paediatrician? 
E
A 
Yes.  Dr Dinwiddie had been our son’s paediatrician for a number of years and we 
had great faith in him, and followed every instruction that he gave us to the best of our 
ability.
Q 
We see, after that admission, your child was discharged.  Can you turn to 2(c), please.
We see this is a letter form the paediatric registrar to Dr Southall, and we see at the top right 
hand corner that your child was admitted on 27 September 89 and discharged on 30 
F
September 89, and the “Diagnosis &Anatomical Site” says “Apnoeic episodes ? cause”, and 
the history is recording that: 
 
“[Child H] was admitted for overnight monitoring.  He has had difficulty in breathing 
since birth with intermittent apnoeas and cyanosis.  He has a diagnosis of 
laryngomalacia made in Great Ormond Street in the past together with fundoplication.
On examination he was well.  Tracheostomy tube was in place.  There were no other 
G
abnormal signs. 
 
TREATMENT AND PROGRESS:  Overnight monitoring was carried out which was 
normal and the plan is to readmit him when he is actually having cyanotic episode for 
repeat recordings.” 
H
T.A.  REED 
Day 6 -  10
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A
So we have reached September 1989.  Did the child, after those sleep studies, then have to 
return to Great Ormond Street because there were problems with the child coughing, going 
red, then blue and then becoming unconscious? 
A 
Yes.  That had become a problem in the recent months really leading up to that 
admission.  He was admitted on that occasion for ventilator assessment.  During that visit to 
Great Ormond Street in February 1990 they witnessed him coughing, what they called 
coughing and stopping.  He would cough, he would go blue, he would collapse on the floor, 
B
and they diagnosed that, I am not sure which it was, hypercapnoea or hypocapnoea, but it was 
something to do with blood flow crossing the lungs.  I do not really understand it, but it was 
something to do with that. 
Q 
The child was admitted to Great Ormond Street in February 1990 for a ventilator 
assessment, and during the course of that these coughing and stopping episodes were looked 
at?
C
A 
Were noted, yes. 
Q 
Was the child at that admission also taken to the intensive care unit to be connected to 
a ventilator for an overnight trial? 
A 
They thought they had found a trigger system ventilator that was suitable for my son.  
He was taken to the intensive care and put on it for one night.  It turned out it did not actually 
do what it was supposed to do.  It was designed to give a number of breaths per minute, I do 
D
not know how many, say four breaths a minute, which meant it automatically did that, rather 
than relying on our son triggering it himself, so obviously that was not suitable, that was 
something that Dr Dinwiddie and ourselves wanted to avoid.  During that admission, in the 
intensive care unit the following morning, when our son had been taken off the ventilator, we 
were told it was not suitable, we saw the registrar who told us that he wanted us to take our 
son back to see Dr Southall because he wanted to do a test on our son that involved giving 
him a gas to breathe in to stall his breathing and then stand by to see what happened, to see if 
E
he was resistantly apnoeic or if his apnoeas were self-accommodating and he would start on 
his own.  We were not keen on the idea, we did not understand what it was about, we were 
worried about our son’s safety and well-being if that kind of test was carried out, and
Dr Habbibi said it was down to us that our son was alive, without us our son would have been 
dead and most people would have put him in an institution the minute he was born and 
forgotten he existed, and that really shocked us. 
F
Q 
Just moving on.  As a result of what the registrar said to you, did the child go back to 
the Brompton Hospital in March 1990? 
A 
Yes.  He also told us that Dr Southall had the money and the resources to develop a 
suitable ventilator for our son, so on that basis we agreed to take him back. 
Q 
Can I ask you now to look at section (d) in these notes.  We see there are some 
clerking notes here which deal with the four problems that we can see on the first page there, 
G
that your child was admitted routinely for overnight monitoring under the care of Dr Southall, 
five problems were identified:   
“cyanotic episodes and abnormal breathing;  coughing bouts 
stridor 
jitteriness 
developmental delay 
H
cow’s milk/soya intolerance” 
T.A.  REED 
Day 6 -  11
 & CO. 

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A
We see a history is set out over the next few pages.  Can I take you to the page which should 
have “9” at the bottom of it.  Under the paragraph that is headed “Summary” it says: 
 
“4½ year old [male with] numerous problems but particularly abnormal breathing 
pattern 
 cyanotic 
episodes 
B
 apnoeic 
spells 
 For 
[overnight] 
monitoring 
-
neurology and dermatology opinions may be [useful] 
-
assess [something] lung function…” 
Did the child have in March 1990 overnight monitoring? 
A 
Yes, he did, I think it was two nights. 
C
Q 
Were various leads attached to his body, which were then attached to various 
monitors? 
A 
Yes, they were.  We were in a cubicle overnight, and I was left in there with him.  He 
had, as Mr Tyson says, various leads on him.  On this time he had to wear a very, very tight 
vest, which was clearly not comfortable for him, and the sensors had burnt his skin slightly 
the previous occasion so he was not keen on it this time round obviously.  I was encouraged 
D
to leave him, as was my husband.  They had got a room for us a long way away from our son, 
but he was upset, he did not want to be left, and so I stayed with him, and he did, as  
Mr Tyson says, I think it was two nights’ sleep studies. 
Q 
Going over to page 10 we see the record for the next day, which is 16 March, where it 
says:
E
 
“Apparently had a good night [with] no problems ….. to be repeated again tonight 
….. [discuss with] MS”, and I think that is Dr Samuels. 
A Yes. 
Q 
Did there come a time after the two nights of recording that you spoke to a doctor 
about the results? 
A 
Yes, it was Dr Martin Samuels.  He came and told us that they wanted to remove my 
F
son’s tracheostomy, they wanted to give him experimental drugs for his asthma, they wanted 
to put him on home monitoring, which was the monitor that we had mentioned before, and 
did I say they wanted to put him on continuous oxygen therapy?  Our son was in normal 
school at that time, he was--- 
Q 
You have got to go a bit slower because this is important and people have got to write 
things down.  So you say Dr Samuels gave a list of things that he wanted done.  Can we just 
G
deal with it slowly.  What was the first thing that he said? 
A 
He wanted to remove his tracheostomy, he wanted to give him experimental drugs for 
his asthma, they wanted to put him on the monitor for overnight recording, and they wanted 
him to have continuous oxygen therapy. I am not clear if that was during the day and the 
night, or just the night. 
Q 
What did you think of those suggestions? 
H
T.A.  REED 
Day 6 -  12
 & CO. 

---

A
A 
We were surprised by them because it was not the reason we had been told we had 
gone back to the Brompton Hospital.  We had been told we were going back because Dr 
Southall had the money and the resources to develop a trigger system ventilator.  So we were 
very taken aback because--- 
MR COONAN:   Can you slow it down? 
B
MR TYSON:   Yes.  Again, keep very slow, because this is an important section of your 
evidence.  You said, “We had gone there because we thought we were going to investigate 
the trigger ventilator system”, and you were taken aback, you said.  Why were you taken 
aback? 
A 
Because our son had been a patient of Great Ormond Street for several years.  As
I said, Dr Dinwiddie, we thought, was his consultant, we were certainly under that 
understanding, and we were following the treatment plan that Great Ormond Street were 
C
recommending.  It was not something that we were wanting, it was something that  
Dr Dinwiddie at Great Ormond Street was recommending.  So we were surprised.  Sorry,  
I am going too fast again. 
Q 
Stop.  You said that this plan that was being put to you by Dr Samuels was not the 
plan that you were following at Great Ormond Street.  In what way was what was being put 
forward by Dr Samuels separate and different from what was being put forward at Great 
D
Ormond Street? 
A 
When our son was a patient in Great Ormond Street, I am going back actually to 
February 1990, he had had to go to theatre for a look down his throat to see how his 
laryngomalacia was doing.  During that admission he had two respiratory arrests in theatre, 
and they brought him back to us and they said that he had had two respiratory arrests, they 
had never seen anything like it before, it was definitely not an ENT problem, it was a 
respiratory problem. 
E
Q 
Keep pausing and watch pens. 
A 
I have forgotten your question, Mr Tyson, actually. 
Q 
Well, the question was in what way was what Dr Samuels was recommending 
different from what Great Ormond Street was recommending? 
A 
We had been told it was a respiratory problem he was having the coughing and 
F
stopping.  There was no intention by Great Ormond Street at all of removing the 
tracheostomy at that time certainly.  It was just totally different – the removal of the trachy, 
the experimental drugs – it was not what we were expecting, so we asked – sorry. 
Q 
You were not expecting it because it was different, in view of the experimental drugs 
and the removal of the tracheostomy. 
A 
And the oxygen therapy. 
G
Q 
And the oxygen therapy.  As a result of what you were told by Dr Samuels, did you 
ask to see anybody else? 
A 
Yes.  We asked if we could see Dr Southall.  Martin Samuels referred to Dr Southall 
quite often as his boss, so it seemed logical that we would ask to see Professor Southall. 
Q 
Were you able to see him? 
H
T.A.  REED 
Day 6 -  13
 & CO. 

---

A
A 
No.  A message came back via Dr Martin Samuels saying that Dr Southall was far too 
busy to come and see us, he was doing an interview for Sky television. 
Q 
When the plan was put to you by Dr Samuels, did you have any discussion about 
whether or not you accepted this new plan? 
A 
We said we would like to discuss it with Dr Dinwiddie.  As I have said before, we had 
great faith in him, we had always followed his instructions, but we did agree that we would 
B
take the monitor home with us, and we asked if we could go home to give us time to discuss 
this treatment plan with Dr Dinwiddie.  We were given lessons on resuscitating our son by 
Sister Jane Noyce in Dr Southall’s team, and we left the hospital and took Dr Southall’s 
monitor with us. 
Q 
So you were trained in the use of the monitor? 
A 
Yes, we were told how to put the sensors on. 
C
Q 
Then you left, after training, with the monitor? 
A 
Yes.  We went home.  We were very keen, as I say, to discuss this treatment plan with 
Dr Dinwiddie. 
Q 
Just pause there for a moment.  In the March admission, did you see Dr Southall at 
all?
D
A 
Absolutely not.  As I say, we requested to see him, because Martin Samuels referred 
to him as his boss, and he was too busy doing an interview for Sky television to come and see 
us.
Q 
Can you put away bundle C1 that you have been looking at, and go to the first tab in 
C2, which should be under (e).  This is an extract from the nursing records during that 
admission at the Brompton in March, Mrs H.  Do you see that, half-way down, there is an 
E
entry for 16 March recording that the child slept well overnight, 
“Cared for by mum [various measurements] PM up and about all care given by 
parents.  Seen by Dr Samuels.  To go home with PCO2 monitor”. 
A Yes. 
F
Q 
This session that you had with Dr Samuels, about how long did it take? 
A 
It was not very long at all.  I could not put a timescale on it, but less than five minutes.  
Slightly more than we had spent with Dr Southall the time before, but not very long at all 
really.
Q 
Dealing with the March admission, the two or three nights, can I ask you two 
questions.  First of all, was there any discussion about involving any other paediatrician with 
G
Dr Samuels? 
A No. 
Q 
Was there any discussion with any other doctor at the Brompton about involving any 
other paediatrician? 
A 
No, there was never a discussion about involving a local paediatrician at all.
H
T.A.  REED 
Day 6 -  14
 & CO. 

---

A
Dr Dinwiddie was my son’s consultant and we had discussed with Dr Dinwiddie when we 
moved from (town named) to (town named) about a local paediatrician.  We were not keen 
because Dr Dinwiddie had known my son and treated him, and my son, to quote  
Dr Dinwiddie, was an unusual case and we did not really want to start off with another 
hospital who did not know him. 
Q 
I need to control both your speed of speech and also I am afraid what you are 
B
speaking about. 
A 
I am sorry, I am Welsh.  We tend to talk a bit fast in Wales. 
Q 
You told us that you did not see Professor Southall at all on that occasion. 
A 
We are talking about the March, no. 
Q 
Were you told, prior to discharge, the results of the sleep study that had taken place? 
C
A 
Normal, I suppose.  I do not recall any results as such but as we had not been told any 
different we assumed they were OK. 
Q 
Would you look, please, at Tab (g), the third tab in in C2?  Turning over the page we 
see that this is a document written by a Dr Bush, who was the paediatric registrar to
Dr Southall.  It is what is called a discharge summary.  We see going back to the first page 
that your son was admitted on 15th and discharged on 17 March 1990.  There was a long 
D
history set out there by that registrar dealing with matters that you have told the Panel about, 
including his jitteriness and developmental delay.  Going over the page, there is a record of 
the examination and the fact of the trachostomy was noted, 
“He was pink.  There was no digital clubbing.  His breathing was noisy.  Pulse 104.  
Heart sounds normal, cardiovascular exam normal, chest hyperexpanded with 
widespread bilateral expiratory wheeze.  Scars from the abdominal surgery were 
E
noted and a faint arythomatous macular rash on the lower abdomen on the right and 
mild right convergent strabismus was noted.  There were no other abnormal signs.  
Treatment and progress: He was monitored overnight and the results will be sent on to 
you.  Follow up will be by Dr Southall’s dept”. 
Do you agree with that? 
A 
I do, but can I just point something out and I have never seen this document before?  
F
It talks about a macular rash.  In fact that is a birth mark our son was born with.  He still has 
it to this day.  It is on the underside of his body and it changes colour.  I say it changes 
colour; it goes slightly darker purple. 
Q 
After you had been discharged and gone home with the monitor, how did the monitor 
work that first night? 
A 
We used it for one night and it just went off all the time.  We were checking on our 
G
son.  He seemed fine.  We really reached the conclusion that he was too old for the monitor, 
that it was probably designed for younger children.  Our son was obviously very mobile.  He 
was four year old at that time.  So it was not very successful, shall we say? 
Q 
As a result of that overnight test that you performed, did you telephone anybody the 
next day? 
H
T.A.  REED 
Day 6 -  15
 & CO. 

---

A
A 
Yes.  The whole point of going home was to discuss this with Dr Dinwiddie.  I rang 
him and he said it was not what they wanted.  It was not part of his treatment;  to return the 
monitor to Dr Southall and to continue to follow his treatment plan. 
Q 
Pausing there, you spoke to Dr Dinwiddie and, as a result of what Dr Dinwiddie told 
you, did you decide to stay with the Brompton plan or stay with the Great Ormond Street 
plan? 
B
A 
Obviously the doctor was familiar with his patient.  As I have stated already, he was 
the clinician we had faith in and we were obviously going to follow his advice.  So
I telephoned Dr Southall at the Brompton Hospital. 
Q 
As a result of your conversation with Dr Dinwiddie, you then telephoned Dr Southall? 
A 
Yes, Dr Southall at the Brompton Hospital.  I thanked him very much for his time, 
because I was taught to be polite to everybody regardless, so I thanked Professor Southall for 
C
his time, and he said, “Return my monitor then” and slammed the phone down on me. 
Q 
In the clinical setting is that the last time that you had any contact with Dr Southall? 
A 
Yes.  My total involvement with Dr Southall was less than five minutes. 
Q 
Do you now know that following that admission, a letter was written by Dr Southall 
to Dr Dinwiddie? 
D
A 
I do now, yes. 
MR TYSON:  Madam, I do not know whether this might be a convenient time, but 
I understand from messages I am getting that my witness would quite like a break. 
THE CHAIRMAN:  Yes, that is fine, Mr Tyson.  We will take a break now.  We will break 
for 20 minutes.  I need to remind you, Mrs H, that while you are on oath you should not 
E
discuss the case or your evidence with anyone. 
(The Panel adjourned for a short time)
MR TYSON:  Mrs H, you told us just before the short break that you had had a discussion 
with Dr Southall and he had put the phone down on you.  You had decided to remain with 
Dr Dinwiddie. 
F
A Yes. 
Q 
Did there come a time when you saw a letter that had been written by Dr Southall to 
Dr Dinwiddie after this admission? 
A Yes. 
Q 
Would you look at the bundle in front of you at (i)?  Can you just read that with me?  
G
It is a letter dated 22 March 1990 to Dr Dinwiddie at the Hospital for Sick Children at Great 
Ormond Street from Dr Southall.  It says, 
“Re Child H:  I thought I had better write to you about our latest contact with Child H 
and his family.  The upshot of it was that we wasted a lot of valuable time, at the end 
of which the parents decided that they would like to continue along their own route 
basically with the parental belief that Child H has a severe, rare illness which warrants 
H
intensive care treatment at home. 
T.A.  REED 
Day 6 -  16
 & CO. 

---

A
I would just summarise his past history as we saw it, to try and put into context our 
recommendations.  Child H has had a history of cyanotic episodes, wheezing and 
cough and has variably been diagnosed as having bronchomalacia with, or without, 
additional reversible airways obstruction.  His previous treatments include nebulised 
intal, ventolin, becotide and acetylcysteine.  A nebuhaler was suggested by the local 
consultant paediatrician in Cardiff, Dr Weaver, but was refused by Child H’s mother.  
B
He has had a Nissen’s fundoplication and a tracheostomy.  The tracheostomy was 
performed for laryngomalacia but the parents now believe that it is most valuable for 
resuscitation purposes”. 
Pausing there for a moment, Mrs H, when it says it is most valuable for resuscitation 
purposes, who was it who told you that it could be used for resuscitation purposes? 
A 
Originally it was Dr Dinwiddie in the admission which we talked about before, when 
C
he came into the ENT ward and they told us that my son had Ondine’s curse.  But after that it 
was in the admission in 1990 when our son stopped breathing in theatre and they told us it 
was not an ENT problem, it was most definitely a respiratory problem.  He did the 
tracheostomy for reasons of ventilation. 
Q 
Going back to the letter, 
D
“The cyanotic episodes are intermittent and are treated by positive airway pressure 
applied through the tracheostomy.  The parental view is that the tracheostomy is 
essential for resuscitation, that some kind of trigger ventilator is needed to cope with 
apnoeic episodes.  They consider that Child H is neurologically normal, although it is 
pretty obvious that he has a tremor and central ataxia”. 
Did you consider Child H to be neurologically normal at this time? 
E
A 
My son had been born with a tremor.  He just had a tremor, that was part of my son, 
but yes he had had problems initially, during the period in hospital in 1986 when, prior to the 
tracheostomy, he had had a lot of apnoea attacks and cyanotic episodes.  We had seen a 
deterioration in him at that time in that he had been reaching out – I remember the Sunday 
before we were in church and he reached out and touched my friend’s wedding ring because 
he could see it glistening in the sun.  He did lose that ability for a little while, he did not reach 
out, but we worked him very hard.  We rolled him over balls, we did all sorts of things and 
F
we got him back basically, so yes, we did consider him to be normal. 
Q 
The letter carries on in the third paragraph: 
“Our impression is that the parents are used to Child H as being chronically sick.
They want the tracheostomy.  They want the ventilator.  They like the idea of him 
having a rare illness and they treat Child H as if he was a baby”. 
G
Did you like the idea of your son having a rare illness? 
A 
Not at all, no.  We wanted a normal little boy.  He was not treated as being 
chronically sick.  He was encouraged, in spite of the trachy, to lead a perfectly normal life.  
He had two elder brothers and we encouraged him to do everything that they could do.  He 
was in a normal school.  He was reading.  He loved life.  He was a wonderful little boy to 
have around and no, we did not view him as chronically sick.  We did not even want him to 
H
T.A.  REED 
Day 6 -  17
 & CO. 

---

A
have a ventilator.  We were purely following the advice of Dr Dinwiddie.  If at any point 
Dr Dinwiddie had said it was needed, that would have been the end of the subject. 
Q 
Going down to the last paragraph, he says, 
“Our suggestion to them was that firstly they use a transcutaneous PO2 monitor 
whenever he is asleep, that they get used to his baseline values and that in the 
B
eventuality of him showing lower baseline values, they institute temporary additional 
inspired oxygen”. 
Pausing there, is that the advice that you understood you got from Dr Samuels? 
A 
Yes.  I mean that is put quite clear.  As I said we were not sure about the inspired 
oxygen, whether that was all of the time or just some of the time, but it makes it clear here 
what he was talking about. 
C
Q It 
continues, 
“Secondly, we felt that reversible airways obstruction is a component of his problem 
and that maybe nebulised budesonide would help”. 
Was that discussed with Dr Samuels? 
D
A 
I guess that was the experimental drug for his asthma that he talked about? 
MR COONAN:  She never answered the question. 
MR TYSON:  She did answer the question.  Were the words “nebulised budesonide” 
mentioned or were the words, “experimental drugs for asthma mentioned”? 
A 
Experimental drugs for asthma. 
E
Q 
The letter continues, 
“In the long run we feel that if his cyanotic episodes can be controlled by monitoring 
and additional inspired oxygen, that he might not need the tracheostomy and that this 
could be closed”. 
F
Was that how it was put to you by Dr Samuels? 
A 
We were just told they wanted to close the trachy.  It sounded to us like it was just 
something they were going to do, close his trachy and put him on experimental drugs for his 
asthma. 
Q He 
says, 
G
“We also feel strongly that his neurological state has not been adequately 
investigated.  We feel that his tremor and ataxia could go along with a brainstem or 
posterior fossa problem which in itself could be related to its cyanotic episodes.  We 
also feel that it is vital that child H has his overall care managed by a local 
paediatrician”. 
You gave evidence about that before the coffee break: 
H
T.A.  REED 
Day 6 -  18
 & CO. 

---

A
“We put this regime to the parents last week and they initially said that they would 
like to accept it.  We therefore spent 24 hours training them in the use of the monitor.  
They were discharged with this on Friday night of last week”. 
Just pausing there, did you initially say that you would like to accept this or did you make it 
subject to any conditions? 
A 
No, we told Dr Samuels that we wanted to discuss the “treatment plan” with 
B
Dr Dinwiddie.  We agreed to take the monitor because obviously we lived in South Wales at 
that time and it would be a long way to come back to London just to pick up the monitor, so 
we said we would take it and then discuss with Dr Dinwiddie the so-called treatment plan. 
Q 
The letter continues, 
“In communication with them today, they have decided to reject this advice and go 
C
for the triggered ventilator approach. They are therefore returning the TCPO2 
monitor to us by registered post”. 
Is that a reference to the telephone call you had with Dr Southall? 
A 
I presume it is, yes. 
Q 
It goes on to say, 
D
“Martin Samuels and I both feel that these parents are not acting in the best interests 
of Child H’s long term future.  We feel that they have become involved with two 
special health authorities rather than their local hospital intentionally.  We are very 
suspicious of their motives and view Child H’s long-term prognosis with great 
concern.  I have left it with the parents that should they change their mind, we are 
here and willing to implement the approach outlined above.  Please do not hesitate to 
E
contact us again if you feel that we can be of assistance.  I am sorry that we do not 
seem to have been able to get through to these parents”. 
Dealing with one aspect of that paragraph, Mrs H, he says, 
“We feel that they have become involved with two special health authorities rather 
than their local hospital intentionally”. 
F
What do you have to say about that? 
A 
Our son was a patient in Lister Hospital in Stevenage.  We were told he needed to go 
to another hospital.  We had the choice I think of Addenbrooke’s Hospital, because it was 
close to Stevenage, or Great Ormond Street in London.  We chose Great Ormond Street 
because obviously any parent wants their best for their children and we believed Great 
Ormond Street would be the best.  As for the other one, as you know I saw a programme on 
G
television.  I did not know it was a separate health authority.  It was in London.  To me they 
were one health authority so there was no intention to get involved with two, it was just an 
intention to see Dr Southall to ask if his monitor would be any use for our son. 
Q 
We see that letter is copied to three people.  Who is Dr Bailey? 
A 
Dr Bailey was our GP. 
H
Q 
Dr Weaver, who is that? 
T.A.  REED 
Day 6 -  19
 & CO. 

---

A
A 
She is the consultant at the local hospital, or what was the local hospital to us then, or 
one of them.  Dr Weaver was the paediatrician at the University Hospital Wales, Cardiff. 
Q 
Had she in the past been involved in any aspect of the care of your child? 
A 
When we went back to Wales --- 
Q 
Just pausing there a moment, you told us that you had lived in Stevenage for a time 
B
and then you moved back to Wales.  At about what time are we talking about?  What date are 
we talking about that you moved back to Wales? 
A 
We moved back in 1988.  We moved back to Wales.  Both my husband and myself 
are Christians.  I am getting there; I am getting to the point.  We went back to what had been 
our local church before we moved from Cardiff to Stevenage in 1981.  It seemed logical that 
we would go back to the church we attended previously; we had friends there, the best man 
from our wedding went there, and relatives of mine went there.  However, so did the 
C
paediatrician, Dr Weaver.  We were not aware of that at the time.  During one meeting that 
we were at we were introduced to Dr Weaver and she asked us if we would like her to see 
him, our son.  We were not very keen.  I had worked with Dr Weaver in the past, I knew her.
She did not remember me, but I remembered her. 
Q 
Can I just cut to the chase here. 
A 
Sorry.  We had seen her once, yes, because at that meeting, that morning, she asked if 
D
we would like her to see him. 
Q 
She had seen the child. 
A 
She had seen him once.  When she asked if we would like her to see him we could not 
really …  It did not seem very polite to say no, so we did see her once. 
Q 
You see the third person there mentioned is a consultant paediatrician at the Royal 
E
Gwent Hospital.  Had the child ever been to the Royal Gwent Hospital? 
A 
No, it seems to me it was actually Dr Southall who was trying to involve another 
health authority, because we had never been there. 
Q 
Had there been any discussion with either Dr Samuels or Dr Southall about the overall 
care of your child being managed locally? 
A No. 
F
Q 
Were you asked for your consent by anybody to involve a paediatrician at the Royal 
Gwent Hospital? 
A 
No, there was no need – to involve one, I mean, not for the consent. 
Q 
Were you asked for your consent to a letter being sent to any paediatrician at the 
Royal Gwent Hospital? 
G
A No. 
Q 
Were you asked for your consent to this particular letter being sent to the Royal 
Gwent Hospital? 
A 
No, absolutely not. 
Q 
Do you have any views, Mrs H, about the fact that this letter was sent to an unnamed 
H
local paediatrician? 
T.A.  REED 
Day 6 -  20
 & CO. 

---

A
A 
I have quite a lot of views about this letter actually.  My belief is that Dr Southall saw 
my child as nothing more than a lab rat.  He was determined to get his test, never mind what, 
and --- 
MR COONAN:  I am sorry, but --- 
MR TYSON:  Yes, it may have been the width of the question which led to the answer. 
B
A Sorry. 
Q 
In terms of confidentiality, did you have any views about this letter, Mrs H? 
A 
Yes. I mean, it gives confidential information.  Why was it needed, that is the point?
We were under Dr Dinwiddie.  There was not any need to contact another hospital.  There 
was no reason why we should go to it.  It was a breach of confidentiality for which we were 
not given any choice, and it was an unnecessary breach of confidentiality.  I would like to say 
C
that in this I drew exception to the fact that Dr Southall – I have just got to find it; excuse me 
a second – refers to my son as “its.” 
Q 
Can I ask you, please, to look at section (o) in the bundle that you have in front of 
you.  Can I ask you to look at the letter dated 3 April 1990, which has got the letterhead of 
the University Hospital of Wales.  It is a letter that is written by Dr Weaver, who is one of the 
recipients of the letter we have just been discussing, to Dr Southall. I just want to ask you 
D
about the first paragraph, which says: 
“Thank you very much for sending me a copy of your letter to Dr Dinwiddie.
Everything I receive from specialists about this little boy confirms the impression 
which I made within 5 minutes of meeting him, that is they are a very unusual family!  
I notice you also sent a copy to the Paediatrician at the Royal Gwent Hospital in 
Newport, so I imagine that the parents have involved yet an other Paediatrician in 
E
[Child H’s] care – there are now three district Health Authorities in South Wales that 
have some involvement with them.” 
Was it you involving a paediatrician at the Royal Gwent or was it Dr Southall involving a 
paediatrician at the Royal Gwent? 
A 
Dr Weaver in this letter says she “imagined” it, and that is right.  We were not doing 
it.  Dr Southall had involved the other health authority, not us. 
F
Q 
Then, going over the page, you see a letter to you by Dr Weaver of the next day where 
she indicates: 
“I have recently received some further correspondence from my colleagues in 
London, and I thought I would offer to see [Child H] with you if you would like me to 
do so.
G
It is quite a long time since I saw him, but I know he has been attending at Great 
Ormond Street and I shall be interested to see how he is getting along. 
If however you find that the Paediatrician at the Royal Gwent Hospital is easier to 
reach, then please just telephone and cancel the appointment which I am enclosing.  
Bedwas is just on the border between the District Health Authorities so that either 
H
hospital is appropriate for you.” 
T.A.  REED 
Day 6 -  21
 & CO. 

---

A
Is the Royal Gwent Hospital and the University Hospital about equidistant from that town 
there mentioned or not? 
A 
No, they probably were not actually. 
Q 
Which is the closest, as far as you know, or the most convenient one to you?  The 
University one or the other one? 
B
A 
Yes, the University.  Having said that, if we had taken our son in, in an emergency, 
there was no casualty unit at UHW at that time, we would have taken him to Cardiff Royal 
Infirmary.  Thankfully, we never had to take him anywhere.  I suppose it would have been a 
toss up of which one we had gone to, but it never happened.  Bearing in mind that we were 
being accused – and we did not know at that time – of Munchausen’s syndrome by proxy and 
one of the things apparently that go along with that is “doctor shopping.”  You could say that 
we were being encouraged to “doctor shop” here, and surely if my husband or I, we were 
C
jointly accused of Munchausen's syndrome by proxy, if either of us had Munchausen's 
syndrome by proxy we would have jumped at the chance of another visit to another hospital. 
Q 
I am now going to deal with matters that happened much later when you were seeking 
access to your medical records.  Can I ask you, whilst I am going through this section of your 
evidence, to have in front of you section (k) in bundle C2, please?  Again, I am grateful to my 
learned friend indicating that I can lead the witness through the documentation in this section.  
D
Did there come a time, Mrs H, where, as a result of the involvement of Dr Southall with your 
child, that the child became a ward of court?  
A Yes. 
Q 
In the wardship proceedings were you represented by solicitors Cartwrights Adams & 
Black? 
A We 
were. 
E
Q 
Turning to the first page in section (k), is that a letter dated 5 November 1991 and we 
see at page 2 that it is to the Medical Records Manager at The Royal Brompton.  is that a 
letter from your solicitors?  Perhaps I can just take you to the first two paragraphs: 
“We act on behalf of the above named whom we represent in wardship proceedings 
concerning their children … 
F
At present the proceedings revolved around [Child H] and we confirm that a full 
Wardship Hearing is listed returnable on the 15th November …”, 
and it indicates the specialist that you had retained to advise you in this matter from the 
Department of Child Health at Bristol Maternity Hospital. 
G
“He has however indicated that it is essential that he sees all medical records, to 
include all nursing care records, held by your goodselves with regard to [Child H].” 
Then the bottom paragraph says: 
“Accordingly, we enclose herewith our Clients’ signed form authority for release of 
these records and we would be grateful if they could be forwarded to us or sent direct 
H
to Dr Peter Fleming by return.” 
T.A.  REED 
Day 6 -  22
 & CO. 

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A
Is that a letter that you recall, that in 1991 a request was made by your solicitors for the notes 
in relation to this matter? 
A 
Yes.  They made a request to every hospital he had been involved with.  That included 
Great Ormond Street, but all the records at Great Ormond Street had gone missing.  Anything 
prior to May 1990 no longer existed and to this day have never been found.
B
Q 
Then if we go over to the page which has at the top “A3”, do we see that this is an 
internal document from the Assistant Unit General Manager, dated 6 November 1991, to 
Dr Southall, about your child: 
“We have today received a letter from a solicitors representing Mr and Mrs H in 
relation to a wardship hearing on the 15th November 1991. 
C
They have requested disclosure of [Child H’s] medical records, and I am writing to 
you to requesting consent to copy and disclose.  Many thanks.” 
Do you see the manager has written under there “Consent Given” and I do not think it will be 
disputed that that is the signature of Dr Southall.  You have since become aware of something 
called an SC file, for reasons that we will come to in the course of this hearing.  Do you know 
whether records were actually sent to Dr Fleming at that time? 
D
A 
Nobody knew that an SC file existed.  All we had were the Brompton records and the 
GP records.  The Great Ormond Street records, as I say, had gone.  There was no SC file, 
nobody knew it existed, and so we had to rely on the records I had, which is largely where 
these have come from I think that you have got today; they have come from me, in relation to 
Great Ormond Street.  No, we did not know of an SC file.  We were told it was the GP’s 
records that had saved us. 
E
Q 
Did there come a time in 1995 where you instructed solicitors, Messrs Huttons, to 
consider giving you advice on taking proceedings against, amongst others, the Brompton 
Hospital, dealing with the way that you felt that your child had been treated at the Brompton? 
A 
Yes, in a roundabout way.  We could not afford to litigate; we have not got money for 
that kind of thing, but I guess you would say it is a fishing expedition.  We knew our son – 
and I am going to mention it because this is the truth – had been part of a research project and 
we wanted to see if any documents that showed what we were saying was right would come 
F
to light if we went to search for documents.  In fact, that is what happened. 
Q 
In 1995 did you ask your solicitors to obtain documents from, amongst other places, 
the Royal Brompton Hospital, with the idea of suing them, but in particular the idea to look at 
them to see the medical records? 
A 
It was a fishing expedition, yes. 
G
Q 
Are you aware that by 1995 Dr Southall had moved from the Brompton Hospital to 
Keele University? 
A 
I was aware of that, yes. 
Q 
In relation to the request made by your solicitors could I ask you please to look at the 
letter with “A4” at the top and numbered 4 at the bottom? 
A 
I am sorry, I have missed that instruction. 
H
T.A.  REED 
Day 6 -  23
 & CO. 

---

A
Q 
It is the next page in the documentation we are looking at.  It has got a number 4 at 
the bottom. 
A 
Right, I have got it. 
Q 
Did you become aware that this was a letter written on 22 February 1995 by Jennifer 
Jones, who we can see is the General Office Research Manager at the Academic Department 
of Paediatrics at North Staffordshire Hospital? 
B
A 
Yes.  I have only recently become aware of this letter.  Can I just say that the SC file, 
it was claimed when we actually got a small part of it, that it was a social care file. 
Q 
You are running ahead. 
A Sorry. 
Q 
We are back in 1995.  From this letter do you note: 
C
“Following the current legal communications regarding the above family”, 
i.e. your involvement with Messrs Huttons, 
“Professor Southall has asked me to request copies of any records you may be 
holding”,
D
that is, your local authority, 
“on the [H] family.  I have to say that subsequent to the move from the Brompton 
Hospital to North Staffordshire we can find no trace of relevant paperwork on this 
family.” 
E
A Yes. 
Q 
You note now that that was written.   
“I understand from Professor Southall that you had copies of medical records, various 
statements, etc. necessary to pursue this matter into Court.” 
F
A 
Can I just say, if this was a social care file, you would expect there to be social --- 
MR COONAN:  I am really going to object to this.  This is a document which does not affect 
this matter.   
THE WITNESS:  Okay.  Sorry. 
G
MR COONAN:  I understand my learned friend’s difficulties, but there are limits. 
MR TYSON:  I acknowledge I have reached the limit and I am moving on. 
(To the witness)  Did there come a time in March of 2000 where you contacted the Chief 
Executive of the North Staffordshire Hospitals to ask about an enquiry being made into 
Professor Southall, and also to find out if there were any medical records held on your child 
at North Staffordshire? 
H
A 
In March 2000, yes. 
T.A.  REED 
Day 6 -  24
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A
Q 
Could you look, please, at a letter, which is letter 5 in the bottom right hand corner, 
and this is a letter from the Chief Executive to you, and did you receive this letter in March 
2000, saying: 
 
“Dear Mrs [H] 
B
 
I am writing to confirm our telephone conversation of 23 March 2000.  You were 
ringing because you were concerned about the involvement of Professor David 
Southall in your son’s treatment at the Great Ormond Street in 1991 during the time 
when Professor Southall was a Consultant at the Brompton Hospital. 
 
Your request in relation to North Staffordshire was that we should seek to ascertain 
whether or not any medical records are held on your son at the North Staffordshire 
C
Hospital and whether or not any covert video surveillance tape exists. 
 
You also indicated, however, that you did not wish Professor Southall to know that 
you had made this enquiry.  I agreed, therefore, that we would review the files which 
are held within the Child Health Department here at the Hospital, but I gave you 
reassurances that we would not contact Professor Southall regarding your queries.
Once we have made a search of our records I will write to you again with our 
D
response.”
Did you get a response in relation to that query that you wrote, Mrs H? 
A 
Yes.  We were told by both David Fillingham and the Data Protection Officer at 
North Staffs that no records existed on our son or our family. 
Q 
You mentioned a name there;  is that the Chief Executive? 
E
A 
Yes, it is. 
Q 
You were told by him and by the Data Protection Officer. 
A 
Yes.  I think you had to pay a ten pound fee, or something, to the data protection 
people for them to look, and we paid our fee.  I have got no correspondence in relation to 
that, but we were told that nothing existed. 
F
Q 
That is in March 2000.  In May 2000 did you contact a Mr Chapman at the Royal 
Brompton Hospital to ascertain whether there were any matters relating to your son still held 
at the Royal Brompton? 
A 
Yes.  I mean, obviously the Brompton Hospital should have medical records because 
our son had been to that hospital, and we wanted to know if again they had the protocols that 
we knew existed, they had been part of our son’s medical records, we found that out in 1995, 
and we wanted to get copies of those as well, but I was told by Mr Chapman that the file no 
G
longer contained the protocols with the ethics approval for research, and all he sent was the 
hospital records as they stood at that time, but he told me how I could get the original set of 
records.
Q 
Pausing there, did you make a little note of your conversation with Mr Chapman, 
which we see at page 7? 
A 
Yes, I did. 
H
T.A.  REED 
Day 6 -  25
 & CO. 

---

A
Q 
Mrs H, is this your note or is it Mr Chapman’s note? 
A 
This is my note made of the telephone conversation.
Q 
Your note says: 
 
“He said the SC File must have been Dr Southall’s own file regarding his research 
undertaking and that he must have taken it with him to North Staffs.” 
B
Just pausing there a moment, we see the reference to the words “SC”;  when did you first 
learn that there were some words “SC” in relation to a file that may be held on your child? 
A 
I think it was in the late 90s I became aware that SC files existed.  I did not at that 
time think that we would have an SC file, and I did not know about the files really, and it was 
not until about 2000, when we were originally bringing the complaint to the GMC, which 
started in 1999 the process started, that I decided to see if we could get the SC file.  We found 
C
out that we had a number.  Sorry, yes, I found out in the GP’s records that there was a 
reference to an SC file in there and I found the SC file number was 2026, and on the back of 
that I started searching for the SC file. 
Q 
Did you mention that number to Mr Chapman of the Royal Brompton in May 2000? 
A 
I think it probably did, yes.  Certainly the SC file, I am not sure about the number. 
D
Q 
Then did you in July get a copy of what medical records held at the Brompton were, 
still in July 2000? 
A 
Yes, I did.  Not the complete set that had been there in 95, but I did get what was left. 
Q 
Can you just look at page 8, please, for a moment, and is that a letter to you from  
Mr Chapman, saying: 
E
 
“Further to our brief conversation [in] July ….. I enclose a copy of the content of 
[Child H’s] medical records at Royal Brompton ….. and trust you will find them in 
order.  As you will see from the top left corner, [Child H’s] records have a reference 
WinDIP 2.1.  This is the software reference for our optical disk scanner to which his 
medical records have been transferred.  The page numbers are not in numerical order. 
They have instead been put into the order that the Hospital follows in storing medical 
records of patients.” 
F
That material that you got in 2000, was it as ample as the material you had got earlier when 
you had involved Messrs Hutton’s? 
A 
I do not think right at this point I had got the content of what Hutton’s had.
Mr Chapman had told me that the records were not complete, but, as I say the file had been 
sent totally to Hutton’s, so we sort of slightly crossed over here really because I do not think 
when I got this letter I had actually got the Hutton’s stuff. 
G
Q 
Did this material, that you were provided in July 2000, did it include the SC file? 
A 
No, no, there was no mention of it. 
Q 
Did you also ask your solicitors for copies of what they had obtained in 1995? 
A 
Yes, I did.  As I say, Mr John Chapman told me where to go, that we were entitled, so 
I contacted Tim Musgrave at Hutton’s solicitors and asked him for a copy of the records that 
H
they had had then, and he sent them to me. 
T.A.  REED 
Day 6 -  26
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A
Q 
Go to pages 9 and 10, we have now reached August 2000, and was this a letter from 
Tim Musgrave, who you have just mentioned, to you, enclosing, as we see in the fourth 
paragraph:
 
“You may recall that I applied to the Court for an Order requiring the Royal 
Brompton ….. NHS Trust ….. to disclose relevant documentation to us for the 
B
purposes of the case.  I received 3 bundles of documents from the Trust including 
documents which related to Professor Southalls research.  I enclose those [three] 
bundles with this letter. Please note that I have not kept copies.” 
Were you in the next paragraph given a health warning as to the use you could put to those 
documents? 
A 
I was told I could get seven years’ imprisonment if I showed them to anyone. 
C
Q 
Pausing there for the moment, did those documents that you got from Mr Musgrave 
include the SC file? 
A No. 
Q 
So that is in August 2000.  In 2001 did you write to North Staffs, making observations 
about Professor Southall and also ask for the whereabouts of the SC file?  Let me take you to 
D
the next letter, which is at page 11. 
A 
Yes, I did write to Ms Smith, yes.  I had found out that Dr Southall held information 
on us at North Staffordshire Hospital.  Are we going to move on to that, Mr Tyson? 
Q 
Yes, we are. 
A Okay. 
E
Q 
Did you write to a lady called Ms Smith at the North Staffordshire Hospital on
March 1, 2001? 
A Yes. 
Q 
This is a letter which has got “11” at the bottom. 
A 
I have jumped ahead, have I not? 
F
Q 
Does it start: 
 
“Further to our telephone conversation this afternoon, we are writing to you in order 
to express our concerns about the conduct of Dr ….. Southall.  The history of our case 
is long and complex, but it is known to all those who will be receiving a copy of this 
letter.
G
 
As you know from your records we approached North Staffordshire hospital some 
while ago after being told by the Brompton ... that a separate file referred to in our 
sons medical records at the Brompton … was probably a file in relation to
Dr Southall’s … undertaking in relation to [our son] while he was working at the 
Brompton ... and that this file had disappeared, and the suggestion was made that  
Dr Southall had taken it with him to North Staffs.  Our question to your hospital was 
looked into and eventually we were told that North Staffs Hospital held no records in 
H
relation to [our son].  While we were prepared to accept that the hospital had no 
T.A.  REED 
Day 6 -  27
 & CO. 

---

A
record of [Child H], we still believed that Dr Southall was holding the SC File/other 
documents somewhere.  However we had no real evidence in relation to this matter 
and therefore we had to let it rest.” 
In March of 1991, letter 13, did you get a letter from a Mrs Sidoli, dated 25 March 2001, to 
you, saying: 
B
 
“With reference to your letter ... I confirm that following an extensive search the 
special case file number 2026 has been found. 
 
We are able to provide you with it as it related to the Trust and it’s employees and 
therefore enclose the relevant documents.  Legally, we cannot disclose information 
which emanates from any other agency and you should contact them separately.” 
C
What did you feel when you got that letter, Mrs H? 
A 
The reason I had written the original letter to Mr Smith was because we had got sight 
of the hospital records.  I should say we now lived in South Wales, so we are not doctor 
shopping; it was a local hospital.  We caught sight of those records, we were shown them and 
there were three letters in there relating to Dr Southall.  There was a letter from -- 
Q 
I am sorry, I need to start again.  On 26 March 2001, you having first asked through 
D
your solicitors for the medical records relating to this child in 1991 – so 10 years later – you
get a letter saying the SC file 2026 has been found.  I was asking you to tell the Panel what 
you felt when you discovered that a file had been found and that it had been found at North 
Staffordshire Hospital where your child was never a patient? 
A 
I already knew that they had information at the Academic Department in Staffs 
because I found reference to it in the Singleton Hospital records, so it was not a surprise to 
actually be told it was there.  It was just that it had taken so long to get it, so much hard work, 
E
so many letters and so many phone calls and it had not been forthcoming.  We had been 
obstructed every which way in our search for it, and to actually get a letter saying, “We have 
got a little bit of it”, was better than nothing. 
Q 
Did it contain very much in it, that which you had been given? 
A No. 
F
Q 
Did it appear to have things missing from it? 
A 
Yes.  We were hoping that when we got the SC file, we would also get the Great 
Ormond Street medical records that had disappeared in 1990.  They did not appear with this 
file.  However to my surprise – I cannot find the words for it really – there was a poem there 
that had been written by me for my husband and children in 1992 and Dr Southall had a copy 
of that poem in his SC file.  I think you will probably find a copy in the SC file you have got. 
G
Q 
I need not take you to it but I need now to move on in the correspondence slightly.  
Can I ask you to look at the letter at page 14 at the bottom of the bundle.  Did you write to  
Ms Smith? 
A I 
did. 
Q 
Following receipt of the documents from the file did you say to her on 31 March 
2001:
H
T.A.  REED 
Day 6 -  28
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A
“Re SC2026, 
Dear Ms Smith, it appears that documents have been removed from this file by 
Dr Southall or withheld by yourselves or another third party…You told me during our 
recent telephone conversation that you have withheld documents in relation to Social 
Services that were contained in the file for legal reasons.  We appreciate the fact that 
as you state in your letter, we can apply to the agency to get these, but it would have 
B
been very useful if you had told us where the agency is located – i.e. Kensington and 
Chelsea SS.  We would appreciate it if you could let us have the information referred 
to in the previous paragraph ASAP.  It would also be helpful if you could let us have a 
list of the documents that we should request, i.e. letter from Dr Southall to …dated…  
We trust that you will not come back to us to say that the documents that we feel 
should be in File SC2026 are not on your premises as you did when we originally 
requested you look for the SC file on the 23 March 2000. 
C
We have spent the last 12 years trying to get to the bottom of this with the support of 
our family and friends, but never in all those years has our search for truth and justice 
for our son had any support from professionals who were in a position to help us”. 
Then you make various comments about the difficulties that you have had in getting the 
information.  You conclude, 
D
“There are two more concerns that we would also like to express:  We find the 
contents of File SC2026 to be rather strange and in our view it could be seen as some 
kind of Trophy/memento, especially as Dr Southall took this file with him from the 
Brompton to the North Staffs.  The Brompton Hospital admit that they have no record 
of this file and could only suggest that it was a file in relation to Dr Southall’s 
research undertakings in relation to Child H while he was working there”. 
E
Is that the letter that you wrote on 31 March 2001? 
A 
Yes, it is. 
Q 
Did you get a reply to this letter from Ms Smith on 3April 2000, saying: 
“I write to regard to your request on 29.03.01 to review the file 2026 to determine 
F
which correspondence refers to a particular Social Services department.  
Unfortunately I am unable to do this and I have been advised to ask you to contact 
each Social Services department that you have had contact with to request any 
information specifically related to your family”. 
A 
Yes, but it is difficult to make a request when you do not know where you are 
looking.  I did contact Kensington & Chelsea and got a letter back saying we had already got 
G
them. 
Q 
Do not worry about your contact with Kensington & Chelsea.  Did you then get a 
letter in December 2001 from the new Chief Executive, Mr Eames, at the North Staffs 
Hospital effectively stating that he considered you to be happy with the action that you had 
had which related to the North Staffordshire Trust, and that he considered the matter closed.  
Did you consider the matter closed? 
H
T.A.  REED 
Day 6 -  29
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A
A 
Far from it, but due to personal reasons in 2001 I had got off the band wagon, if you 
like, for a while.  I was expecting another child so I was letting this lie.  Unfortunately I lost 
the baby and so there had been a lull in the storm, if you like, so far as me going to them, so  
I guess that was why he thought I had gone away.  I had not actually been sent the 
documents; I had been told to go looking from them and I had not been given any more of the 
SC file.  I guess because I had gone quiet, as I say, he thought that was enough.  He 
considered the matter closed; I most certainly did not.  My search for the SC file was not 
B
over.
Q 
You had some material that you had been given by North Staffs but not all of it. 
A 
No,  nothing like all of it, no. 
Q 
Did you pick up the cudgel again and speak to Mr Chapman of the Brompton in April 
2002, and did you contact him to tell him anything? 
C
A 
Yes.  We had come to terms with the loss of our baby at that time and I contacted him 
again.  As Mr Tyson says, I took up the cudgel again and I informed Mr Chapman that they 
had found the file at North Staffs. 
Q 
Did he confirm anything to you about what the words “SC” stood for? 
A 
Yes.  I asked him about the description we had been given, which was that it was a 
social care file.  He said that that was not the case.  The SC file number did not exist on any 
D
medical records or social services records generated at the Brompton Hospital.  They only 
related to documents from Dr Southall’s department that had been generated there so he 
believed that it was a research file that he had taken with him. 
Q 
After that telephone conversation with him did you write to him the letter at page 18 
in the bundle, the next page, I think, on 19 April and did you say this, 
E
“Dear Mr Chapman, thank you for speaking to me on the telephone this morning.  
You know of course that the questions raised were in relation to the SC file that was 
referred to in Child H’s medical records at the Brompton Hospital. 
You once again clearly stated that this was a file that was held by Dr Southall in the 
academic department and that it was a file containing Dr Southall’s research work 
undertaken in relation to Child H.  You told me that the entire academic department 
F
was relocated to North Staffs when Dr Southall moved there and that is why the file 
cannot be located at the Brompton Hospital. 
You were able to clarify that the SC File was not a social care file, my understanding 
of this is that any file of that nature would be held by Social Services. 
I was able to tell you that the SC file was in fact located in the academic department at 
G
North Staffs hospital last year following an ‘extensive search’. 
We were able to show that Dr Southall did hold a file on Child H at North Staffs” 
A Yes. 
Q 
Did he reply to that letter, which we see at page 19, Mrs H? 
H
A 
Yes, he did. 
T.A.  REED 
Day 6 -  30
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A
Q 
Does that come from Mr Chapman, 
“Thank you for your letter of 19 April 2002 which followed our conversation as a 
result of which you asked me to clarify a reference on certain papers in Child H’s 
medical records containing the reference ‘SC2026’, when his hospital number is 
C47636.  I wrote in my letter of 16 May that I did not know what SC2026 referred 
B
to”.
The 16 May there referred to in this April letter, was that an earlier year than 2002? 
A 
Yes, I presume it was. 
MR TYSON:  I do not know whether my learned friend is able to make any admission in this 
regard.  I can prove from another document what the year is. 
C
MR COONAN:  If you show me I will consider it.  (Document handed)
A 
It might have been the year before. 
MR COONAN:  It is 16 May 2000. 
MR TYSON:  Madam, we will come to this letter in due course when we hear from Mr 
D
Chapman.  Can I ask you to insert, as a result of my learned friend’s agreement as ever on 
technical matters, 
 
“I wrote in my letter of 16 May 2000”, 
instead of 2002, that he did not know what SC2026 referred to.  The letter to you goes on, 
Mrs H, 
E
“As far as I have been able to establish in the past two years, the SC2026 reference 
appears to have been applied by the Department of Paediatrics (Clinical Physiology) 
of which Dr David Southall was head until July 1992.  It appears only on reports by 
this department.  I can see no other use of the reference in any other documents in 
Child H’s medical records.  It does not feature in any of the social Services documents 
so I am certain it does not refer to ‘social care’. 
F
Dr Southall was head of a unit within the Department of Paediatrics in the National 
Heart and Lung Institute (NHLI) (see his letter of 27 June 1991 in Child H’s medical 
records).  The entire unit headed by Dr Southall relocated to North Staffordshire 
Hospital at Stoke-on-Trent when Dr Southall left in July 1992 to become Professor of 
Paediatrics.  The NHLI Academic Department undertakes medical education and 
research into heart and lung disease in infants and children.  My enquiries in the 
G
Academic Department of Paediatrics for further records of Child H’s treatment and 
care revealed nothing.  I concluded that Dr Southall could have taken further records 
to North Staffordshire Hospital.  Your letter informs me that your inquiries to North 
Staffordshire Hospital found that Professor Southall held a file about Child H there.
I trust this letter is helpful.  I have, with your permission, sent a copy of it to Mary 
Timms, solicitor at Field Fisher Waterhouse”. 
H
T.A.  REED 
Day 6 -  31
 & CO. 

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A
A Yes. 
Q 
Moving on from there, Mrs H, did you make further attempts with North Staffs to try 
and get the balance of the SC file? 
A 
I did, yes.  I decided to go on another fishing trip to see in fact if the Great Ormond 
Street records, the original records, would come out, so I went back to them and I was 
contacted then by Kath Sidoli, North Staffs, to say they held no records on my son at all. 
B
Q 
I think you said that North Staffs held no documents on your son at all.  Is that what 
she told you? 
A Yes. 
MR COONAN:  I cannot see what the witness is reading.  I do not know whether it is a 
document of her own that she is reading from. 
C
MR TYSON:  Do you just have in front of you the file that we have been going through? 
A Yes. 
MR COONAN:  The witness came into the witness box initially with a sheaf of documents. 
A 
I put those documents on the floor. 
D
MR TYSON:  Were you told by this lady that North Staffs held nothing? 
A 
Yes.  I contacted Kath Sidoli and she told me that they held no records on my son at 
all at the North Staffordshire Hospital, and no SC file.  I contacted her and said that they 
certainly had had a record, and she said she did not know where it was, she would try to find 
it.
Q 
Did you then write again to North Staffs, the letter at page 20, in June?  Ms Sidoli is 
E
the lady in the North Staffs Hospital, is that right? 
A 
She is the lady who sent me the documents the year before and had obviously 
forgotten that she had when I spoke to her. 
Q You 
say, 
“You will remember telephoning me on the 24th May, the conversation we had was 
F
‘interesting’. 
During that conversation it was agreed that you would write to me iin the next two 
weeks telling me where the file SC2026 had now been sent, you were not able to give 
me that information at the time of our conversation, as the purpose of your telephone 
call was to tell me that you held nothing in relation to [Child H] at North Staffs.  Of 
course I was able to remind you of a letter that you sent to me last year that told me 
G
that you did hold a file in relation to [Child H].” 
Just going back a moment, can we look at page 13?  Is that the letter that you got from this 
lady a year earlier, saying that she had found it? 
A 
That is the one, yes. 
Q 
You were able to remind her that she had sent you this letter a year earlier, saying that 
H
she had it? 
T.A.  REED 
Day 6 -  32
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---

A
A Yes. 
Q 
Picking up the letter at page 20 at the bottom of the second big paragraph: 
“Of course I was able to remind you of a letter that you sent to me last year that told 
me that you did hold a file in relation to [Child H]. 
B
It was in fact because we had requested that you send us a copy of that file that you 
were ringing me. 
When I reminded you about your previous letter, and we had cleared up a few other 
equally feeble excuses you told me that the file had been sent ‘somewhere’ earlier that 
week, but was unable to tell me where or to whom it had been sent.  I would like to 
point out that we had requested a copy of that file some weeks earlier, so you had in 
C
fact sent it ‘away’ after we and the GMC solicitors had requested it. 
We look forward to hearing from you in writing in the very near future.” 
Did you get a reply back from Ms Sidoli which we see at page 21, dated 13 June 2002, 
saying:
D
“I am writing following our telephone conversation recently when you requested 
information held by the Trust on yourself and your family, in particular the file 
number 2026.  As I explained at the time the Child Health Enquiry has been 
concluded.
Information belonging to the Brompton Hospital and Professor Southall has since 
been returned to them and is therefore no longer held by the Trust.  Shortly after your 
E
enquiry I received a letter from Field Fisher Waterhouse, who appear to be acting on 
behalf of the General Medical Council and yourself and your husband, also requesting 
the file number 2026.  Therefore to avoid any duplication I have asked the General 
Medical Council to communicate directly with Professor Southall’s solicitor’s on your 
behalf.”
Pausing there, Mrs H, it says: 
F
“Information belonging to the Brompton Hospital … has been returned to them.” 
Did you contact the Brompton Hospital after receipt of this letter and ask if any material had 
been returned to them? 
A 
I spoke to Mr John Chapman.  I have always found him very helpful, very honest, and 
I asked him if he had had anything from North Staffs because I had been told that they had 
G
sent stuff belonging to them back and they had received nothing. 
Q 
To this day, Mrs H , do you consider that you have received a full copy of the SC file 
even though you have received more than you have received before? 
A 
No, I am sure I have not.  Dr Southall did seek recordings on our son.  They have not 
been found.  Well, they have not been given to me.  I think, Ms Ellson saw tapes, but no, we 
have not had the complete file.  I do not think we will ever get a complete file. 
H
T.A.  REED 
Day 6 -  33
 & CO. 

---

A
Q 
There is one other matter.  I just want to ask you something completely different,  
Mrs H, and that is about the state of health of Mr H.  Is he able to come to give evidence? 
A No. 
Q 
What is wrong with him? 
A 
My husband had an emergency quadruple heart bypass in 1998.  Three of the 
bypasses have failed.  He has chronic angina and the stress of coming here would be too 
B
much, and the stress of the video link would have been too much for him as well.  He could 
not have handled it.  He tells me with angina pain you cannot concentrate on anything else 
and so his doctor considered it, as he did, too stressful.  I am not going to lose my husband to 
something like this.  He is the father of my four children and his health is more important. 
MR TYSON:  Thank you very much. 
C
Cross-examined by MR COONAN
Q 
Mrs H, is your husband here today? 
A No. 
Q 
Not in the public gallery? 
A 
My husband is not well enough to be here. 
D
Q 
He has not travelled up with you? 
A 
No, I had to come on my own. 
Q 
How long has he had this condition? 
A The 
---? 
E
Q 
The condition you have just described? 
A 
I am trying to think actually.  He originally started having chest pain in 1997, and out 
of the blue.  He was a keen mountain cyclist, etc.  It was decided he should have an 
angiogram, which they followed the blood through the blood vessels and it was discovered he 
needed a quadruple heart bypass. 
Q 
When did he have that? 
F
A 
He was waiting for that and he had it in the end on May 1 1998. 
Q 
How has his condition been after the bypass? 
A 
He has continued to have problems, and as I say, now they have discovered that three 
of the heart bypasses have failed. 
Q 
When did they discover that? 
G
A Last 
year. 
Q 
Last year.  So we are absolutely right about the date, 2005? 
A 
Yes, I am pretty sure he went to see his cardiologist last year. 
Q 
Does he work? 
A 
Yes, he works in the hospital in Morriston, Swansea. 
H
T.A.  REED 
Day 6 -  34
 & CO. 

---

A
Q Doing 
what? 
A 
He is a medical technical officer, dental technician. 
Q 
A five-day week? 
A Yes. 
Q 
What is the feeling as to the reason why he cannot come to give evidence? 
B
A 
Because the stress would be too great for him and he has had a doctor’s letter stating 
that.
Q 
You were asked for your opinion.  Leave aside doctor’s letters. 
A 
I am not a doctor.  I cannot have an opinion on that.  It is between my husband and his 
doctor.  It is nothing to do with me. 
C
Q 
Mrs H, you were asked by Mr Tyson a number of questions about your husband’s 
health and I am now exploring them with you.  Do you follow? 
A 
My husband’s health?   
Q 
You were, just a few minutes ago. 
A 
Right, sorry.  Yes. 
D
Q Yes? 
A Yes. 
Q 
That is what you and I have just been talking about? 
A Yes. 
Q 
So what is it about his condition that prevents him from, first of all, travelling to 
E
London? 
A 
It is not the travelling to London, it is the stress of coming here and he has not seen 
Dr Southall since the meeting in 1991.  It would just be too stressful. 
Q 
Is the stress do you think associated with answering questions which are put to him? 
A 
You would have to ask him.   
F
Q 
You have told us that it is about stress. 
A 
My husband just says if he came he would have an angina attack because of the stress.  
I can only say what my husband has told me.  It is his judgement call, him and his doctor.  He 
has angina and I cannot answer questions about his health really.  All I know is that he does 
not cope, he has angina attacks and he does not feel he could come and give evidence. 
Q 
You mean he does not feel as though he can answer questions about your son’s 
G
treatment? 
A 
It would be too stressful for him to come and give evidence at a GMC hearing.  It is 
very stressful.  At a GMC hearing, yes. 
Q 
Because your husband is not afraid or reluctant to answer questions in interviews 
carried out with journalists, is he? 
A 
He has given interviews, yes.  It is totally different circumstances, but yes, he has 
H
given interviews. 
T.A.  REED 
Day 6 -  35
 & CO. 

---

A
Q 
You see, on October 9 this year, about four weeks before this case opened, you and 
your husband appeared in a television programme in Wales, did you not? 
A 
Yes, we did.  It had been taped a little while before. 
Q 
Maybe a little while before, but certainly in 2006.  Is that right? 
A Yes. 
B
Q 
Your husband was interviewed by the journalist in that programme, was he not? 
A Yes. 
Q 
He was interviewed on his own, on screen? 
A 
Yes, on his own on the screen.  We were there obviously. 
C
Q 
You were filmed and interviewed with your husband, walking along with your son 
and yourself which, I can only take to be near Swansea, along the beach? 
A 
Yes.  It was not along the beach, but yes, it was near the beach. 
Q 
Along the strand path alongside the beach? 
A Yes. 
D
Q 
Your husband gave every indication on that programme of being willing to answer 
questions put to him by a journalist, was he not? 
A Yes. 
Q 
But he will not come here to answer questions put on behalf of the Panel? 
A 
He says it would be too stressful. 
E
Q 
Mrs H, can we just go back, please, to the first letter in time, which is, for my 
purposes, relevant, and C1, tab 2A.  This is the letter of 7 March from Dr Dinwiddie to 
Dr Southall.  Before we look at the content of that letter can I just ask you a preliminary 
matter and I am using that as a reference point.  Prior to March 1989 had Dr Weaver provided 
any treatment or care to your child? 
A 
1990 – sorry, I missed the … 
F
Q 
Prior to March 1989? 
A 
As I said, we had seen Dr Weaver once. 
Q 
So, as of the date of this letter Dr Weaver – she is a she – was no longer involved 
actively in your son’s care? 
A No. 
G
MR SIMANOWITZ:  I am afraid I have not got that letter.  The only letter in A is dated 23 
January 1998. 
MR COONAN:  This is C1, tab 2 A.  Mrs H, can we just pause a moment?  It is 7 March 
1989.  (After a pause)  Just to recap, I hope accurately, by the time of this letter Dr Weaver 
was taking no active part in the care or treatment of your child? 
A 
I do not think she was.  We saw her once, as I say.  I cannot remember exactly when it 
H
was, but certainly by 1990, when we saw Dr Southall, she was not. 
T.A.  REED 
Day 6 -  36
 & CO. 

---

A
Q 
In other words, to make it clear, Dr Weaver had not taken part in any care or 
treatment of your son between March 1989 and March 1990 
A 
As I say, I am not sure of the date that we actually did see her, but we only saw her 
once.
Q 
When you did see her, did she suggest a nebuhaler should be used? 
B
A 
She suggested that we use an inhaler for our son, which is when you breathe in 
through the mouth.  Dr Dinwiddie described a nebuliser, which you breathe through the 
trachea.  We could not understand how our son could use an inhaler, used to breathe through 
the mouth, when in actual fact he breathes through a tracheostomy.  So the nebuliser seemed 
to be the most logical thing, the thing that Dr Dinwiddie, who was his clinician of record, as
I say, had prescribed. 
C
Q 
It is a short question. When Dr Weaver suggested, as I suggest she did, using a 
nebuhaler, that you in effect rejected that advice? 
A 
Dr Dinwiddie was his --- 
Q 
Is it “yes” or “no”, and then we will move on to the specifics. 
A 
He already had a nebuliser that Dr Dinwiddie prescribed for him, so an inhaler is just 
another form of that.  So he was already having a nebuliser via Dr Dinwiddie. 
D
Q 
You are saying there was no need for the advice that she gave; it was superfluous? 
A 
You would not use both.  Yes, I guess we were saying “no.”  Yes, we were following 
Dr Dinwiddie’s treatment plan. 
Q 
So you rejected Dr Weaver’s suggestion? 
A Yes. 
E
Q 
Now let us turn to look at this letter of 7 March 1989.  There are a couple of features 
of this I want to ask you about.  During the course of the evidence this morning you told the 
Panel that you saw this letter, not at the time of writing it, but at some stage.  First of all, can  
I ask you, please, when did you first see this letter? 
A 
I think it was probably on the first admission in 1999 to the Brompton Hospital. 
F
Q 
The circumstances in which you saw that letter were what? 
A 
We were taking our son for, I do not know, maybe an ECG or something, I cannot 
remember, and I was just given his records to carry down to the department.  They were just 
handed to me, so I had a look at them and I saw this letter. 
Q 
That was round about the first admission in September 1989? 
A Yes. 
G
Q 
When you saw the letter you would have noted perhaps, if you read it carefully, the 
last paragraph: 
“I would be very interested if you could see him and arrange the necessary further 
investigations and advise in any other treatment that you think might be helpful in this 
particular situation.” 
H
T.A.  REED 
Day 6 -  37
 & CO. 

---

A
A 
Yes. I say I saw the letter.  Really what jumped out at me was the third paragraph.   
I do not think I read the rest. 
Q 
You did not read particularly the last paragraph? 
A 
No, that third paragraph is what jumped out at me. 
Q 
When you saw the third paragraph and you saw what appears to be Dr Dinwiddie’s 
B
handwriting on the question of Munchausen’s, can I ask you, did you subsequently ask 
Dr Dinwiddie what on earth he meant by that? 
A 
No, I asked Dr Martin Samuels when we went back to the ward.  He said that if they 
had ever thought it, it certainly was not the case now, and not to tell his boss that we had seen 
the letter. 
Q 
That was in September 1989, was it? 
C
A 
Yes, it was the first admission. 
Q 
But you never asked Dr Dinwiddie what he, Dr Dinwiddie, meant by that? 
A 
I cannot remember, to be honest.  I probably did, but I cannot remember. 
Q 
I am going to move really to the central part of this, which is the admission in March 
1990, and for these purposes please will you look at the next volume, which is bundle C2 at 
D
tab (i)?  You told us that you did not see Dr Southall during this admission, and I am not in a 
position to dispute that, but I do want to ask you, please, about what you remember in 
particular Dr Samuels saying to you, right? 
A Yes. 
Q 
First of all, it is fair, is it not, that these events occurred in March 1990? 
A Yes. 
E
Q 
It is over sixteen years ago, yes? 
A Yes. 
Q 
This letter, which of course you did not see at the time but you saw subsequently, sets 
out what in this case Dr Southall is saying was their – that is using the plural, is it not, “our 
suggestion”, and so forth, it is the sort of royal “we”, as it were, do you see? 
F
A Yes. 
Q 
Let us just look together, please, at a number of these factors.  You, I think, have 
agreed, and I am looking at the last paragraph on the first page, you had agreed that
Dr Samuels did suggest that you use a transcutaneous PO2 monitor, so that is correct? 
A Yes. 
G
Q 
Did he say to you that they would therefore, in using it, be able to get used to his 
baseline values? 
A 
No.  What he said to us was simply they wanted to close his trachy, give him 
experimental drugs for his asthma, give him oxygen therapy.  It was not really explained out 
like it is here in this letter.  I do not know what baseline values – I mean, baseline values do 
not mean much to me, I do not know quite what that would mean. 
H
T.A.  REED 
Day 6 -  38
 & CO. 

---

A
Q 
Did you not ask Dr Samuels any questions about these matters that he was putting to 
you? 
A 
I think we just said that it was not what Dr Dinwiddie had suggested, and we wanted 
to ask Dr Dinwiddie, but really we wanted to see Dr Southall for him to explain, and, as I say, 
he did not come and see us. 
Q 
That may be, but did you not ask Dr Samuels any questions about this treatment plan 
B
that was being put to you? 
A 
It was totally different to the one that Great Ormond Street was saying, so, I mean, we 
were totally confused. 
Q 
All the more reason, you see, to ask questions, and I am just probing as to whether 
you did. 
A 
We were going to ask Dr Southall, he was not available, and obviously we are going 
C
to consult the clinician of record, which is Dr Dinwiddie, and, you know, if he thought it was 
right, he could have explained it to us.  We had two opposing views – well, not opposing 
views, but different treatment plans, and, I mean, we knew Great Ormond Street, we knew  
Dr Dinwiddie, we had had five years worth of dealing with him, and he could have explained 
it if he had agreed with the treatment plan. 
Q 
You see, quite apart from the elements in that paragraph, and then the other elements 
D
over the page, do you accept that Dr Samuels mentioned that H’s neurological state ought to 
be further investigated? 
A No. 
Q 
He did not say that? 
A 
That was not mentioned. 
E
Q 
It was suggested that your child’s overall care should be managed by a local 
paediatrician. 
A 
No.  As I say, it did not happen. 
Q 
You see, I suggest that this is a long time ago, and I want to suggest to you it is 
precisely because of that that your memory is at fault. 
A 
My memory is not at fault.  He did not mention it.  I think I can remember quite a lot 
F
of this even though it did happen sixteen years ago. 
Q 
So the subject matter of care by a local paediatrician was never even mentioned? 
A 
With Martin Samuels? 
Q Yes. 
A No. 
G
Q 
Well, I am going to have to suggest to you, you see, that it was, and that the whole of 
those elements that we see in that bottom paragraph and the top paragraph on the second page 
were put to you, and that you and your husband agreed at that stage to the constituent 
elements. 
A 
Which were that we would see a local paediatrician, is that what you are saying? 
H
Q 
Well, the idea of it, and you accepted at that stage. 
T.A.  REED 
Day 6 -  39
 & CO. 

---

A
A 
We accepted, as I say, the use of the monitor.  All really that came up in that was the 
treatment plan and the difference between their treatment plan and the treatment plan of Great 
Ormond Street, you know.  I do not think we really went anywhere else with it. 
Q 
Following the proposal, and I suggest the agreement, you were trained by Sister 
Noyce in the use of the monitor, were you not, before H was discharged? 
A Yes. 
B
Q 
You went home, tried out the monitor, and you had a telephone conversation with
Dr Dinwiddie. 
A 
Yes.  I think we went home, we tried the monitor the first night, and obviously the 
next day I was going to consult Dr Dinwiddie, so that is exactly what I did. 
Q 
Absolutely.  I just want to understand really the thrust of your evidence here.  Are you 
C
saying that in effect when you phoned Dr Dinwiddie he told you not to follow the Brompton 
plan? 
A 
Dr Dinwiddie told us it was not what he had expected, and to continue with his 
treatment plan, and to return Dr Southall’s monitor to him, yes. 
Q 
Again, I am sorry to press you, and allowing for the fact it is sixteen years ago, are 
you saying that Dr Dinwiddie was giving you the impression that you should stop the 
D
Brompton plan? 
A 
Dr Dinwiddie told us to continue with his treatment plan, which was different to the 
Brompton Hospital treatment plan, so I guess you can interpret it in that way.  I mean,  
Dr Dinwiddie was my son’s doctor, we were going to follow his treatment plan. 
Q 
It is not my interpretation that is important.  What is important is your interpretation. 
A 
We were following the treatment plan of Great Ormond Street, yes. 
E
Q 
I know that you did, but it is important that I explore this.  Are you saying to this 
Panel that at the time your strong impression was at the very least that Dr Dinwiddie was 
saying, “Do not follow the Brompton plan”? 
A 
Dr Dinwiddie told us to follow his treatment plan. 
Q Right. 
F
THE CHAIRMAN:   Mr Coonan, I would be looking for some convenient point to break for 
lunch.  Mrs H has been on the witness stand--- 
MR COONAN:   Now would be as good a time as any, madam. 
THE CHAIRMAN:   In that case we will take a lunch break until two o'clock now.  I need to 
G
remind you again, Mrs H, not to discuss your evidence in the case with anyone, and I take 
this opportunity also, if there are any members of the press here, to remind them that the 
family in this case is being anonymised and should not be reported.  So we will be back at 
two.
(Luncheon adjournment)
H
T.A.  REED 
Day 6 -  40
 & CO. 

---

A
MR COONAN:   Mrs H, I am not going to detain you very long. I was asking you some 
questions arising out of the letter of 27 March 1990.  Just with that as a backdrop, could I just 
make it clear to you, so the Panel understand as well, that I am not suggesting to you that you 
were asked for or gave consent to this particular letter being sent, do you understand?  Nor 
am I suggesting to you that you were asked for or gave consent to any letter being sent.
I have dealt with all I need to in relation to that letter, and I want to move on just very briefly 
to the telephone call you had now with Dr Southall a few days later.  We have dealt with the 
B
phone call you had with Dr Dinwiddie, and we are now in the phone call with Dr Southall.
You told the Panel earlier this morning, shortly before lunch, that you had seen, although 
perhaps not taken in, the final paragraph of Dr Dinwiddie’s referral letter. 
A Yes. 
Q 
Have a look at it again if you wish.  It is in the previous volume, C1 1(a).  You have 
told us it was during the admission in September that you managed to have a look at this 
C
because it was in the clinical notes which were accompanying your son elsewhere at the 
hospital.  Again, I am not suggesting otherwise, but you may not have taken in the final 
paragraph, as you said, and did that remain the position by the time that he was admitted in 
March 1990;  in other words, you had not fully appreciated that Professor Southall was being 
asked to advise about treatment? 
A 
No, we did not appreciate that at all. 
D
Q 
When you spoke to Dr Southall, can you just remember exactly what it was that you 
said to him? 
A 
As I say, I thanked him very much for his time, I appreciated it, and I said I had 
sought Dr Dinwiddie’s advice and he had told us to follow his treatment plan and to return 
the monitor to Professor Southall – Dr Southall, sorry. 
Q 
You told Dr Southall that.  Again, I cannot put to you the exact words because it is so 
E
long ago, sixteen years ago, but did you have a short conversation? 
A 
With Dr Southall? 
Q Yes. 
A 
Yes, very brief. 
Q 
At the end of that brief conversation, then the phone was put down? 
F
A Yes. 
 
Q 
Simple as that. 
A 
Well, I would have said it was slammed down, but certainly it--- 
Q 
It is terribly subjective, is it not, slamming the phone down or--- 
A 
Well, he said, “Send my monitor back then”, and the phone went down.  There was no 
G
“Goodbye” or “Thank you for your call”, or anything like that. 
Q 
Of course, you do not know what he was doing at the other end. 
A 
No, I do not, that is true. 
Q 
Also, can I just suggest this to you, and these are firm instructions, that Dr Southall 
left it with you that you were to come back if you changed your mind. 
H
A 
No.  He said, “Send it back to me then”, and put the phone down. 
T.A.  REED 
Day 6 -  41
 & CO. 

---

A
Q 
Because if you go back--- 
A 
I know that is what he says in his letter of the 24th.
Q 
In the letter, you see, that is exactly what it says. 
A 
No, that was not – I mean, I could see when we left the Brompton Hospital to go and 
discuss with Dr Dinwiddie, I would presume then if Dr Dinwiddie had said, “Yes, go back to 
B
Dr Southall”, then I presume it would follow that he was there, ready and willing to 
implement his plan, but that is not how it went.  We rang Dr Dinwiddie, but there was no 
mention of that particular paragraph to me.  I suppose we just assumed that the one would 
follow the other really. 
Q 
Mrs H, I do not want to, as it were, make a big thing of this, but the fact is that, what, 
a matter of three or four days after this phone call--- 
C
A 
It was the same day. 
Q 
You are saying this letter was the same day as the phone call? 
A 
I think it was, yes. 
Q 
What day of the week did you make the phone call? 
A 
Well, he says it is the same day, does he not, in the letter?  He says that – I am pretty 
D
sure he does--- 
Q 
Well, he does.  I am just wondering what your recollection was as opposed to what 
you can reconstruct from the letter, you see.  Do you have a recollection that it was the same 
day, 22 March, that you phoned him? 
A 
Well, I mean, I would not have known at the time that he had written this letter on the 
same day obviously, but I have seen this letter in the past, so the fact that he wrote this letter 
E
the same day as I made the phone call--- 
Q 
At any rate, let us assume it is the same day, the same day as the phone call,  
Dr Southall is writing, and we look at it four lines from the bottom: 
 
“I have left it with the parents that should they change their mind we are here and 
willing to implement the approach outlined above”. 
F
That is the case, is it not?  That is how you left it? 
A 
No.  We left it in the hospital, as I say, it was not with Dr Southall, it was Martin 
Samuels, that we would go home with the monitor, I would contact Dr Dinwiddie and see if 
that was okay, the new treatment plan in essence was okay with him.  As I say, he said to 
follow his treatment plan.  I cannot say anymore than that really.  If Dr Dinwiddie had said to 
go back, we would have gone back. 
G
Q 
Can I just, again leaving the phone call to one side, this phone call sixteen years ago, 
and move about nine years later.  Did you instruct somebody called Penny Mellor to be your 
advocate?
A 
For the Griffith inquiry, do you mean, or--- 
Q 
Well, at any time. 
H
A 
I heard of Penny Mellor.  I thought she was part of the Griffith inquiry, so yes, I did. 
T.A.  REED 
Day 6 -  42
 & CO. 

---

A
Q 
That was the way to answer it, either a “Yes” or a “No”.  So the Griffiths inquiry, 
since you have raised it, was an inquiry in effect set up by the Trust to investigate certain 
aspects of Dr Southall’s clinical management, and we will hear about this later. 
A 
We were not part of that inquiry, but yes. 
Q 
But you instructed her, in about, I suggest – at the latest – 1999. 
B
A 
I think it was around 1999, yes, but “instruct” is the wrong word.  We were in Wales.  
She was in North Staffs.  She was giving evidence.  I did not know who Penny Mellor was at 
that time.  She was giving evidence.  In fact I thought she was part of the Griffith inquiry, so
I gave her stuff, yes. 
Q 
Did you give her documents? 
A 
I think I gave her some to pass on to the Griffith Inquiry. 
C
Q 
Yes, you did. 
A 
Right.  But we were not part of that inquiry, were we? 
Q 
Two wholly separate matters.  They concern documentation.  During the course of 
your evidence this morning you were being asked about a document in C2, which is letter (g).  
Could you turn that up, please?  This morning you said to the Panel that you had not seen this 
D
document before.  I just want to explore that with you and I suggest that you are wrong about 
that.  You must have seen it before because it is part of the main record. 
A What 
main 
records? 
Q 
The documents which were supplied to you, a long time ago, consisted at least of 
documents of which this was one. 
A 
Sorry, documents supplied from where? 
E
Q 
At any stage before today you had seen this before, you must have. 
A 
I may have done but I cannot recall it. 
Q 
I shall comment on this later and I give you an opportunity of answering.  You now 
say you may have done but you cannot recall it.  This morning you were positive you had 
never seen it. 
F
A 
If you are saying I have, then maybe you are right, but I do not remember. 
Q 
Finally, again a matter of documentation.  Before I ask you to look at this document 
can I ask you a couple of preliminary questions to set the scene?  During the 1990s, and in 
particular round about 1994, you were trying to get hold of the Great Ormond Street notes, 
were you not? 
A 
The solicitor did, yes. 
G
Q 
The solicitor acting on your behalf. 
A Yes. 
Q 
Solicitors at that time acting for Great Ormond Street were who? 
A Field 
Fisher 
Waterhouse. 
H
Q 
The same solicitors you have now. 
T.A.  REED 
Day 6 -  43
 & CO. 

---

A
A 
Yes.  Sorry, you said acting for Great Ormond Street. 
Q 
Yes.  Do you remember – if you cannot I will jog your memory by putting a 
document in front of you – at that stage understanding that the Great Ormond Street Hospital 
records were in existence? 
A 
No.  They were missing up to a certain point which was 1990.  After that they did 
have them. 
B
Q After 
when? 
A 
After the period of 1990.  When my son went into hospital in February 1990 for the 
ventilator assessment, they went missing around that time or just after.  They had the notes 
that followed on from that period of time so they had 1991 records. 
Q 
Have you seen those? 
C
A 
A couple of pages. 
Q 
That is all? 
A 
That is all. 
Q 
I am going to ask you to look at this letter, please.  Can it be distributed? (Same 
handed)
D
A 
I say a couple of pages.  I cannot remember.  I certainly have not seen any records 
prior to 1990. 
THE CHAIRMAN:  Would this be D2? 
MR COONAN:  Yes, madam.  Thank you.  Mrs H, you see it is a letter addressed to Mid-
Glamorgan County Council in relation to you as the subject of it.  I am looking at the middle 
E
paragraph,
 
“From speaking to some of the other solicitors involved in this case”. 
Pausing there, was that a reference to potential litigation involving a number of parties being 
brought by you? 
A 
A number of parties? 
F
Q 
A number of potential defendants to legal action being brought by you? 
A 
It was Great Ormond Street Dr Dinwiddie, I think, and Professor Southall from the 
Brompton.  The solicitors were looking for those records yes. 
Q 
So from your standpoint it was with the possibility of bringing legal action against 
Great Ormond Street and Dr Dinwiddie, and the Brompton and Professor Southall. 
G
A 
It was a fishing expedition, yes.  But yes, if you like.  We instructed solicitors. 
Q 
Whatever it was, their names were going to appear as defendants on a writ, to put it 
bluntly.
A Yes. 
Q 
The middle paragraph says, 
H
T.A.  REED 
Day 6 -  44
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---

A
“From speaking to some of the other solicitors involved in this case, it is our intention 
to grant voluntary disclosure of Great Ormond Street Hospital records but to exclude 
documents which have been sent to the Hospital purely for information purposes.  We 
would therefore indicate to Messrs Huttons, solicitors for the H family, that it would 
be necessary for them to contact either yourselves or the Social Services Department 
if they wish to obtain copies of such documents as the case conferences”. 
B
Again, this is all about Great Ormond Street principally. 
A Yes. 
Q 
I want to ask you, as far as you know did you ever get those documents that Field 
Fisher Waterhouse appeared to have possession of? 
A 
Which documents, sorry? 
C
Q 
The ones being referred to here. 
A 
If you are talking about records from Great Ormond Street, we have got a letter in our 
possession which states that Great Ormond Street did not have any records prior to 1990-91.
I guess they got some records, as I say, after March 1990, but nothing before then.  In terms 
of social service department letters, we had those anyway.  We were given those by social 
services.
D
Q 
I just want to be clear about this.  Do you think you have received everything that 
Field Fisher Waterhouse had, or apparently had, in 1994, or do you not know? 
A 
that Field Fisher Waterhouse had?  They are not our solicitors. 
Q 
Acting on behalf of the hospital, do you follow?  You see the letter says, Mrs H,  
“It is our intention to grant voluntary disclosure of Great Ormond Street hospital 
E
records”. 
Do you see that?  They were acting for Great Ormond Street. 
A 
Yes.  Field Fisher Waterhouse were going to get the records, but that is not my 
solicitors so why would I see them? 
Q 
Because they would then be disclosed to Huttons, your solicitors. 
F
A 
Our solicitors at the time did not have any records prior to 1990.  I have it in writing 
that they did not exist.  Whether Field Fisher Waterhouse had them, I do not know. 
Q 
Is the position this, that you do not at the moment know whether such documents as 
Field Fisher Waterhouse had were fully disclosed to Huttons, your solicitors?  You do not 
know? 
A 
We had to sign consent forms – I mean, I am not in control of that, am I?  That is 
G
between solicitors.  If Field Fisher Waterhouse withheld from Huttons, I do not know.  All
I know is that we had a letter which was sent to Huttons, our solicitors, saying – I think that is 
right.  Field Fisher Waterhouse wrote to them saying there were no documents to be found 
prior to 1990 in relation to Great Ormond Street. 
MR COONAN:  Thank you, Mrs H. 
H
T.A.  REED 
Day 6 -  45
 & CO. 

---

A
Re-examined by MR TYSON
MR TYSON:  Presumably you could give that letter to your present solicitors once you get 
home, could you? 
A 
You should have it somewhere, but yes.  I certainly gave it to the General Medical 
Council.  I have certainly given it to the General Medical Council to prove that there were no 
medical records in relation to Great Ormond Street prior to 1990. 
B
Q 
You were asked, and it was suggested to you that you had agreed to a local 
paediatrician from the Royal Gwent Hospital becoming involved in your child’s care.  Did 
you ever agree to that? 
A 
Absolutely not.  The Royal Gwent did not come into the conversation.  If anyone it 
would have been a local paediatrician somewhere else, but it was not discussed. 
C
Q 
You were asked about the Griffith Inquiry.  Were you involved in that in any way, or 
were you not involved in any way because of where your child was treated? 
A 
In March I wrote to David Fillingham in 2000 and I actually referred to the Griffith 
Inquiry and asked him if we were part of it.  That was one of the reasons I wrote.  We found 
that we were not part of it because anything that happened to our son in relation to us took 
place at the Brompton Hospital London so we did not form any part of any inquiry. 
D
Q 
Did you understand that the Griffith Inquiry related to Professor Southall’s dealings 
whilst he was at North Staffordshire? 
A 
We did afterwards.  When I asked David Fillingham, I was later told we were not part 
of that inquiry, categorically told we were not part of that inquiry and that they could not look 
at any of the issues we had raised.  As a supplement to the Griffith Inquiry the MSCHN(?) 
put in a separate report which did include some of our documents, but I have never seen that 
report.  I do not know what it said. 
E
Q 
Did you understand that Miss Mellor was part of the inquiry team? 
A 
That was my understanding at the time, yes. 
MR TYSON:  I have no further questions of this witness.  I do not know whether the Panel 
have questions. 
F
Questioned by THE PANEL
MRS LLOYD:  Good afternoon, Mrs H.  Mrs H, there are just one or two questions I would 
like to ask you for clarification.  I understand it is your evidence that you tried the TCP02 
monitor for one night with your son, and you stated it was not successful. 
A Yes. 
G
Q 
Why did you not try it for longer? 
A 
It alarmed all night long.  We checked our son, obviously and he was perfectly all 
right.  It just was not going to work.  It was designed for a younger baby.  As I say, he was 
four and it just was not suitable really.  As I say, I contacted Dr Dinwiddie and he advised us 
to send the monitor back.  If he had said to me, “Carry on, persevere, try and use it”, I would 
have done.  But he did not give me that indication at all. 
H
T.A.  REED 
Day 6 -  46
 & CO. 

---

A
Q 
Coming on to that conversation that you had with Dr Dinwiddie, you said that he 
suggested that you return it and you then contacted Dr Southall.  In your earlier evidence, 
which you have already been cross-examined on, you said that Dr Southall slammed the 
phone down on you. 
A 
If you are on the end of the phone you are left with an impression, are you not, and 
my impression was that he slammed the phone down on me, yes. 
B
Q 
I am just wondering how you can get an impression if you are not actually in the same 
room. 
A 
It was more that there was an abrupt end to the conversation. He did not say, like
I said “Thank you for your time”, etc., or “Thank you for your phone call”, something like 
that, which is how I would end a conversation; he did not say that. 
Q 
When you were cross-examined by Mr Coonan, you later stated that he put the phone 
C
down.  What I need to establish is whether he put the phone down or whether he slammed it 
down, because you were not in the same room.  How can you state that he slammed the 
phone down? 
A 
The phone went dead very rapidly.  If I was slamming the phone down, that is how
I would slam it down, I suppose.  The line would go very abruptly dead.  There was no, 
“goodbye”.  No, “Thank you for your phone call”. The line just went dead, or back to 
dialling tone. 
D
Q 
The other thing I wanted to clarify with you was that you have used the term “trachy” 
several times in your evidence.  Could you just advise the Panel as to whether this is a term 
you devised or whether it is a medical term? 
A 
It probably is a term that is used within medical circles, if you like.  It is probably just 
a shortened term.  My son still has a patent tracheostomy and so it has just become, over  
16 years, part of life, I suppose.  I think it came out of the ENT ward in Great Ormond Street 
E
originally.  It was shortened to “trachy”. 
MR McFARLANE:  Good afternoon, Mrs H.  I can confirm that I do use the term “trachy” 
when referring to a tracheostomy.  If we are looking at the time when you went to the Royal 
Brompton Hospital in September 1989, and afterwards, how many times did you see 
Dr Dinwiddie after that particular admission to the Royal Brompton Hospital? 
A After 
1989? 
F
Q 
After September 1989. 
A 
Our son was a patient of Dr Dinwiddie.  We saw him fairly regular.   
Q 
When you say regular, how many times a year? 
A 
At least once every three months I would have said. 
G
Q 
For how many years? 
A 
After that point?  We saw him up until May 1991.  The last time we saw 
Dr Dinwiddie was in May 1991. 
Q 
So just under two years, so you would have seen him six or seven times.   
A 
The last time we saw him was when he told us that Dr Southall had intervened in his 
treatment plan and he was calling a case conference.  That was the last time, apart from in the 
H
case conference on 10 July 1991, that we saw Dr Dinwiddie.  As a result of the out of court 
T.A.  REED 
Day 6 -  47
 & CO. 

---

A
hearing in November 1991, both Dr Southall and Dr Dinwiddie were ordered out of our case 
and told to have no more involvement, so we were actually under Dr Weaver from that point.  
She was my son’s paediatrician then, our son’s paediatrician from that point on.  But 
Dr Dinwiddie had continued to treat my son.  We continued to follow his treatment plan.  He 
was still pursuing a ventilator.  By this time we were using a Nellcor pulse oximeter at home 
and providing the recordings for Dr Dinwiddie, and based on that he was in negotiations with 
a firm called EMI to develop a trigger system ventilator, and that was still ongoing when 
B
Dr Southall intervened in the treatment plan.  His intervention brought that all to an end, 
which is perfectly all right if our son did not need one.  But our son has got medical problems 
which, since Dr Southall’s intervention, have been totally ignored and in fact could have cost 
him his life.Southall6d2mr – 2.30 p.m. – answer continued 
And that snowball had started rolling and once it started rolling you could not stop it and it 
would keep gathering snow, and we had to go with the flow and that resulted in us losing our 
C
son for a year and all the trauma that brought with it. 
Q 
If I can refer you to the referral letter that Dr Dinwiddie wrote to Dr Southall in 
March 1989, which is in --- 
A 
It is all right, I remember it. 
Q 
You remember that, yes.  You said to us that when you read the little portion in 
D
manuscript which reads: 
“The question of Munchausen by proxy has also been raised”, 
you found that to be quite surprising.  Did you ever discuss this sentence with Dr Dinwiddie? 
A 
I may have done, but certainly Dr Dinwiddie never gave us any indication at all that 
he thought anything along these lines.  I may have said to him, “Where did this come from?”  
E
If I did, then it was not an issue, obviously, because he continued to follow the treatment 
plan, we continued to follow him. 
Q 
What you are saying is that you saw this, even though – certainly I got the impression 
that you were very upset when you read this in September 1989, inadvertently, but you were 
prepared to overlook it? 
A 
When I got back to the ward I asked Martin Samuels.  I pointed it out to him, 
F
Dr Southall’s – I do not know what he was.  He worked with him.  I asked him what it was 
about and he said, “Oh, if ever anybody had ever thought that, it certainly was not the case 
now”, and not to tell Dr Southall that we had seen it.  I probably did – I do not know if
I mentioned it to Dinwiddie.  I presume I did, but it was not an issue between us. 
Q 
So what you are saying is you were reassured by Dr Samuels’ explanation? 
A Stupidly, 
yes. 
G
Q 
And you did not wish to take it further? 
A That 
is 
right. 
DR MCFARLANE:  Thank you very much indeed. 
THE CHAIRMAN:  Mr Simanowitz is a lay member. 
H
T.A.  REED 
Day 6 -  48
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---

A
MR SIMANOWITZ:  Good afternoon.  I really would like to follow up that line of 
questioning because I am a bit intrigued.  At that time to read a note like that in a letter from a 
doctor whom you trusted and to see for the first time that this is what he is saying, how is it 
that you did not phone him up, rush off to see him, say, “How can you say a thing like that?”? 
A 
I may have done.  I really cannot remember, but if I did or we did talk about it we 
were reassured by Dr Dinwiddie.   If he thought that, you would expect Dr Dinwiddie to have 
taken some action or to inform social services or whatever, and that did not happen. 
B
Q 
But he did think that because he wrote it in the letter. 
A 
I do not know, I do not have your answers, but if he wrote that in a letter in 1989 why 
was it that nothing happened until 1991?  Nobody made any approaches.  In 1990 Dr Weaver 
and Dr Southall approached our local Mid-Glamorgan Social Services, unbeknown to us.
There was a meeting held; it was found that our son was in a loving, caring home, he was in 
normal school and there were no concerns.  Following that meeting my GP came and told me 
C
that they had had a meeting and I wrote to – that is right, yes, I did, because I contacted 
Dr Dinwiddie then and told him this meeting had taken place and he said he did not know 
about it.  Time moved on, the decision had been made, our son was in a loving, caring home, 
and Dr Dinwiddie continued to treat him and then in 1991 of course we found that 
Dr Southall had intervened in the treatment plan and he had invoked Kensington & Chelsea 
social services, who had nothing to do with us, knew nothing about us. 
D
Q 
Forgive me, I think you have answered the question. 
A Thank 
you. 
Q 
In the same pattern, almost a year later something else quite striking and serious 
happens because Dr Dinwiddie’s plan of action is changed completely, the suggestions made, 
and you were given a monitor which you decide to have a go, but everything is quite different 
from what Dr Dinwiddie was doing.  Again, why did you not phone him up and say ---? 
E
A 
This was 1990 and we were given the monitor in 1990. 
Q Yes. 
A 
Sorry, I think the question you asked a minute ago related to 1991, or have I got lost?  
I am sorry. 
Q 
What I am trying to get at is that in 1989 something happened which you could easily 
F
have contacted Dr Dinwiddie about, but you did not, and then in 1990, a year later, again 
something happens.  Forgive me, I would have thought that something --- 
A 
The case conference? 
Q 
The change when you went to Brompton and you were told they were going to change 
the plan of treatment, they were going to close the trachy and it was completely against what 
Dr Dinwiddie had told you.  Why did you not immediately contact Dr Dinwiddie? 
G
A I 
did. 
Q 
You phoned him up, did you? 
A 
Yes, that is the conversation we were talking about a little while ago.  I phoned him 
up and he told me to return the monitor to him – sorry, to return the monitor to Dr Southall. 
Q 
So you had a detailed conversation with him and told him all the instructions that had 
H
been given? 
T.A.  REED 
Day 6 -  49
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---

A
A 
Yes, I told him that they wanted to take [Child H’s] trachy out, they wanted blah, 
blah, blah, and that is when Dr Dinwiddie told me to return the monitor.  That was in 1990, 
yes.  Then following that, in the June, when I returned the monitor, as I say Dr Southall and 
Dr Weaver then contacted Mid-Glamorgan social services and tried to get our son taken off 
us, it now transpires.  That did not work.  I found out about it – sorry, just let me, before  
I forget – I found out about that meeting and I asked Dr Dinwiddie about that and he said he 
did not know, so I got social services then to write to Dr Dinwiddie telling him, the clinician 
B
of record, that the meeting had taken place, and that was the first he knew of it. 
Q 
I was not asking you about the meeting at all. 
A Right. 
Q 
I have one more question.  Can I ask you to look at C2, tab (j), the second letter, the 
letter dated 18 March signed by Dr Dinwiddie, in which he says, “To whom it may concern.”  
C
How did that letter come about to be written? 
A 
We had just moved fairly recently to a new area, 1988/1989.  It was decided between 
Dr Dinwiddie and ourselves that he would remain [Child H’s] clinician of record, but as we 
were moving to a new area, in case we had problems with [Child H], caring for his 
tracheostomy or some kind of emergency, we would have to go to a local hospital obviously 
to get help.  He wrote this letter so that we could give this to any doctor that we might come 
across in an emergency unit. 
D
Q 
Did you ask for it or was it his suggestion? 
A 
It was a mutual – yes, it was a mutual thing because [Child H] was not being referred 
to a hospital, it was just an introduction to show his background history, really, so they would 
know, and of course then they could contact him and he would fill them in on the whole 
picture. 
E
Q 
So it was merely by way of an introduction? 
A 
It was an introduction, yes. 
Q 
The last sentence, when Dr Dinwiddie says he will certainly benefit from an 
ultrasonic nebuliser; did you ask him to put that in? 
A 
That was in relation to the Corrie Weaver – I am sorry, I am getting tired – the Corrie 
Weaver appointment, when she suggested the inhaler and we had gone to Dr Dinwiddie and 
F
asked him about the inhaler and he said, “Well, you know, he’s got a nebuliser.  How would 
an inhaler work?” and that is what that was really about, to say he needs a nebuliser.  He did 
not say that an inhaler will not work, but that is what that was in reference to really. 
Q 
This letter was written after you had moved to Wales and seen Dr Corrie Weaver? 
A 
Yes, I would say it was, but …  No, sorry, the ultrasonic nebuliser was a piece of 
equipment that children with trachys sometimes used to moisten the airway at night and that 
G
is what this was.   It was a specialist piece of equipment that would have needed purchasing 
and we had to buy it, so that is what this was about.  It was about the purchasing and the need 
for that nebuliser. 
Q 
Did you ask for that to be put in so that you would get this? 
A 
No, he is just putting in that [Child H] would benefit from an ultrasonic nebuliser.   
I do not know why he put it in. 
H
T.A.  REED 
Day 6 -  50
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A
MR SIMANOWITZ:  Thank you very much. 
THE WITNESS:  Sorry, I cannot really answer you on that one. 
THE CHAIRMAN:  Dr Sarkar is a medical member of the Panel. 
DR SARKAR:  Good afternoon, Mrs H.  I have a number of questions, you may not be 
B
pleased to hear, and I will take you exclusively to a folder which we have been given as C7.
I hope that is in order.  (After a pause)  C7, as you will probably have noticed, is a copy of 
the SC file held on Child H.  I now want to take you to page 13, which is at the beginning.  It 
is a discharge summary by the ENT department of Great Ormond Street Hospital.  The last 
but one paragraph reads: 
“The patient was then referred to Dr Milla, Consultant Gastroenterologist.  He 
C
requested that video recordings were made of the child swallowing when fed both by 
mother and fed by the nurses.  The patient’s parents did not agree to this further 
investigation and he was discharged home.” 
May I ask you for clarification why you did not agree to this? 
A 
It was following the operation that he had had for the Nissen’s fundoplication, etc., 
and when he was feeding he seemed to be going like this.  (The witness demonstrated)  We 
D
could not work out why and they suggested that they wanted to video him.  We said, again, 
can we see how it goes, and we went home and we actually realised the reason he was going 
like that was because he was teething and his back teeth were coming through and it was 
hurting him, obviously as he chewed, and that was the end of that.  When the tooth came 
through, the problem went. 
Q 
But when the video recording was suggested it says, if we are to believe Dr Robert 
E
Quiney, that the gastroenterologist had requested a video recording but you did not agree to 
that.
A 
It was Dr Milla who suggested it.  We had a very brief meeting with – well, he just 
came to see our son.  I do not know why he suggested the videoing really.  If they said, 
“You’ve got to be videoed” we would have been videoed, but they did not say we had to be 
and we just wanted to see if it was just passing thing, and obviously it was, because our son 
was teething. 
F
Q 
The next question is relating to that document again.  Towards the very bottom you 
will see a circulation list and it says, in the penultimate line, “cc General Surgeon.”  
A 
Yes.  That would have been the person who did the surgery on [Child H].  He was a 
general surgeon within GOS.  You would expect I think a doctor to send a letter within the 
hospital when you were sharing the care of the child.  To my mind that is very different from 
sending a letter to somewhere else.  This I would not class as a breach of confidentiality 
G
because all the doctors had been sharing the care of the child, particularly at that time.  There 
were a couple of teams involved. 
Q 
I wanted to just make two points.  Number one, nobody actually had asked for your 
consent for the copy of the discharge letter to go to the general surgeon? 
A 
No, but as I am saying, this is about him anyway because I think, if I can just have a 
look --- 
H
T.A.  REED 
Day 6 -  51
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A
Q 1988. 
A 
It is following that operation.  He is the guy who had carried out the surgery, or at 
least his registrars or someone, so I would have expected a letter to go to him. 
Q 
The second point I want to make, and I want to see if you agree with me or not, that 
you will see that he was only called “General Surgeon”, there was no name mentioned.  It 
could have been anybody in the big hospital, although you probably correctly identified who 
B
it was who attended.  But with the internal post system of the hospital it would have been 
floating around, possibly? 
A 
Possibly, but I imagine they meet in corridors and maybe they pass the letter …  I do 
not know.  It depends on the relationship that people have between them working together,  
I suppose.  They were working together, that is the point.  They were a team, they were all 
members of that team, so you would expect them to share information, just as we expected 
Dr Southall to share information with Dr Dinwiddie, as Dr Dinwiddie was his doctor. 
C
Q 
Can I take you now to another discharge summary and this is dictated and signed – 
well, not quite signed – by Dr Jane Ratcliffe, registrar to Dr Dinwiddie.  That appears on page 
16.
A 
(After a pause)  Yes. 
Q 
In the middle of the last paragraph it says: 
D
“Dr C. Weaver, Consultant Paediatrician at the University Hospital in Cardiff has 
agreed to look after him locally.” 
A 
Yes, it does. 
Q 
This is in October 1988, after the relatively brief admission of seven days? 
E
A 
Yes.  As I said, we just moved.  That is right, at this point we had literally just moved 
from Stevenage in Hertfordshire to Cardiff.  We had met Dr Weaver in church, as I said to 
you.  She was introduced.  We said we would go and see her, but that was as far as it went.  
We had not said, “Oh yes, you’re now the paediatrician” because Dr Dinwiddie was, at Great 
Ormond Street, so I do not know if there was contact between Dr Ratcliffe and Dr Weaver.   
I do not know.  They must have had contact between them but it was not something we were 
aware of. 
F
Q 
I wanted to make it clear for the Panel that this referral to Dr Corrina Weaver which 
Dr Ratcliffe talks about, who is working as a junior to Dr Dinwiddie, you were not aware of 
this referral being made? 
A 
No.  Sorry, can you just repeat the last bit again?  We were not aware ---? 
Q 
You were not aware that Dr Jane Ratcliffe, working under Dr Dinwiddie, had indeed 
G
referred Child H to Dr Corinna Weaver? 
A 
No, we had no idea.  As I said, we just met her in church.  She said she would see him 
if we wanted her to.  We thought we better be polite and say yes.  In fact, if we wanted a local 
paediatrician involved we would have asked for Dr Peter Gray, who was a brilliant 
paediatrician and was a member of the same church.  So I am sure if I wanted a local 
paediatrician I could have gone and there would have been ways to have got him to be 
consultant, but we did not need one locally. 
H
T.A.  REED 
Day 6 -  52
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A
Q 
How many times has Child H been seen by Dr Weaver in total? 
A 
In total?  He saw her once prior to 1991 when he was taken off us. As I say, in 
November 1991, in the out-of-court hearing, Dr Southall and Dr Dinwiddie were ordered out 
and Dr Weaver became the paediatrician then who cared for him.  So, she saw him while he 
was away.  I presume she saw him while he was away from home.  He was away from us for 
a year.  It was decided in the out-of-court hearing that our son should come home.  He came 
home in … Our son was in hospital for four months and they took him off us in July of 1991.  
B
They kept him in hospital until mid-November of 1991, so I guess during that whole time she 
would have been there, she was the person in charge, if you like.  He had been removed from 
our care, and then when he came back to our care she was the paediatrician until we moved to 
Swansea in 1993, when her involvement finished. 
Q 
So she has actually seen Child H on a number of occasions – at least more than once? 
A 
As I say, our son was in hospital for four months, so she would have seen him 
C
regularly during that time, and her involvement with us ended when the care order – was it 
when the care order came to an end – the care order came to an end and the supervision order 
ran out, and we never saw her again.  That was in 1993, in about May of 93.  The last time we 
saw Dr Weaver - our son still has a patent tracheostomy, as I say, which was not closed, 
although it was claimed that it was – and she decided that he still needed the tracheostomy, he 
was still using it, and he has to this day still got a tracheostomy.  In fact, in the whole of that 
time he has never seen an ENT surgeon.  He has really gone ignored for the last sixteen years.
D
We now find out that in 91, when away from our care, he was diagnosed with epilepsy, which 
nobody chose to tell us--- 
Q 
Can I restrict you to the particular letter. 
A Sorry. 
Q 
No, it is perfectly all right.  I now want to take you to page 64 of that bundle.  It is a 
E
letter from Cartwrights Solicitors to Dr Southall, and the letter is dated 19 June 1991.  In the 
third line from the top it says: 
 
“…[you] have asked Dr Dinwiddie who is the clinician of record to attend and give 
full particulars of the case.” 
A 
Sorry, I have lost it. 
F
Q 
I will read the full paragraph: 
 
“We act for the parents of the above [which is Child H] who learned with alarm that 
you have summoned a meeting at your hospital on 27th June to discuss their sons case 
and have asked Dr Dinwiddie who is the clinician of record to attend and give full 
particulars of the case.” 
G
A 
Right.  Yes, sorry. 
Q 
So it goes on to say that at least you knew that Dr Dinwiddie was being invited to this 
meeting, because the lawyers must have learnt from you? 
A 
Yes.  We went to see Dr Dinwiddie in May 1991, as I say.  We saw him in the 
playroom on 5B, the ward 5B, and it was during that out-patients appointment that he told us 
H
that Dr Southall had intervened in his treatment plan and he had called a case conference and 
T.A.  REED 
Day 6 -  53
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A
he would have to attend, and he hoped that he would be able to go there and convince him 
that, you know, he was wrong basically, but we still did not know what it was all about.  We 
did not know that we had been accused of Munchausen syndrome by proxy.  So  
Dr Dinwiddie had told us about the meeting, yes. 
Q 
You said that by that time you had read the letter that Dr Dinwiddie had written, and 
the words “Munchausen by proxy”, although handwritten, did not escape your attention, but 
B
you did not take this opportunity to ask him, but here is a case conference being called for 
Munchausen by proxy, you thought about a year ago that that might be the case, “What is 
going on?” 
A 
Yes.  I suppose, as I say, we had asked Martin Samuels about it, then Dr Dinwiddie 
carried on with his treatment plan, we were following his treatment plan, and what we were 
told was that this was about the ventilator – no, Dr Southall wanted my son to undergo 
particular tests, he wanted him to undergo this test, and Dr Dinwiddie had apparently told
C
Dr Southall (this is hearsay, obviously, but this is what he told us), that he told Dr Southall 
that if he wanted to have his tests, he would have to write to us and ask us himself.  
Obviously, Dr Southall had not written to us to ask, and so he said that Dr Southall had 
intervened in his treatment plan in order to get the tests. 
Q Okay. 
D
MR TYSON:   I hesitate to interrupt the questioning, but we are going slightly off the heads 
of charge, with respect. 
THE CHAIRMAN:   Dr Sarkar, have you got the clarification that you were seeking? 
DR SARKAR:  Well, the paperwork that has been submitted to the Panel, if they are no 
longer relevant I think it would help us if the paperwork was removed, because otherwise it 
E
confuses at least me to know what is relevant and what is not.  If that is the case indeed, 
madam, I would request the GMC’s barrister to take a short break and remove the paperwork 
so that at least I am not confused. 
A 
I have to say that this forms part of the bigger picture, in fact, it is the whole picture, 
but the GMC have not taken forward these aspects, so I cannot tell you, although I have 
sworn to tell you the whole truth and nothing but the truth, I cannot actually tell you the 
whole truth because it is not part of these proceedings, it is not in the remit of the GMC 
F
hearing.
THE CHAIRMAN:   That is the point.  I think probably Dr Sarkar is taking the view that 
material that has been put in front of us, even if you have not referred to it, may raise 
questions in the Panel’s mind if we have not been specifically told not to read it, so perhaps 
you could just clarify the position on that. 
G
MR TYSON:   Yes.  I had to show you the whole of the SC file just to show you what the SC 
file was and had in it, but not to study it in detail.  The heads of charge relate to original 
clinical documents that are in this file but nowhere else.  That is what the heads of charge are, 
as we see from Appendix One how many originals there are in the SC file, that it would have 
been unfair of me not to have put before the Panel what the whole of the SC file is.  I mean,  
I do not want to stop any Panel questioning, provided it is just a question of relevance.  The 
heads of charge relate to documents in the SC file that should not be in there, rather than 
H
documents that are in the SC file and perhaps have good reason to be in there. 
T.A.  REED 
Day 6 -  54
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A
A 
And actually would tell the whole story, but--- 
MR TYSON:   It was just with that in mind I just sought to remind the Panel what the issues 
are that they have to deal with under the heads of charge, but I do not want to stop any Panel 
member asking questions. 
THE CHAIRMAN:   Dr Sarkar, does that give you reassurance? 
B
DR SARKAR:  It does give me reassurance, but the way I was viewing it is that if the 
information is in front of me and in relation to a case in front of us, unless Madam Chairman 
or the Legal Assessor tells me otherwise, I would need to establish the broader picture 
because it has relevance in my mind now, you may overrule me on that, but I was trying to 
understand Mrs H’s involvement with the various professionals in regards to her son’s 
treatment. 
C
THE CHAIRMAN:   Perhaps it would help if I asked the Legal Assessor to comment on this. 
MR TYSON:   Perhaps before the Legal Assessor does, I mean, there is enormous 
documentation in this case, and I could for instance produce this child’s records from the 
Brompton, or other hospitals, not Great Ormond Street for the reasons the witness has given.
We have sought to reduce the documentation to a minimum, but, having said that, it was felt 
D
appropriate and still is appropriate that the Panel should be able to see the whole of the SC 
file, albeit not the whole of the others, in order to see what the gravamen of the charge is 
relating to Appendix One.  If Dr Sarkar or anyone else wants to explore the professional 
relationship between this mother of a patient and other clinicians, then there are other files 
not before the Panel that could give a different picture that one got just by looking at the SC 
file;  for instance, for what it is worth, I have seen voluminous correspondence, not 
voluminous but correspondence, with doctors dealing with the various technical people 
E
asking about trigger ventilators, and the like. If the object of this Panellist’s questions,
Dr Sarkar’s questions, is to seek to establish the relationship between this witness and 
clinicians involved in the child’s care, then the picture from the SC file is not going to assist 
in establishing those relationships.  I remind the Panel that the two issues relating to this 
witness and the heads of charge are, firstly, whether or not it is appropriate to send the letter 
of March to an unnamed paediatrician, and, secondly, whether it is appropriate to have 
original medical records in an SC file.  Those are the two issues relating to this patient.  I am 
F
reminded of course there is a third issue, which is under 13(c), which is an issue of why does 
the SC file relating to this child end up in the North Staffordshire Hospital when this child 
was only treated at the Brompton?  Those are the three issues relating to this child, and none 
of those issues, though I will be corrected by the Legal Assessor or any guidance from the 
Panel, relate to, in my submission, the line of questioning that Dr Sarkar was embarking 
upon.
G
THE LEGAL ASSESSOR:   Madam, Mr Tyson has encapsulated in his remarks the issues 
that are before the Panel in regard to this patient and the evidence that has been given before 
you.  Of course, it is not at all unusual for quantities of information and documentation to be 
put before Panels when conducting their inquiries, but what is essential is that lines of 
questioning should be restricted to the issues which are germane to the decision which they 
have to make.  Now, much matter will appear by way of background or periphery in the 
documentation here, as is quite often the situation in other cases, but the essential matter is to 
H
concentrate upon the specific issues which are before the Panel.  Now, the line of questioning 
T.A.  REED 
Day 6 -  55
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A
which Dr Sarkar is pursuing, you may think, is not specifically relevant to the issues which 
are before you.  Of course, it is open to the Panel to ask questions which concern them, but it 
is important that they should have well in mind that they should concentrate on the issues 
themselves rather than on peripheral matters which may not be in any way germane to the 
issues.
My advice, madam, is that Dr Sarkar’s questions, which may well perfectly properly concern 
B
him, on the face of it do not seem to be specifically relevant to the issues, and in those 
circumstances my advice is that this is not a line of questions which would really be helpful 
to the Panel in regard to the issues which they have to determine. 
THE CHAIRMAN:   Dr Sarkar, you have heard that advice, and I hope perhaps it helps 
reassure you in the sense of the reason as to why we have the volume of material before us, 
that in making diligent enquiry we do not necessarily have to delve into the details of every 
C
document that is placed before us, and indeed, as I understand Mr Tyson is pointing out, that 
if we were to do so might even be unjust, because we then do not have other information that 
is pertinent to the same topics. 
MR COONAN:   Madam, could I just rise.  I appreciate you in effect repeating the advice 
that the learned Legal Assessor has given.  Might I suggest that in effect strangers withdraw 
while you have this discussion in private, because there may be other opinions to be 
D
expressed by members of the Panel on the document, I know not. 
MR TYSON:   Including us? 
MR COONAN:   Including us, yes, that we ought to withdraw whilst the Panel discuss it. 
THE CHAIRMAN:   I will ask Dr Sarkar if he would prefer to discuss this in private or 
E
whether he is now satisfied with the answers he has received so far? 
DR SARKAR:  Madam Chairman, I am very satisfied by the advice the learned Legal 
Assessor has given and I have no further questions. 
THE CHAIRMAN:   I think that matter is resolved then.  Thank you.  If there are no further 
questions from the Panel, I myself do not have any questions, are there any questions from 
F
either counsel arising from the Panel’s questions? 
MR COONAN:   No, thank you. 
Further re-examined by MR TYSON
Q 
You were asked about your contact with Dr Weaver, and I think I noted down that 
G
you only had seen her once before you went to the Brompton Hospital, is that right? 
A 
I am sorry, can you repeat that? 
Q 
Had you only seen Dr Weaver once before you went to the Brompton? 
A Yes. 
MR TYSON:   I have no further questions for this witness. 
H
T.A.  REED 
Day 6 -  56
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A
THE CHAIRMAN:   Mrs H, thank you for coming.  That now completes your evidence.  You 
are released from oath and you may stand down. 
(The witness withdrew)
MR TYSON:   Madam, my next witness is going to be Ms D, for which we will need Panel 
bundle C2 at section 4.  I know not whether, and I suspect not, you have just before section 5 
B
a section (k).  I do not think you have, but I would like you to insert a section (k).
(Documents handed)  Madam, the issue that this mother of a patient goes to, there are matters 
relating to this child in the SC files, which you will see in Appendix One relating to Child D.  
You may recall Professor David taking us through incoming and outgoing correspondence 
and the like.  There are issues relating to this child in Appendix Two relating to material 
found in the Academic Department computer.  There is one particular incident of fact you 
need to determine, which is dealt with at Appendix Three, which was the manner of a 
C
conversation that this witness who I am going to call had with Professor Southall on 15 
December 1994.  So those are the three matters, the three issues in the heads that this witness 
goes to.  Again, I am grateful to my learned friend who indicated that I can lead this witness 
up to her child’s entry to the North Staffs Hospital.  I call Ms D.  Can I ask you to indicate, 
madam, what time you were going to rise for a break this afternoon? 
THE CHAIRMAN:  Well, I am content to fit in with what would be a convenient time.   
D
I think we should take a break, and one looks for some point in the middle of the afternoon.  
Do you feel it would be better to take a break now before this witness? 
MR TYSON:  I am happy to call this witness.  It was just if you gave a rough indication as to 
when you would want me to metaphorically draw stumps. 
THE CHAIRMAN:  In about twenty minutes perhaps. 
E
MR TYSON:  I will look to see how we are doing at about half-past. 
Mrs D, Sworn
Examined by MR TYSON
(Following introductions by the Chairman)
F
Q 
Mrs D, there should be a piece of paper on the desk in front of you.  Could you please 
write down your full name and address on there?  (Witness wrote accordingly and same 
handed)  Mrs D, I see that you have got three files in front of you.  You will only need to be 
bothered, when I am asking questions, with File C2, at Section 4.  Perhaps we could quickly 
go through the earlier matters in this section.  Can I ask you to look at the letter under Tab 
(a), please, which is a letter dated 24 April 1989 from Dr Rodgers?  Was he your GP? 
G
A He 
was. 
Q 
To the Paediatric dietician at your local hospital.  It relates to your child who would 
appear to be about five or six months old when this letter was written. 
A That 
is 
right. 
Q It 
says, 
H
T.A.  REED 
Day 6 -  57
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A
“Thank you for seeing this baby who would appear to be one of the most allergic 
children I have come across.  His mother is a nurse (RGN) who also has multiple 
allergies and is coping really very well with young D’s problems”. 
Just pausing there for a moment, it says that you are a nurse.  What kind of nurse were you 
for part of your career? 
A 
I was a registered general nurse and I also did my paediatric training at Great Ormond 
B
Street to RSCN. 
Q 
This is a letter at (a) asking for advice.  Turning over to Tab (b), in July 1989, when 
your child was then about eight months old, did your GP refer him to the local paediatric 
consultant, Dr Connell, and again he was described as one of the most allergic specimens.  
Was the issue then that there had been a reaction to your child’s first triple and polio? 
A 
Yes, that is right. 
C
Q 
He asked him to look into the matter.  At (c) there was a response to that from  
Dr Connell dated 9 August 1989, saying, 
“Thank you very much for referring this nine month boy with rather complicated 
multiple allergies, the main symptoms of these are episodes of apparent abdominal 
pain with colic and screaming, swelling of the eyes and urticarial skin rashes with 
D
eczema.  In addition, as you say, a severe febrile reaction to his first DPT 
immunisation”.
Did that letter go over the page in the second main paragraph saying words to the effect,
“I would agree with you that the history leaves little room for doubt about the allergic nature 
of the problems.  I think in practice his parents have done extremely well and it struck me 
that they have an extremely well balanced and sensible approach to his diet”. 
E
A 
That is how things were. 
Q 
Later that year in 1989 did Dr Connell refer your child to the Department of 
Immunology at Great Ormond Street? 
A He 
did. 
F
Q 
Just to pick up the first paragraph, 
“I would be very grateful if you could give your opinion on this child who suffers 
from multiple allergies.  The main clinical manifestations of these are recurrent 
urticaria and eczema, recurrent abdominal pain, swelling of the eyes and also a rather 
severe reaction to his immunisations”. 
G
A 
That is correct. 
Q 
Does it deal with the matter of immunisations at the bottom of the first page, 
 
“His other problem has been one of reaction to immunisations”. 
The main bit dealt with reactions and eczema, 
H
T.A.  REED 
Day 6 -  58
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A
“His other problem has been one of reaction to immunisations.  His first DPT and 
polio was complicated by fever and screaming for a week.  We therefore admitted 
him to the ward for his second immunisation at the age of 9 months.  Despite this 
being covered with Piriton he had quite a severe generalised urticarial skin reaction 
with extreme irritability.  He received intravenous hydrocortisone.  He was never 
shocked.  His skin rashes took about two weeks to settle down.  He was also initially 
quite hypothermic following the immunisation, but then went on to make a good 
B
recovery.  He is not a child who is particularly prone to infections and hasn’t had any 
features of immunodeficiency as such, but I think he does genuinely have a lot of 
problems with multiple food allergy.  His mother has an extremely sensible and 
balanced approach to the problem and copes with him very well.  I would be very 
grateful for your advice in general and also specifically to know whether you feel he 
needs investigation for any underlying immunological disorder.  Secondly, for any 
particular advice you might have about his dietary management”. 
C
A 
That is also correct. 
Q 
Did Dr Connell get a reply at (e) from a Dr Strobel, who was then a senior lecturer 
and consultant paediatric immunologist? 
A Yes. 
D
Q 
The reason for not getting a reply from the professor he had first written to we can see 
from the first paragraph: 
“Thank you very much for your letter addressed to Professor Soothill, which he has 
forwarded to me because after his retirement he does not see any new referrals. 
Child D’s history is quite fascinating and I do not think there is any doubt that most of 
E
his problems have been food related possibly from an allergic background.  The 
mother seems to cope very well with managing his diet.  The next step obviously 
would be to reintroduce food items which had been excluded in order not to unduly 
restrict his diet”. 
A 
That is correct. 
F
Q 
Does he then go on to deal with the question of immunisation, and in the next 
paragraph the question of his urticaria?  In the next paragraph does it go on to say, 
 
With your permission I have sent the parents a direct appointment”. 
Did your child subsequently see Dr Strobel on a number of occasions between 1989 and 
1994? 
G
A He 
did. 
Q 
Were various food challenges carried out and the like relating to various aspects of 
your child’s allergies? 
A 
There were only a few geo-food challenges carried out because Professor Strobel 
wanted to go the slow route.  Because he could see my son’s reactions and how he was at the 
time, and because he was thriving on the diet that he had, he did go very slowly. 
H
T.A.  REED 
Day 6 -  59
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A
Q 
Did there come a time in 1994 – we have moved on five years – when you became 
concerned about your child’s sleeping at night? 
A 
After the second immunisation, as the record shows, my son became quite 
hypothermic.   
Q 
Pausing there, there are a number of lay people in this room, what do you mean by 
“hypothermic”? 
B
A 
He would be quite cold and his temperature would drop.  After he had his third 
immunisation in hospital in 1993, when he had another severe reaction worse than the second 
immunisation, these episodes became much worse.  I therefore became even more 
increasingly concerned about my son’s problems at night time.  He had been in a room on his 
own, but by then, because I was so concerned, I had him in a bed beside my bed because  
I wanted to make sure that he was OK at night time.  I then spoke to somebody from the 
Study for Infant Death Society to see whether a monitor would be possible to let me know 
C
when my son was having any difficulties at night time, so that he could go back into his own 
room and also to make sure that he was kept safe. 
Q 
Did you discuss these concerns with your general practitioner? 
A I 
did. 
Q 
As a result of that did he refer you on to anybody? 
D
A 
He referred me on to Professor Southall, because I was able to give the name of 
Professor Southall to my GP. 
Q 
How had you got that name? 
A 
From the Study for Infant Death Society.  They recommended Professor Southall as 
being able to help with the monitor. 
E
Q 
Could you look please, under Tab (f), which should be a letter of 6 October 1994?  
We see that is a letter from Dr Rodgers, who was still your general practitioner, is that right? 
A He 
was. 
Q 
He wrote here to Professor Southall at the Paediatrics Department, City General 
Hospital, Stoke, 
F
“Dear Professor, re child D: I would be grateful if you could see the above child who 
is the most allergic patient I have ever known.  His mother is an SRN and copes very 
well.  There are relationship problems in that his father has alcohol problem.  He 
attends Dr Strobel at Great Ormond Street.  His mother is very worried about him at 
night as he gets frequent episodes of becoming pale, shut-down and query 
hypothermic.  Would he be suitable for a PO meter”. 
G
A 
That is correct.  The “query hypothermic”, in Great Ormond Street on a few 
admissions it was recorded that my son’s temperature did drop down to about 33.5. 
Q 
What do you understand by the words, “P O metre”? 
A 
Proof of oxygen. 
Q 
As a result of that letter, did you go and see Professor Southall for the first time in 
H
November 1994? 
T.A.  REED 
Day 6 -  60
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A
A We 
did. 
MR TYSON:  Madam, that might be a convenient moment. 
THE CHAIRMAN:  Thank you, Mr Tyson.  We will break now for 20 minutes.  Mrs D,  
I have to tell you that while you are giving evidence and are on oath, during the break you 
must not discuss the case or your evidence with anyone. 
B
(The Panel adjourned for a short time)
Q 
Mrs D, we have just been looking at a letter of October 1994, where your GP, at your 
behest, had referred your son to see Professor Southall about a monitor? 
A Yes. 
C
Q 
In November 1994 did you, your partner and your child go up to Stoke on Trent and 
see Professor Southall? 
A We 
did. 
Q 
Was there some minor logistical difficulty in actually finding his department because 
it is located in a rather bizarre part of the hospital? 
A 
We went to the main part of the hospital and asked where Professor Southall’s clinic 
D
was and we were directed outside of the building.  I can remember how far it was because we 
had heavy bags and it took quite a long time to get to this other department. 
Q 
Then in this department was there a discussion about Child D? 
A 
At this department I think there was just either a receptionist and a nurse and 
Professor Southall and I explained to Professor Southall my concerns for my son at night-
time and I also explained about his allergy problems. 
E
Q 
Can you look please at (g) and can you go to the third page in, which might on the 
bottom right-hand side have the page number 601 on it? 
A Yes. 
 
Q 
This is a note that was taken apparently at the time of this consultation and I just want 
to go through it quickly with you to see if these are the kind of things that were discussed. 
F
A 
They were.  Some is incorrect that I can see already. 
Q 
Let us just go through it.  It give his weight and height there.  This is on 29 November 
1994, I think it is.  It says that the history of present complaint is low body temperature and 
multiple allergies.  The first injection led to a too high temperature and he was unwell for a 
week afterwards.  The second injection was delayed until two years ago and there was no 
pertussis, so he did not have the whooping cough. 
G
A 
He did not. 
Q 
Then it says: 
“Face swelled. 
Temperature dropped] 
Flushing but T [temperature] still low. 
H
IV Hydrocortisone given. 
T.A.  REED 
Day 6 -  61
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A
Went into ‘shock’.
LOC [loss of consciousness] 
Blue lips 
Unrousable.”
Then the note is recorded about the third injection, which was in hospital. Which hospital was 
that, Mrs D? 
B
A 
In Wexham Park Hospital, Slough. 
Q It 
says: 
“Same thing happened. 
LOC [loss of consciousness] 
Blue –
 resps
C
Irreg. resps. 
Similar happened whilst he was at home.” 
There is slight difficulty with the left-hand side of the photocopying here, but it appears that 
there was discussion of things happening at home over the last three years, usually when he is 
asleep he gets very pale, irregular breathing, stops breathing for seven seconds, temperature 
D
goes down to 34.2 axilla, and rectal ( I think that is) 35.8.
“Space blanket no help. 
Next day – very pale.” 
Then he has been on adrenaline and steroids at home and there is a list of medication.  Then 
E
under the history he is given, I think that may be – it is difficult to see – anaphylactic shock to 
egg, milk, apricot, strawberry, wheat.  It is recorded that there is a very restricted diet and 
then it is recorded that the child has had eczema and is better since taking oral Becotide.  It 
gives a family social history about your and your partner and indicates that the asthma is 
under control at the moment and there are some initials which I do not know the significance 
of.  I am told it is “Short of breath on exercise”, and I am grateful.  Exercise leads to a 
swollen face and flushed.  It says that oral Becotide was dropped to one cap a day because of 
F
growth problems.  Then it deals with allergy reaction to animals and that he had been under 
Dr Stroble at Great Ormond Street and he is not worried about these drops in temperature. 
“Mum + GP concerned. 
Under a dietician at hospital. 
Skin very sensitive to many things.  Under dermatologist …”. 
G
Where was the dermatologist? 
A 
That was Dr Atherton at Great Ormond Street. 
Q Then: 
“Fits related to high temps.  Last one 2 yrs ago.” 
H
T.A.  REED 
Day 6 -  62
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A
Just pausing there on this note, are these the kind of things that were discussed? 
A 
They are, but they are not quite correct. 
Q 
Is there anything in particular that you want to draw the Panel’s attention to? 
A 
The second injection was delayed but that could have been not having the correct 
time, but he did not go into shock with the second injection, he just had a generalised severe 
reaction and his temperature dropped.  He did not have full shock for the second injection.  
B
The third injection he did go into an anaphylactic-type shock and it was a much more severe 
reaction.  The problems that he was having at home were not as severe as that.  He did have 
the odd allergic reaction if he maybe picked up something, which is how we knew he had a 
severe reaction to apricot.  In the supermarket he just picked up an apricot, bit into it, then he 
had severe problems, but generally at night-time it was the paleness, very, very cold, and 
irregular breathing. 
C
Q 
Then it is recorded that he was seen by Professor Southall: 
“Cushingoid.
Urticarial + eczematous rash … 
Mum concerned that recording may not show anything because of lack of allergies in 
hospital”,
D
and it was indicated that the child should be admitted in about ten days’ time for continuous 
temperature recordings, skin, axilla and oxygen recording.  Is that more or less how it went 
on the first out-patient’s appointment that you had with Professor Southall in November 
1994? 
A 
This is basically what was discussed, but when it says about Dr Stroble not worried 
about these drops, he was worried because there is a letter in Great Ormond Street records to 
E
say, after his third immunisation, that these drops in temperature and reactions are a constant 
source of maternal and medical worry, but he was not worried enough to refer [Child D] 
because he did not know what was happening to my son at the time.  He was worried about 
these reactions but he did not understand what was happening, which is why I did ask for a 
referral to Professor Southall to have some help because none of the doctors could explain 
what was happening to my son.  Dr Atherton actually said it was as if he was hibernating.  He 
could not understand what was happening either, but they did see my son like this in hospital. 
F
Q 
How did Professor Southall come across to you at that first out-patient appointment? 
A 
From what I remember nothing untoward.  He seemed professional.  I spoke about 
how my son was.  He did not really ask many questions.  He examined [Child D] and other 
than him not really asking any questions the meeting seemed to go okay and I got the 
impression that he was able to help my son.   
G
Q 
Were you there for help with the allergies or were you there for help in getting a 
monitor? 
A 
I did not ask Professor Southall questions about allergies because he was not an 
allergist.  I was there really for some help to find out why my son had these problems at 
night-time and for some help in alerting to us when he had a problem.  I do not know who 
could help explain why my son had these reactions but I did not go there for 
Professor Southall to see my son as a clinical doctor under his allergy problems. 
H
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Day 6 -  63
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A
Q 
I think you told us before tea about the purpose of you being there, because you 
wanted him out of your bedroom and you were worried about his breathing difficulties at 
night.  Is that right? 
A 
Not that I wanted him out of my bedroom, but I felt that at that time he was five, six, 
he should be in a room of his own, but because he had had these problems at night-time I was 
too scared to let him go back into his own room.  But he was never in the bed with me, it was 
in a cot by the side of my bed, so that I could be aware and alert to when he was having these 
B
problems. 
Q 
Was it agreed that you would come back in about a fortnight’s time and your child 
would be admitted for monitoring? 
A 
Yes.  Professor Southall said that we would hear from them re the date of coming 
back in. 
C
Q 
Was he admitted on about 12 December and was in hospital for about three nights? 
A 
That is correct. 
Q 
If we go over the page that we have been looking at to page 606 we can see again on 
that , over the next page and over the next page, 608, the notes taken by the clerking doctor 
who admitted him.  Indeed, it goes over the next page as well, 606, 607, 608, 603 and 604, 
where it says, two-thirds of the way down, “Admit for recordings”? 
D
A 
Sorry, which page is that? 
Q 
At page 604.  It is not quite in chronological order. 
A 
I have found it now. 
Q 
It starts at page 606, goes to page 607, goes to 608, then to 603 and then to 604? 
A Yes. 
E
Q 
All those are the notes taken by the doctor who admitted the child in December and if 
you are asked about those matters doubtless you can answer questions about that note, but I 
am not going to take you to the note yet unless there is anything particular you want to raise 
about it. 
A 
I actually do not remember seeing the doctor and giving an account but that could be 
because of the time lapse, I do not know, but on the first page, 607, the doctor states that my 
F
son needed adrenalin “x 6.” He had only ever had adrenaline at one time at that time, and he 
had had prednisolone x 6, but never adrenaline.  He also calls my son “Stephen.” 
Q 
Then we see that under that signature there is something that says “13/12/94”, and  
I think that is the next day, a note for the 13 December 1994. 
MR COONAN:  I just wonder if you have the exact dates?  I know they are cut off. 
G
R TYSON:  From a note that I have made it is 13/12/94 at the bottom of page 604.  It says 
“Review.”  It indicated that a tape had been saved and the matter had been discussed with
Dr Samuels and you were to stay for further ONR, and I think that is “overnight recordings.”
It is recorded that there was a need to contact Dr Stroble and Dr Connell for copies of 
summary letters and lists of investigations and results.  Then, over the page, at page 609, it is 
recorded that there had been a discussion with Professor Stroble of Great Ormond Street 
H
about the highly complex history and the child being a highly allergic child and various other 
T.A.  REED 
Day 6 -  64
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A
matters there recorded, including, at the end of that, that Professor Stroble has seen an acute 
urticarial reaction.  Then on the next day, 14/12/94, there is a review: 
“When TCPCO2 attached last night   … 19
-
Sats - 98%  - well in himself … 
This morning dipped down to 17 …”, 
B
but oxygen saturations normal, 
“[Child D] well.” 
Can you help us?  Do you know when it is talking about down to 19 or down to 17, what 
those relate to? 
C
A 
All I know is that it is the oxygen, but I do not really know the levels, but I do know 
at one time they were 50 and the alarms were going, so I assume that that was outside the 
normal limits because of the alarms going off. 
Q 
Then it is recorded at the bottom of that that there is going to be a discussion with 
Professor Southall re further plans.  On the 15th, which I think is the last day you were there, 
it is recorded here that there was a ward round, I think that is, with Professor Southall, and 
D
you recall seeing Professor Southall on the last day that your child was at the hospital. 
A We 
did. 
Q 
It is recorded in relation to that that: 
 
“Mum worried about [temperature]. 
 
Mum has taken ….. rectal [temperature] – 35.6 
E
 
When she tries to take it he moves around  
 
Lowest axillary [temperature] 34.2 
-
he is ice cold 
-
no colour. 
Mum is concerned because he does this when he is about to have an anaphylactic 
reaction.
F
 
He has delayed anaphylactic reactions 
-
mum is worried.” 
Just pausing there, is that what you told the Professor, that he had delayed anaphylactic 
reactions? 
A 
I did say at one time that I felt my son did have delayed allergic reactions, but none of 
this was discussed on that ward round, so the doctor that is writing this, whether this was 
G
before I came up to see them on the ward round, whether they were discussing this when
I was not there, but this is not a completely accurate account. 
Q 
Was a discussion of the things we have said so far, are these concerns that you had 
raised? 
A 
Yes, but I was concerned about the one delayed reaction that he had had which was 
observed at [hospital named] when he had his third immunisation, and that obviously had 
H
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Day 6 -  65
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A
worried me that he could possibly have other delayed reactions at other times, because I just 
did not know what was happening to him at night time.   
Q 
It is said that he had needed prednisolone 30 mg five times in six months.  Is that what 
you had said? 
A 
I may have said that.  It could have been the five times, six times in that time because 
he did have an episode where he was reacting quite badly and he was obviously very 
B
overloaded, so I could have made that comment, but it was not adrenalin, it was prednisolone. 
Q 
“…because of difficulty breathing, swelling ….. vomiting”. 
A 
That is correct.  At that time he was running around, hitting into things, and he was 
also having problems at school at that time. 
Q 
“He has nocturnal hypothermic events [about] 3 [times a] week – feels very cold – 
C
pale”.
A 
That is correct. 
Q 
He has “Angioneurotic oedema can occur every day” or “evening” – I am not going to 
say what that word is:  
“other problems during day  
D
–
starts shaking  
–
pale
–
cold.
Only needed [intramuscular] adrenaline [once] – when given” – is that “when given 
rice”? 
E
A 
 I cannot read that, but at that time he was only given adrenalin once, and that was by 
the casualty officer.  I think that could be “milk”. 
Q 
“If he was at home at the time, mum wouldn’t worry 
 
He’s only been dropping [temperature] since he started school [and increased] 
frequency of angioneurotic oedema. 
F
 
Mum [and] child sleep in same room. 
 
Mum can’t sleep. 
 
Has had blind challenges to wheat 2 [months] ago. 
-
reacted [very] badly 
-
serious [reaction].” 
G
Listen carefully to the question:  are those the kind of things that you told doctors at the 
hospital? 
A 
I did tell the doctor at the hospital that I had taken my son’s temperature once rectally, 
because I had been told to do so by Professor Strobel when he became very, very cold, 
because they needed to know what his core temperature was, and that was on only one 
occasion that I ever took his temperature rectally. 
H
Q 
That note that I have attempted to read out on 15 November--- 
T.A.  REED 
Day 6 -  66
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A
A 
Basically they are the things that had been discussed in the past, yes. 
Q 
What I want to take you now to is your memories of any discussion you had on  
15 December with Professor Southall, and in your own words take us to how any discussion 
that you had with Professor Southall went that day. 
A 
Is it possible to say that there is an omission on the 15th of the 12th prior to the ward 
round?  The evening of the 14th was when my son became quite ill and a doctor was called to 
B
see him, because he was cold, clammy, his temperature had gone down to 33.5, and the 
TcPO2 had gone down to 9.  When this doctor came to see my son, she went to make a 
telephone call, came back and spoke to the nurses.  Nothing was done to my son.  It was 
when I received records, it states that she had made a telephone call and no treatment was to 
be given, observe only.  That is in the nurses’ records, but that is omitted from the doctor’s 
records, and those nursing records are also missing from the medical records. 
C
Q 
Perhaps while you are making that comment, can you just go to the next tab, which is 
(h), where we have the nursing notes, and could you go to page 620 and see at the bottom of 
the page where it says: 
 
“Very settled night.  Saturated well throughout.  However during early part of the 
night TcPO2 [to] 9, temperature via monitor 33.5-35.5 throughout, although when 
taken via axilla approximately 1° higher.  Seen by Registrar last night when [taking 
D
temperature] and very ‘clammy’ to touch, nil ordered, to observe only.  Mum 
resident.”
Is that the note you were referring to? 
A 
That is the account, but the records that I have been looking at at home, that my 
solicitor for the civil case - those two pages are missing from those records, that is why  
I thought that they were not in the medical records, but there is no account of that in the 
E
doctor’s records. 
Q 
You told us that an incident happened, which we have just seen, on the evening of the 
14th which is not in the medical notes but is in the nursing notes.  Then I was asking you 
about on the next day to tell the Panel in your own words of when you told us that you saw 
Professor Southall at some time, how that went and what kind of things were said? 
A 
I had been waiting with my son and ex-partner, which I believe was the play centre on 
F
the ward.  It was coming to about early afternoon and we still had not seen anybody, and 
because we came from a long distance I was getting quite concerned because we needed to 
know what was happening because of travelling home.  I then saw Professor Southall and a 
number of doctors and a couple of nurses on what I believed to be a ward round.  I believe 
that it could have been in the corridor that they were walking in.  As we were in this other 
room I thought that I needed to go out to speak to them otherwise they might miss us, and  
I wanted to sort of, you know, know what was going to happen to my son, whether we could 
G
go home that day.  So I went out to talk to the doctors.  My son and my ex-partner were there 
at the time, but apparently when I went up to talk to Professor Southall a nurse came to him 
and asked him to go off and have a cup of coffee. 
Q 
Sorry, asked who to? 
A 
My ex-partner, but I was only aware of that at a later date. 
H
Q 
So you went to talk to Professor Southall in this group? 
T.A.  REED 
Day 6 -  67
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A
A 
Yes, but initially my ex-partner and my son were there as well. 
Q 
Then what happened? 
A 
I might not get this all in the correct order because it did happen quite a long time ago. 
Q 
Can you take it slowly because a note will have to be taken of this. 
A 
I believe that Professor Southall stated that everything was normal.  I questioned this, 
B
especially with my son having the reaction that he had had the night before, and I questioned 
Professor Southall that how could it be normal with alarms going off, and what was 
happening to my son.  Professor Southall became quite angry and said that there is no such 
thing as delayed reactions, and--- 
Q He 
said? 
A 
“There is no such thing as delayed reactions”. 
C
Q Yes. 
A 
The way he spoke to me, I just felt very, very sick in my stomach, and I just felt that 
he was stopping me from asking any more questions by the tone and the anger in his voice.
At the time I did not understand why he was so angry with me, but in hindsight I believe it 
was because I was asking questions, and Professor Southall later went on to accuse me of 
exaggerating my son’s problems, and I believe that he did not want me to raise questions that 
D
things were not okay the night before, or indeed the three nights of the recordings. 
Q 
Was there any other discussion about any other clinician to be involved with the 
child? 
A 
Professor Southall said that he would refer him to Professor Warner, and he said that 
he was an allergist, and I got the impression that he was a world renowned allergist, and I felt 
from that that maybe he could help my son, because I then realised that Professor Southall 
E
was saying that everything was normal, and I then realised he would not be able to help my 
son, so I said, “Yes”, I would accept a referral to Professor Warner, but I was not given the 
real reasons why he was referring my son to Professor Warner, and implications.  He did turn 
round and say that he would be contacting Professor Warner and if I had not heard from 
Professor Warner myself within two weeks, that I must ring Professor Warner myself, which 
I did do. 
F
Q 
You told the Panel that he became angry and you felt sick because of the tone and 
anger in his voice.  At what part of this conversation did he become angry, and what were the 
words that you thought were particularly anger making words? 
A 
When he said everything was normal, that was a calm voice, and I believe, and, as  
I said, I may have got things not in the correct order, but I believe now that, looking back and 
getting my head round that day, that I believe it was when I questioned Professor Southall 
that he became very angry and said there was no such thing as delayed reaction.  It was the 
G
anger that I just could not understand at the time. 
Q 
When he said, “There is no such thing as delayed reaction”, how was his voice in 
terms of volume? 
A 
It was quite loud, louder than he had been speaking, but it was more the anger I think. 
Q 
Were you given the opportunity to ask questions? 
H
A 
I felt so sick, and also with Professor Southall sort of like raising and turning away,
T.A.  REED 
Day 6 -  68
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A
I was too frightened to ask any more questions, or to raise the issue of how my son had been 
those three nights. 
Q 
You say he turned away.  Did he turn away in the course of this conversation? 
A 
Yes, I believe he did, because I think that was a sign, that, no, you know, I cannot ask 
him any more questions. 
B
Q 
Did he make any gestures at all that you can recall? 
A 
I believe that he just put his hand up and he said that there is no such thing as delayed 
reaction, it was as if, like, dismissive of me, 
Q 
You are showing, for the sake of the transcript, a raising of the right hand. 
A 
That is what I remember.  As this all happened so long ago there are some things that 
you do forget, but there are also things that are imprinted in my memory and you do not 
C
forget.  If I can give another example, at the case conference in the room, prior to 
discussions---
Q 
No, I do not think I need to take you to the case conference. 
A 
But there are things that – it was just Professor Southall laughing with another doctor, 
and that will stay in my head, the same as he was on that occasion. 
D
Q 
We are talking about an incident now nearly twelve years ago.  What are the aspects 
of this conversation that are really imprinted in your memory? 
A 
Because of the sickness that I felt at the time. 
Q 
What are the aspects about what he said or did that is imprinted in your memory? 
A 
Because he had said that everything was normal and it clearly was not, and that made 
me feel, well, how can my son be helped if the doctor was denying what was seen in his own 
E
hospital and that other doctors had seen as well.  I was worried for the safety of my son, 
because I had gone there thinking that Professor Southall would be able to help, which is the 
impression that he gave. 
Q 
Is the phrase you told the Panel of “There is no such thing as delayed reaction”, is that 
imprinted in your memory? 
A 
That is, because of the way it was said and the anger at the time. 
F
Q 
Is his raised voice imprinted in your memory? 
A 
Yes, it is. 
Q 
Is his raised hand and walking away imprinted in your memory? 
A 
The raised hand, it could be that he just turned away, I could not be certain that he 
walked or he just moved one step, but it was a turning as he waved his hand, and that is in my 
G
memory. 
Q 
You say that you had gone to Professor Southall to see about whether your child 
could have a monitor.  Was there any discussion, or did you have any opportunity to discuss 
whether your child could have a monitor? 
A 
I just got the impression, because he had said everything was normal – I was not 
given the opportunity to ask him questions, but I just accepted that he obviously was not 
H
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A
going to suggest a monitor, but because he had suggested Professor Warner I felt that there 
was some hope and some light because maybe Professor Warner could help.   
Q 
When we mentioned Professor Warner earlier, you indicated that there was a question 
as to the real reasons why Professor Warner was going to get involved.  What did you 
consider to be the real reasons why? 
A 
It was not until two years later that I realised the real reasons and it was because – 
B
MR COONAN:  I am sorry, we are dealing with the events of 15 December. 
MR TYSON:  I will not take that any further.  There came a time, which the Panel has heard 
about, when Professor Warner saw your child on a great number of occasions. 
A 
That is correct. 
C
Q 
Down in Southampton. 
A Yes. 
Q 
There is a document which the Panel has seen from Professor Warner, which is in the 
Panel bundle under Appendix one, dated 22 December.  Could you look please at another 
bundle, C6?  Let us look at page 25.  By 1997 had you had a diagnosis from Professor 
Warner of what was wrong with your child? 
D
A 
There was a diagnosis by Professor Warner at the end of July 1997.
Q 
Was the diagnosis that he had extensive and severe allergies; asthma, eczema; 
episodes of acute angio oedema urticaria and anaphylaxis? 
A 
That is correct. 
Q 
Turning to page 30 – that letter is 2(h) in Appendix One under this patient – at 1(i) in 
E
Appendix one.  Do we now see a letter from Professor Warner to Professor Southall at the 
same time, 2 December, saying, 
“Child D certainly has acute severe allergy.  If he is exposed to any of the food 
allergens it may well be necessary for him to receive adrenaline, either inhaled or 
injected…With regard to being cared for in a wheelchair, as far as I am aware this is 
neither necessary nor actually happening”. 
F
A 
That is correct. 
Q 
Did there come a time – the correspondence I have taken you to is 1997 – where you 
started requesting your son’s notes? 
A 
I did make a complaint to the General Medical Council, because I felt the seriousness 
of Professor Southall’s actions -- 
G
Q 
I am not asking about the complaint to the General Medical Council. 
A 
It is because the General Medical Council asked me to get the medical records.  That 
is when I started to access the records.  That was in October 1997. 
Q 
Could you look, please, at Section (k) in C2.  Do you have that? 
A 
Yes, I do. 
H
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Day 6 -  70
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A
Q 
Is this letter in your handwriting? 
A It 
is. 
Q 
It is a letter from you to a Mr Blythin.  Who is Mr Blythin? 
A 
I think he was under Mr Fillingham at North Staffordshire General Hospital.  He was 
not the Chief Executive, but I had been given his name when I contacted the hospital by 
phone and they said that this was the person to write to. 
B
Q 
So you wrote in October 1997 to that person at North Staffordshire Hospital saying 
you would like a copy of your son’s notes, 
“He was an in-patient under Professor Southall in the City General Hospital 
December 1994”. 
C
A 
That is correct. 
Q 
As a result of that did you get any notes? 
A 
I received 18 pages, because they itemised the bill and I was quite shocked at  
the relevant few pages in the medical records that were sent to me. 
Q 
So you received 18 pages.  Did you feel that those 18 pages were complete? 
D
A 
I knew that they were not complete because of other records I was aware that had 
been sent to Professor Southall before I had asked for the records.  They were not in those 
records.
Q 
Did you then write, in November 1997 – letter number 2 – on 30 November 1997? 
A 
I faxed this letter to Mr Fillingham at North Staffordshire. 
E
Q 
Who is Mr Fillingham? 
A 
He is the Chief Executive at the North Staffordshire Hospital.   
Q 
Did you say, 
“I have recently received copies of my son’s medical notes held at Staffordshire 
Hospital.  These appear to be incomplete.  It also appears that there are two files held 
F
on my son”. 
A 
That is correct. 
Q It 
continues, 
“Under the Access to medical health Records 1990 I would ask for copies of these 
G
notes also. 
According to the Act, exceptions can only be applied if information is likely to cause 
‘serious harm’ – note, ‘serious harm’ not, for example, distress. 
Therefore I see no reason for Professor Southall to withhold any notes held on my 
son.  There are certain letters and reports that I am requesting”. 
H
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Day 6 -  71
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A
Did you go on to identify the file numbers after you said, “Yours sincerely”? 
A I 
did. 
Q 
Is one of them ending 22043, and is that the note that you received from that file? 
A 
That is correct. 
Q 
Does the other file end in SC3874.  Did you receive anything from that file which you 
B
had identified? 
A 
I received nothing from the file, but in the file I had received there were, on a few of 
the pages, the heading “SC” and it was because I noticed it was a different number.  That is 
why I gathered at that time that there must be another file, because there were two different 
numbers in those medical records.   Because it was incomplete, I felt that that would be the 
only possible explanation, that there were two files. 
C
Q 
Did you get an acknowledgement of that letter on 22 December 1997?  We can see 
the acknowledgement begins on page 4 relating to the letter asking for the file SC3874.  On 
page 5 there is a letter from Mr Fillingham saying, 
“I have since received your letter of 30 November and confirm that the issues raised 
in this letter will be investigated and that I will respond to the new points you have 
raised as soon as possible”. 
D
A 
They acknowledged my letter, but they rarely referred to what I had asked, which was 
about the SC file, but they did acknowledge the letter. 
Q 
Did you reply to that letter on 7 January 1998, which we have at page 6, 
“Following on from my last letter I felt it was important that you were aware of the 
E
letter from Jonathan Haverson to Professor Southall 10 December 1996.  This was not 
in D’s notes from Staffordshire.  Also a letter from Dr Franklin May 1997, letters 
from Professor Warner as recently as November 1997.  I requested my son’s notes 
from Mr Boughey and was charged £54.  This was for incomplete notes.  Also approx 
18 pages were copied and sent and charged for”. 
Did you get a reply to that letter of 12 January from Mr Fillingham indicating, 
F
“Thank you for your recent letter providing me with further details of your 
complaint”. 
At that time were you principally complaining about the treatment of your son at the hospital 
generally? 
A 
That is correct. 
G
Q He 
said, 
“There are a number of issues on which you require clarification and further 
explanation.  This being the case I have written to Mrs Hopper, Business Manager”, 
asking her to look into the matter. 
H
A 
I think he asked Mrs Hopper to investigate my original complaint. 
T.A.  REED 
Day 6 -  72
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A
Q 
Did you return to your chase for the SC file later in January, which we can see on 
page 8 where you said in the letter dated 16 January 1998, 
“Dear Mr Fillingham, I would like to have access to my son’s file, letters in SC3874 
as soon as possible.  Does this file contain analysis of the tape saved during D’s 
admission in December 1994?  Also, would it be possible to explain why I did not 
B
receive this when I first asked for access to all of D’s hospital records?” 
A 
I did carry on chasing the file because Professor Southall was still not accepting 
professor Warner’s diagnosis and I felt that this may help with the complaint and also to 
show that my son indeed did have problems in the hospital. 
Q 
Did you, on 20 January, set out a long letter – this is the letter at page 9 dated 20 
C
January 1998 – 
“Thank you for your letter of 12 January saying you have asked Mrs Angela Hooper 
to re-open the investigation of my original complaint”. 
Again, your original complaint was about the treatment of your son generally in hospital. 
A That 
is 
right. 
D
Q You 
say, 
“The hospital has now had more than three months to complete investigations into my 
complaint.  Despite your kind offer of assistance, I cannot accept further delays.
I would ask for overdue access to the contents of my son’s SC file and any other files 
the hospital holds.  Also the specific letters that were missing from the file sent to me 
E
by Mr Boughey”. 
A 
That is correct. 
Q 
Did you set out a number of matters that you felt outstanding with the hospital at that 
time?  Can I take you, please, to paragraph 14 of the matters, which we see at the bottom of 
page 10?  At paragraph 14 of your complaints did you set out: 
F
“He kept a secret medical file …”. 
A 
Sorry, that is “separate.” 
Q 
I am sorry, I was corrected by the witness.  I did not mean to raise the temperature 
with that and I do apologise. 
G
“He kept a separate medical file on [Child D] into which part of [Child D’s] medical 
record was placed, which meant [Child D’s] official record was incomplete and he 
was denied his statutory right to access the whole of his medical record.” 
A 
That is correct. 
H
Q 
Did you add another paragraph, paragraph 15: 
T.A.  REED 
Day 6 -  73
 & CO. 

---

A
“The evidence suggests that the existence of this separate filing system was not 
known to the authorities of North Staffordshire Hospital, otherwise the contents of 
this file would have been disclosed earlier.” 
A 
I did write that because I felt I did not understand the reason why the file was not 
being released. 
B
Q 
Did you end by saying that you hoped that this clarified some of the issues along with 
the concerns in your last letter? 
A 
That is correct. 
Q 
Then did you get a reply from Mr Fillingham on 3 February, which amongst other 
things indicated (this is the fourth paragraph down): 
C
“I appreciate your concerns relating to the release of [Child D’s] medical records. 
Given the complexity of your complaint and the nature of the medical records it has 
been necessary for me to seek advice from the Trust’s Solicitors, Lexington 
Partnership.  I wish to assure you of the Trust’s co-operation in releasing the medical 
records as soon as possible.” 
D
A 
I did, which I did not understand why they needed to contact their solicitors but that 
did have me worried. 
Q 
Did you get an assurance, over the page, that if you had any further concerns or 
questions you were to contact him directly? 
A 
Yes.  Mr Fillingham was always as helpful as I think he was able to be. 
E
Q 
On 9 March (page 14) did you write, effectively, a chaser seeking information? 
A I 
did. 
Q 
On 30 March did you get a letter from Mr Fillingham (page 16) and did it indicate 
that accompanying this letter was a document (which we will come to) and you had an 
apology for the length of time it had taken him to investigate all the points, and then did he go 
on to say: 
F
“You have already had access to [Child D’s] medical records under unit number 
L22043 some time ago.  As you are already aware, there has been extensive 
correspondence and copy documentation from agencies such as Staffordshire Social 
Services, Great Ormond Street Children’s Hospital …”, 
and the health authority that is local to your home. 
G
“The Trust us unable to disclose these documents as they are confidential and do not 
form part of [Child D’s] medical records.  I would suggest that you contact these 
organisations directly for access to these notes providing them with your form of 
authority.  However, enclosed are copies from [Child D’s] health records which we 
are at liberty to disclose under the Health Records Act 1990.” 
H
Can you recall now what documents you got at that time in March 1998? 
T.A.  REED 
Day 6 -  74
 & CO. 

---

A
A 
I had still only received, I think on about two other occasions, just a few other letters 
that were just sent, I think about seven pages at one time and a few more at another, that I just 
put in the bundle; but they still were not significant and I did not understand why they were 
not sent at the same time.  I did contact the other authorities at the time, especially in relation 
to when a strategy meeting was held on 6/3/1997 at Great Ormond Street Social Services, but 
I was told that because Professor Southall had chaired that meeting they were his property 
and that they were not allowed to release them.  So, I had never seen minutes of that meeting, 
B
other than a handwritten note by Professor Stroble in Great Ormond Street records. 
Q 
Accompanying this letter, as I understand it, was the report following the report that 
was made investigating your complaints generally? 
A 
That is correct. 
Q 
It sets out in the first page (page 18) the various matters of which you complained at 
C
the various times and it records that on 24 November part of your complaint was that it was 
wrong to charge a fee for further disclosure of your child’s medical records and the fee was 
excessive.  Then it records – and these are the letters we have seen – you stated that the 
medical records released by the hospital were incomplete and you requested specific letters.  
On 5 and 7 January you raised specific complaints relating to the content of the medical 
records and the charge for the release of them. 
A I 
did. 
D
Q 
Then the matter re-opened and you requested, on 13 January, a response to previous 
correspondence and on 16 January – again, we have seen these letters already – a request for 
access to y our son’s files.  On 20 January it is recorded – and I think it is the second point in 
– overdue access to your son’s special case file. 
A 
This is the first time that I was aware that they were calling it a special case file. 
E
Q 
Then the letter went on, as you see, to summarise the 17 points that you wished the 
Trust to address and we deal with the points 14 and 15 there, which we have read earlier 
under your manuscript.  That is at the bottom of page 19.  We have seen those in the letter 
you wrote. 
A 
That is correct. 
Q 
Then there were details given in this report of the investigation and there were details 
F
given out – and we see this at paragraph 20 – of the outcome in your investigation.  It deals 
with the various paragraphs in your main letter of complaint, and if we go over the page to 
page 21 do we see that the matters relating to health records were dealt with below.  Do you 
see that sole line on page 21? 
A Yes. 
Q 
Then coming over to page 22 is there this section on health records: 
G
“Unfortunately we have, in error, disclosed information (letters, reports, etc.) to  
[Mrs D] which were confidential to other agencies and did not form part of the health 
records.
The fee charged for access to [Child D’s] Health Record file was in accordance with 
the Access to Health Records Act 1980 and in accordance with this and North 
H
Staffordshire Hospital Trust Policy is regarded as a reasonable fee. 
T.A.  REED 
Day 6 -  75
 & CO. 

---

A
With regard to further correspondence requested by [Mrs D] we have, where 
appropriate, arranged for its disclosure.” 
Did you consider that a satisfactory answer to your concerns about incomplete access to your 
child’s medical records? 
A 
I did not really understand their comments because I felt that they had not answered 
B
my questions at all about a separate file and why I had not received that separate file.  I think 
that when they said they had disclosed the information in error, that was when I did receive a 
few other letters that were from Professor Warner and other agencies, but they still did not 
make any comments on the SC file and why they were not releasing the SC file and other 
letters that I had specifically asked for. 
Q 
As a result of your concerns did you take the matter up with the Ombudsman, which 
C
we can see at page 23? 
A 
I took the complaint, yes, I did take the complaint with the Ombudsman. 
Q 
We can see it is a letter of 22 January 1999 from you to the gentlemen there of the 
Screening Unit of the Office of the Health Service Commissioner for England (Ombudsman) 
and does it start: 
D
“I am now in a position to provide you with all the documentary evidence you may 
require to investigate my case”, 
and then do you go on in the bottom paragraph to say: 
“It is my view that Professor Southall at North Staffordshire has not acceded to my 
request for access to all my son’s medical records, as the hospital claims that some of 
E
these are the property of Professor Southall, as they form part of his research.  I must 
point out that my son’s referral was an NHS referral and at no time was my 
permission sought for my son to participate in any ‘research’ programme.” 
A 
I did write this letter. 
THE CHAIRMAN:  Mr Tyson, we are approaching 5 o’clock.  Were you intending to take 
F
Mrs D through the rest of this correspondence? 
MR TYSON:  I was.  I was going to take her through the rest of (k), and it may be as good a 
time as any to stop. 
THE CHAIRMAN:  You do not feel the need to complete this particular section? 
G
MR TYSON:  No.  She is going to come tomorrow in any event. 
THE CHAIRMAN:  So you can pick it up? 
MR TYSON:  I can pick it up.  I had not realised the time, but I am perfectly content to stop 
now.
H
T.A.  REED 
Day 6 -  76
 & CO. 

---

A
THE CHAIRMAN:  In that case, if you are content we will stop now for today.  We will 
reassemble at 9.30 tomorrow morning.  I just need to remind you again that over tonight, this 
evening, not to discuss the case or your evidence. 
THE WITNESS:  I understand.  Thank you. 
(The Panel adjourned until 9.30 a.m. on Tuesday, 21 November 2006)
B
C
D
E
F
G
H
T.A.  REED 
Day 6 -  77
 & CO. 

---

GENERAL MEDICAL COUNCIL
FITNESS TO PRACTISE PANEL (PROFESSIONAL CONDUCT)
Tuesday 21 November 2006
44 Hallam Street, London, W1W 6JJ
Chairman:   
  
Dr Jacqueline Mitton 
Panel Members:
Mrs Leora Lloyd 
Mr Alexander McFarlane 
Dr Sameer Sarkar 
Mr Arnold Simanowitz 
Legal Assessor:   
Mr Robin Hay 
CASE OF: 
SOUTHALL, David Patrick 
(DAY SEVEN)
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 JOLLIFE 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
MRS D, Continued 
 
Examined by MR TYSON, Continued 
 
 
  1 
 
Cross-examined by MR COONAN   
 
 
  8 
 Re-examined 
by 
MR 
TYSON 
    22 
 Questioned 
by 
THE 
PANEL 
    24 
MRS ELINOR BETH PARRY, Sworn 
 Examined 
by 
MR 
TYSON 
    29 
 Cross-examined 
by 
MR 
COONAN 
   42 
 Re-examined 
by 
MR 
TYSON 
    49 
 Questioned 
by 
THE 
PANEL 
    50 
 
Further cross-examined by MR COONAN   
 
53 
 Further 
re-examined 
by 
MR 
TYSON 
   54 
MR JOHN WILLIAM CHAPMAN, Affirmed 
 Examined 
by 
MR 
TYSON 
    55 

---

A
THE CHAIRMAN:  Good morning.   (After a pause)  Mr Tyson? 
MRS D, Re-called
Examined by MR TYSON, Continued
Q 
Good morning, Mrs D? 
B
A Good 
morning. 
Q 
We were going through your attempts in 1987, 1988 and 1989 to find the SC file 
relating to your child.  Can I take you back, please, to bundle C2 at section 4(k), at page 23? 
A 
This is not my file.  (Same handed)
Q 
Before I take you to this document – and do not answer this question until I have 
C
heard what my learned friend has to say – is there anything about the documentation which 
I took you to yesterday that you want to say something to the Panel about? 
MR COONAN:  There may be many things that she might want to say about the 
documentation.  I do not know, madam, where this might be leading us, it is such an open-
ended question.  Either it is going to be directed to the matters that you have been invited to 
consider, or not, I do not know.  I am in the dark. 
D
MR TYSON:  Madam, perhaps I can ask your Legal Assessor to bear in mind what I am 
about to say.  Of course, I cannot speak to my witness, but I understand that my witness 
indicated to my solicitor this morning that there was something about one of the documents 
I took her through yesterday that she wanted to say something to the Panel about.  Of course, 
my solicitor could not speak to her either about what it is that this witness wanted to say.  
I indicated to my learned friend that he and I, indeed everybody, was in the dark about what 
E
this witness wanted to say, but having had that information, if this witness has something she 
wants to say about one of the documents that I have already taken her to, I think she should 
be entitled so to do. 
THE LEGAL ASSESSOR:  Madam, it is always difficult when the Panel is in the dark and 
counsel is in the dark, but as Mr Tyson has said, it is appropriate for a witness to make further 
comment about a document or evidence that has been given hitherto.  The difficulty arises if 
F
what is about to be said is something which would not ordinarily be admissible.  However, 
the safety net is here in this way, because if, when the witness says what she feels she wishes 
to say, it is apparent to counsel that this is a matter which should not be before the Panel then 
doubtless the matter will be raised.  The further part of the safety net is that you are, of 
course, a professional Panel, and if, indeed, you were to hear something which in the ordinary 
course would not be admissible, you are sufficiently able to put those matters out of your 
minds as and when it comes to considering the issues before you.  My advice to you is that 
G
you should hear what the witness has to say, hear anything to be said by counsel in the course 
of what she is saying, and then you must decide whether or not you should attach any weight 
to what she is going to put before you. 
THE CHAIRMAN:  Is that advice acceptable to you both, Mr Tyson and Mr Coonan? 
MR COONAN:  It is to me, yes. 
H
T.A.  REED 
Day 7 -  1
 & CO. 

---

A
MR TYSON:  It is to me, but I do not know whether it is to your Panel. 
THE CHAIRMAN:  I see nods all round. 
MR TYSON:  (To the witness)  Mrs D, is there anything about the documentation which 
I took you to last night that you wish to tell the Panel about? 
A 
It is actually about a document that fits in prior to this document of 22 January 1999 
B
and to the report from North Staffordshire Hospital in March 1998. 
Q 
We looked at that at --- 
A 
It actually is not in this bundle but it is very relevant to the search for the files, which
is what brought my attention to it.  It actually was not in this bundle, but that was my mistake. 
Q 
Is there another document between the one of March 1998 and January 1999 that you 
C
think is relevant to your search? 
A 
That is correct. 
Q 
Could you identify that document? 
A 
It is a document that was sent to North Staffordshire, Mr Fillingham, by Claire Davis, 
Berkshire Social Services, to do with the medical records that I had obtained and that there 
were obviously records missing and they also brought concerns from her in this letter.  Is it 
D
possible to briefly mention what was in the letter? 
MR COONAN:  I would like to see the letter first before the comments made about it. 
THE WITNESS:  I have a copy here, if I am allowed. 
MR TYSON:  Perhaps you can produce it, but not formally, so counsel can just see it.
E
(Document produced and handed to Mr Tyson and Mr Coonan)  Madam, I make no 
application that that letter should go in. 
MR COONAN:  In those circumstances I am content, because I do not think it is admissible. 
MR TYSON:  (To the witness)  As you said, you received certain information from the local 
authority, but thereafter in January 1999 you wrote to the Ombudsman, which we can see at 
F
page 23, and you indicated that you were now in a position to provide the Ombudsman with 
all the documentary evidence he may required to investigate your case.  You said: 
“It is my view that Professor Southall at North Staffordshire has not acceded to my 
request for access to all my son’s medical records, as the hospital claims that some of 
these are the property of Professor Southall, as they form part of his research.   
G
Pausing there for a moment, Mrs D, where did you get the information about what the 
hospital was claiming that you mentioned in that letter? 
A 
I believe to the best of my knowledge that this was via a phone call when I referred, 
I think to Mrs Findler on numerous phone calls to try and obtain copies of the SC file.
I explained to her how I knew that there was an SC file because on three documents in the 
medical records that relate to recording information and patient data it had an SC number.
This is when I believe she said to me that this is part of Professor Southall’s research and then 
H
T.A.  REED 
Day 7 -  2
 & CO. 

---

A
is his property.  I did later then try and clarify this in writing with North Staffordshire, but 
I do feel that I did see it written down somewhere but I cannot find that information. 
Q 
Mrs Findler, does she work for North Staffs? 
A 
She does.  I am not sure in what title. 
Q 
You went on to add: 
B
“I must point out that my son’s referral was an NHS referral and at no time was my 
permission sought for my son to participate in an ‘research’ programme.” 
A 
That is correct. 
Q 
As a result of involving the Ombudsman did you get the SC file? 
C
A 
I did not.  I had a reply from the Ombudsman which unfortunately, with the amount of 
files, I have lost – this was about six months later – and he stated that because of the time that 
my son was at North Staffordshire that it was actually out of his remit to investigate this 
further and so I had no success there. 
Q 
Did you take the matter up again with the Trust and on 22 March did you write to 
Mrs Findler at the Trust?  Could you turn to the letter at page 25 please? 
D
A 
I wrote to Mrs Findler after actually speaking to Mr Linsay at the General Medical 
Council regarding the search and the problems that I was having obtaining copies of the SC 
file and I asked for his help in obtaining these.  He then spoke to Mrs Findler by phone and 
also then spoke to me and assured me that the hospital would be forwarding this 
correspondence on and I still never received this correspondence. 
Q 
Did you write on 22 March: 
E
“Dear Mrs Findler 
I am waiting to receive correspondence in my son’s …  notes after Mr Lindsay from 
the GMC spoke to you.  He assured me that there would be no further delays.
I would also like to request as soon as possible all computerised records on my son … 
F
under the Data Protection Act.” 
A 
I did, because I felt that maybe the SC file was being held on computer as well and 
that would be a way of obtaining the records. 
Q 
On the 29th did you receive a reply to that letter from the executive director, 
Mr Blythin, which we see in page 26? 
G
“Further to my letter dated 23rd March I am now in a position to respond as follows: 
With reference to your request for copies of documentation since September 1997, 
I confirm that there is no additional documentation other than that which was sent to 
you on 30th March 1998.” 
H
T.A.  REED 
Day 7 -  3
 & CO. 

---

A
A 
I did receive this letter but they are still not answering the issue of other records that 
I believed were in the SC file regarding my son’s admission at North Staffordshire Hospital. 
Q He 
says: 
“There is, however, copy documentation from agencies such as Slough Social 
Services, East Berkshire Community Health and Southampton General Hospital 
B
which the Trust is unable to disclose.  I would suggest, therefore, that you contact 
these organisations directly for access to these notes providing them with your form 
of authority. 
Regarding the computerised records, I have asked Stuart Webb, Information Security 
Project Manager, to contact you direct concerning access to these documents.” 
C
A I 
did. 
Q 
When you got that assurance on page 26 that there was no additional documentation, 
what did you consider in relation to that answer? 
A 
I was aware that there was other additional documentation that was not in the other 
hospital records because I had already received records from the other authorities, including 
social services, and Great Ormond Street social services actually stated that some of the 
D
documentation was Professor Southall’s property because he had chaired that meeting, and 
I was unable to obtain copies of that from anywhere. 
Q 
Did you reply to that letter of the 29th by your letter of 30 March at page 27 to 
Mr Blythin: 
“Hoping to have your response shortly.  There is another matter that I would be 
E
grateful for your clarification. 
Mr Fillingham stated that I would not be allowed access to the second file on my son 
… (SC file) as this was not part of my son’s medical records. 
Is the second file part of Professor Southall’s research? 
F
Could you please clarify this question as soon a possible to the above fax number.  
Also if the file is not part of the research could you please clarify what the file 
contains and why it was held on my son …”. 
A 
I did write this letter because I felt that if they were not medical records, I felt the only 
other reason was the research which has been told to me on the phone, that these records 
could be part of research or were part of research. 
G
Q 
Did you get answer to that question on page 28, which was saying: 
 
“I have asked for consideration to be given to your queries, following which I will 
write to you again.” 
A 
There were still no answers. 
H
T.A.  REED 
Day 7 -  4
 & CO. 

---

A
Q 
Then did you write again, effectively chasing, on page 29: 
 
“Despite several phone calls and queries I have not received a telephone call or fax 
from yourself re the S/C file 3874 held on my son ….. I recently received 
computerised records which stated a diagnosis of dysponea and respiratory 
abnormalities despite Prof Southall stating that everything was normal.” 
B
A 
I did write this letter, but I believe that there may be some confusion with the date, 
because I have put on there April 99 and I stated that I had received computerised records, 
but I actually did not receive those until June 99, so whether that was with my stress at the 
time I put the wrong date, I do not know, but I did write that letter.  In fact, the computerised 
records that it is talking about was only faxed to me.  That has not been seen in any of the 
medical records. 
C
Q 
We will come on to those computerised records in a moment.  Again, did you chase 
the matter in May 1999, the letter at page 30: 
 
“I would be grateful if you could respond to my queries re the file on my son ….. S/C 
3874.  I received a letter from you dated 30th March 99 in which you stated that you 
were asking for consideration to my queries.  This was five weeks ago and as yet 
I have not received any further response.” 
D
A 
I did carry on chasing up the records because by then I was aware that Professor 
Southall had made further contacts with child protection regarding his concerns for my son 
despite his name being removed from the “at risk”, and I felt that it was only possibly by 
receiving the SC file that I could protect my son and keep him safe with the information that 
may be held in there. 
E
Q 
Did you get a letter in response to that from Mr Blythin, which we have at page 31: 
 
“Further to your letter ….. I am writing to inform you that the investigation into the 
questions you raised in your letter ….. are taking longer than anticipated.” 
A 
I think it was just acknowledging my letter, but there was still no answer to my 
concerns.
F
Q 
Could you look at section 6 within the file that you have in front of you and go to tab 
(b) within 6.  Do you have that, Mrs D? 
A I 
do. 
Q 
Did you become aware later that at about this time Professor Southall wrote to the 
Deputy Business Manager on North Staffordshire Hospital on 16 April about your son D: 
G
 
“In no way was [Child D] subject to any form of research in my department.  
I enclose his special case file so that you can look through it and decide how you 
describe the various contents of this.  My view is that they are part of social services 
and other hospital records rather than being directly related to his admission to the 
North Staffordshire Hospital under my care as a consultant paediatrician.” 
H
T.A.  REED 
Day 7 -  5
 & CO. 

---

A
A 
Unfortunately I cannot remember when I did receive this letter.  I am not sure whether 
I only saw this when we eventually did receive the SC file or before, but as it shows, 
Professor Southall did acknowledge that it did form part of other hospital records. 
Q 
Did there come a time when you found or were sent the computerised records that 
were held on the main computer at North Staffs Hospital relating to your child? 
A 
Sorry, could you repeat the question? 
B
Q 
Did there come a time when you received the computer documentation? 
A 
I did receive the computer documentation. 
Q 
Can you turn back to where we were before, which is 4(k) at page 32.  Is this a letter 
from the Information Security Project Manager to you dated 27 May 1999: 
C
 
“Please find enclosed copies of the computerised records held on computer systems at 
North Staffordshire NHS Trust for [Child D] as you previously requested.” 
Turning over the page at page 33, did you get this document, which appears to contain a 
number of dates relating to your admissions? 
A 
I did receive this document.  I believe that there was another document very similar to 
this that actually quoted diagnosis. 
D
Q 
Can we turn over the page to page 34, and does this give descriptions of the 
symptoms involving respiratory systems and other chest, dysponea and respiratory 
abnormalities? 
A 
I did not receive this in the first set.  This was what was actually faxed to me.  It was 
just a précis saying “diagnosis” but not with this amount of information on there, so I realised 
that there was information missing and I contacted Mr Webb again and he said, “Yes”, there 
E
was a printout diagnosis and he faxed me that day this paper. 
MR TYSON:   Can I just show a document to my learned friend.  (Same handed to 
Mr Coonan)  (To the witness)  If you look at this document, please.  (Same handed)  Does 
that have manuscript on it saying: 
 “2.6.99 
F
 
[Ms D] phoned 
-
waned to see diagnosis of her son 
-
faxed through”. 
A 
That is correct.  This is what I was referring to. 
G
Q 
Is there a fax date on that saying 2 June at 1708?  Perhaps the members of the Panel 
can put that in their bundle perhaps at 34A.  (Same handed)  Turning 34A upside down, is 
that the same as page 34? 
A 
As far as I can see, yes. 
Q 
So you have got the document that we see at page 34 later, having discussed the 
matter that you wanted to see something about a diagnosis? 
H
A 
That is correct. 
T.A.  REED 
Day 7 -  6
 & CO. 

---

A
Q 
You see that there is a diagnosis there that appears to be dysponea respiratory 
abnormalities.  How did that information compare with the information that you had had 
from Professor Southall about your son when you had seen him in 1994? 
A 
Professor Southall actually stated that everything was normal, but he also stated in the 
chronology that on analysis of tape recordings there were no abnormalities.  That is why 
I was surprised there were no records or analysis in the medical records showing what was 
B
analysed after tape recording. 
Q 
Looking at page 35, did you get that information with the letter from Mr Webb that 
we see at 32? 
A I 
did. 
Q 
Did you notice anything about that in terms of the numbering on it, or the like? 
C
A 
I noticed again that it had missing at the top but number 3874, again relating to 
recordings, but I was surprised to find at the bottom of the page about a Brompton number 
and the words “Outcome:  Death?”;  I just did not understand this patient data.  It appears, 
whether it was related to the Brompton Hospital, I do not know. 
Q 
So having received the computer data in May, did you renew your search for the 
actual SC file, which we can see at page 36? 
D
A 
I did, because I felt that there obviously was more documentation missing. 
Q 
Was this a letter to Mr Blythin: 
 
“Despite numerous telephone calls in which I have spoken to your secretary because 
neither yourself or Mrs Fidler have ever been available, and faxes sent, you have still 
failed to contact me in reference to my question regarding S/C file ….. 3874 held on 
E
my son ….. I was told that this file was not part of [my child’s] medical records.  
I therefore asked if it was research, whether CVS was undertaken.  I originally asked 
these questions [in February] 1999.  Please can these questions be answered, also can 
I now have access.” 
A 
I did ask these questions because I wanted it in writing exactly what the SC file 
contained, but also by this time I was made aware that the room in North Staffordshire that 
F
my son was in for the three nights was the room that CVS was undertaken. 
Q 
For members of the Panel who do not know what CVS means, what does that mean? 
A 
Covert video surveillance.  I would like to say that I did have no concerns whether 
there was covert video surveillance there, but I felt that, you know, I should maybe have been 
aware.
G
Q 
As a result of that letter did you get access to the SC file? 
A 
I still did not have access to the SC file.  I would like to say, if it is possible, that when 
I said that I was not concerned about the covert video surveillance was that there were 
suggestions that Professor Southall was accusing me of harming my son and I felt that with 
that, that would show that I was not harming my son. 
H
T.A.  REED 
Day 7 -  7
 & CO. 

---

A
Q 
Did there come a time in July 2002, so this is moving on about three years after the 
correspondence that we are looking at, did you do a statutory declaration in support of your 
complaint to the General Medical Council? 
A 
Should I have that in front of me, or not? 
Q 
No, you should not.  I am just asking you to confirm whether you did a statutory 
declaration in support of your complaint to the General Medical Council in July 2002? 
B
A 
I did make a statutory declaration, but I am not too sure of the date. 
Q 
I do not think it is disputed that it was July 2002.  By that time, July 2002, did you 
have access to your SC file? 
A 
I still had no access. 
Q 
Can you tell the Panel, please, when, and the circumstances in which, you got access 
C
to your SC file? 
A 
Do I need to speak about the in-between period where there were things going on that 
I was told I would have access to? 
Q 
No.  I want you to tell the Panel when you got access.  I am told I can lead.  Did you 
have a solicitor acting for you in relation to your civil claim called Rachel Vasmer? 
A I 
did. 
D
Q 
Did she make inquiries on your behalf to seek to obtain the SC file? 
A 
Mrs Vasmer made inquiries for over a year herself to obtain copies of the SC file. 
Q 
Did there come a time, out of the blue, when she was asked simply to pay the access 
fee, and the SC file was sent to her in July 2003.
A 
She did, but prior to that she had stated that she might have to make application to the 
E
court to obtain the records, on two occasions.  Then she was asked to pay the access fee and 
was sent the records I think in June 2003. 
Q 
You told us yesterday that when you initially asked for the North Staffordshire 
records for your child, you received 18 pages. 
A 
That is correct. 
F
Q 
When you received the SC file, which we have at C6, were you surprised at its 
volume? 
A 
I was surprised at the volume, but I still felt there was documentation missing from 
the SC file. 
MR TYSON:  Thank you, Mrs D.  Wait there because there may be more questions. 
G
Cross-examined by MR COONAN
MR COONAN:  Mrs D, just to clarify one small matter in relation to the questions Mr Tyson 
was asking you.  Your solicitor, Mrs Vasmer, in connection with a potential civil action you 
were bringing was in communication with solicitors acting for the trust, was she not? 
A 
She was.  That was a George Davis. 
H
T.A.  REED 
Day 7 -  8
 & CO. 

---

A
Q 
Yes, George Davis & Company were the solicitors for the trust.  She was 
communicating with them and you tell us for quite some time, you said for over a year. 
A 
It was six months with George Davis and then six months with Hempsons. 
Q 
It was as a result of following Hempsons involvement. 
A Yes. 
B
Q 
But of course, Hempsons were not acting for the trust, were they? 
A 
I do not know. 
Q 
I am told that is right.  So following Hempsons intervention on behalf of the trust, it 
was shortly after that that the SC files appeared. 
A Six 
months. 
C
MR TYSON:  My learned friend appeared to be saying that Hempsons were acting on behalf 
of the trust.  I understand that Hempsons were acting on behalf of their current client. 
MR COONAN:  I just want to clarify this.  Hempsons were involved at a later stage because 
of the legal action that you brought against the trust and other agencies. 
A 
That may be where the involvement was. 
D
Q 
Absolutely, but at first it was George Davis. 
A That 
is 
right. 
Q 
It was following their involvement, over a period of time, that the SC files then 
appeared.
A 
That is correct. 
E
Q 
I just wanted to clarify that.  Mrs D, I want to take you back a long time ago, 12 years 
ago to December 1994 when you saw Dr Southall.  Do you remember where you were when 
you saw him? 
A 
Was this on the ward round? 
Q 
You tell me where it was you saw him.  I do not know. 
A 
In December 1994 it was on 15th because my son was admitted on the 12th.  This was 
F
after three nights recordings and I saw Professor Southall on the afternoon of that day. 
Q Where? 
A 
I believe it was in a corridor, but I cannot be absolutely certain whether it was a large 
room or a corridor, but I believe it was in the corridor outside the play room. 
Q 
Where is the ward where your son was in relation to the corridor? 
G
A 
I cannot be absolutely 100 per cent certain because it was a long time ago, but if 
I could explain, from what I can recollect, the day room was here, the corridor was here, and 
I believe the ward and the room may have been at the top.  I believe but I cannot be 
absolutely 100 per cent certain. 
Q 
You are in a corridor.  You are not sure whereabouts it was. 
A 
I know it was in the close vicinity of the playroom and the ward we were in. 
H
T.A.  REED 
Day 7 -  9
 & CO. 

---

A
Q 
Is this right, you then saw Dr Southall, in the corridor? 
A Yes. 
Q 
With some other doctors. 
A 
With some other doctors and I believe there could have been one or two nurses there. 
Q 
Was Dr Samuels part of the group of doctors? 
B
A 
I had never met Dr Samuels so I was not aware of who the other doctors were, but the 
records show that Dr Samuels was there so I believe he was on the ward round. 
Q 
Pause there.  I do not want you to engage in reconstruction 12 years later by reference 
to medical records.  I am asking for your recollection. 
A 
I do not know who the other doctors were. 
C
Q 
Do you see the danger of trying to reconstruct events by looking at documents which 
are not yours? 
A 
That is only in relation to you questioning me on the name of the doctor. 
Q 
But you do not know is the answer. 
A 
I do not know who the doctors were. 
D
Q 
Were they coming down the corridor? 
A 
I hope you realise, as you said again, that it was 12 years ago and there are aspects of 
that meeting about which I am not very clear, but there are aspects, as I explained yesterday, 
that are imprinted in my memory. 
Q 
That may be, and we will explore those in a minute.  My question was, were they 
walking towards you? 
E
A 
I am not too sure.  All I remember was that I looked and I saw Professor Southall 
there with a number of other doctors with a trolley with the records on.  That is what 
I remember seeing. 
Q 
Did these doctors appear to be talking together? 
A They 
did. 
F
Q 
You went up to them because you had questions to ask. 
A 
I went up to them because I did not want them to miss seeing my son because he was 
not in the ward or in the room. 
Q 
But you had questions to ask, things to say. 
A 
No.  We were told that we would be seeing them because we were supposed to be 
going home that day. 
G
Q 
But you went up to the group to speak to Dr Southall, did you not? 
A 
I went up to the group to let them know that we were there. 
Q 
But to speak to them. 
A 
I assumed that they wanted to speak to us, because my son was supposed to be going 
home. 
H
T.A.  REED 
Day 7 -  10
 & CO. 

---

A
Q 
I am trying to understand the dynamics.  You are in one area.  You see this group and 
you go up to the group intending to speak to them. 
A 
From my recollection, I believe I may have just stood there so that they would be 
aware that we were there. 
Q 
You remember that, do you? 
A 
I remember standing there, but I cannot remember whether it was me that initiated 
B
talking to the doctors or whether the doctors initiated talking to me. 
Q 
You were at a time when your son entered hospital in December 1994, so you must 
have been a rather anxious mother. 
A 
I was anxious at times, yes. 
Q 
You must have been additionally anxious because of the events of the previous 
C
evening.
A 
I was worried, but my son had had events similar to that before so I was no more 
anxious than I had been for a long long time. 
Q 
You drew particular attention yesterday, the attention of the Panel, to the nursing 
record, did you not? 
A 
I did make note. 
D
Q 
Obviously you wanted to know from Dr Southall, as the consultant, what the position 
was, did you not? 
A I 
did. 
Q 
He told you – let us see if we can agree about this – that everything appeared or was 
normal. 
E
A 
That is correct. 
Q 
You appreciate I cannot put to you verbatim pieces of conversation because of the 
time lapse.  You understand? 
A Yes. 
Q 
So I am putting to you the gist of what I do not challenge.  You were told that 
F
everything was normal. 
A 
That is correct. 
Q 
That he, Dr Southall, wanted to refer your son to Professor Warner. 
A 
That is correct. 
Q 
Who was an expert allergist of experience and expertise across the world. 
G
A 
That is correct. 
Q 
When Dr Southall told you of those two factors, it would have been absolutely clear 
to you that you would not, in the circumstances, be getting the monitor. 
A 
As I said yesterday, I was aware that we would not be receiving the monitor. 
Q 
Which is what you actually wanted to have, is it not? 
H
T.A.  REED 
Day 7 -  11
 & CO. 

---

A
A 
I felt that if the doctors could not explain what was happening to my son or he could 
not be helped, that was the only way, so I was actually pleased at the referral to somebody 
that may be able to explain what was happening to my son, and more to help him so there 
would not be a need for a monitor. 
Q 
But you must have been disappointed that you were not getting a monitor and that 
Dr Southall had not, at that stage, provided a solution to the problem. 
B
A 
I believe that I accepted that he was not going to give a monitor, and I felt that he did 
not understand my son’s problems, because he was not an allergist and I felt that at least he 
was referring me to somebody who may be able to help. 
Q 
So you felt that he did not understand your son’s problems. 
A 
Because he said that everything was normal. 
C
Q 
You are quite a vocal woman, are you not? 
A 
Could you please explain? 
Q 
You are quite vocal. 
A 
What do you mean by “vocal”? 
Q 
You are not afraid to express what you think. 
D
A 
I would not really call myself vocal. 
Q 
You are quite demanding. 
A 
I would not call myself demanding. 
Q 
You would not? 
A 
No, I would not.  As I said, I did not demand a monitor and when I realised that we 
E
were going home without a monitor I did not even broach the subject with Professor Southall. 
Q 
The third matter about which you and I are not going to be in dispute, is that 
Dr Southall probably said words to the effect that there was no such thing as a delayed 
reaction.
A 
He did indeed.  To my recollection he did state that. 
F
Q 
I am not challenging that, again with the proviso that it is not verbatim because of the 
lapse of time, but words to that effect there is no dispute about. 
A Right. 
Q 
But I do want to come to the area about which there is dispute.  You told the Panel 
yesterday that Dr Southall said these things, and in particular when he said there was no such 
thing as a delayed reaction, with an angry voice. 
G
A 
He did raise his voice. 
Q 
Let us look at that.  He raised his voice.  Yesterday you described it as representing 
anger.
A 
A raised voice with an angry tone. 
Q 
How often had you had to experience how Dr Southall talks? 
H
T.A.  REED 
Day 7 -  12
 & CO. 

---

A
A 
I had only seen him on the one occasion prior to that and he had not raised his voice at 
all.
Q 
You had seen him almost on a one to one basis in a consultation room, had you not? 
A 
At that one time we did, yes. 
Q 
Here you are, coming across a group in a corridor, doctors, probably nurses, talking 
B
together and you – I do not mean to be pejorative – intervene. 
A 
I do not believe I intervened.  I believe I stood there and waited, because that would 
not be my way. 
Q 
Who else was around in this corridor? 
A 
As you say, going back so many years at first I felt that my ex-partner was there, 
because he was there at the beginning, but it was clear that he was not in the corridor.  
C
Peripheral to how Professor Southall spoke to me, other than realising at first the doctors and 
the nurses there, it was insignificant really whether my ex-partner was nearby. 
Q 
You have told us he was not there. 
A 
He was not there, no. 
Q 
I will come back to that in a minute.  Were other parents or members of the public 
D
present?
A 
I did not see anybody.  It seemed quite quiet in the corridor. 
Q 
I just want to examine this.  You are saying that because of a raised voice, which you 
had not experienced when you met him the first time, and the tone of that voice, you 
concluded, and concluded at that time that he was angry.  Is that right? 
A 
I felt sick at the way Professor Southall spoke to me and I can only remember that as 
E
being when somebody speaks angrily at you. 
Q 
Not sick because you had received disappointing news? 
A 
No, because at that time I was not aware that we were not going home with the 
monitor.  As I explained before, I was actually happier that Professor Southall was referring 
my son to somebody that could sort out the problem rather than the need for the monitor. 
F
Q 
Let me come straight to the point.  I am going to suggest to you that Dr Southall was 
not angry, he did not raise his voice and he was not dismissive. 
A That 
is 
incorrect. 
Q 
There is a difference, is there not, would you say, both in quality and degree between 
somebody who would appear to you to be angry with a raised voice on the one hand, and on 
the other hand, somebody who was merely abrupt in conversation?  There is a difference, is 
G
there not? 
A 
I think there is a big difference. 
Q 
There is a difference.  Your partner, let us just look at him for a minute.  He, you tell 
us, was present at least at the beginning of this episode. 
A 
That is correct. 
H
T.A.  REED 
Day 7 -  13
 & CO. 

---

A
Q 
But at some stage in this short encounter, a nurse came up to him and asked him to 
come away for a cup of coffee. 
A 
I did not hear that and I did not see that.  It is only with talking with my ex-partner 
that that is what he explained happened. 
Q 
When did he tell you that? 
A 
This was not that long ago, so I do not remember it at the time.  I do not remember 
B
him saying that at the time. 
Q 
But when did he tell you that? 
A 
It was in conversation, I think, after I was aware that he was not going to make a 
statement to the General Medical Council. 
Q 
After you realised that he was not going to make a statement? 
C
A Yes. 
Q 
But he has made a statement, has he not? 
A 
I was not aware because I have not been in that much contact with him. 
Q 
Are you saying you do not know that he has made a statement to the General Medical 
Council? 
D
A 
I believe the General Medical Council were going to ask him to make a statement, but 
whether he actually made one, I am not absolutely certain. 
Q 
So if what you are saying is right, and this account you have given – namely, that he 
has told you that he went off and had a cup of coffee -- 
A 
I do not know whether he actually went off or was told to go off.  I do not know 
whether he actually went. 
E
Q 
Let us go back to the beginning.  As far as you were aware, at the time of this 
encounter your partner was present. 
A 
Because he was there initially.  I hope you realise that it was a long time after the 
incident that I was asked to give an account of this, and that was in my first statement in 
2002, so I gave an account to the best of my knowledge.  I was not asked to go into detail in 
that account so in my first statement it was a very brief description. 
F
Q 
Let us go back.  Your understanding, your own recollection was that your partner had 
been present during this encounter.  Is that right? 
A 
I felt that he was, yes. 
Q 
On that basis there would have been no reason why he would not have been able to 
hear and see what Dr Southall was saying. 
G
A 
He obviously was not there because -- 
Q 
Let us just think for a moment.  If he was there, on the assumption that you have 
given us that he was there, he would have been able to witness the event, would he not? 
A 
That is correct. 
Q 
The account you gave yesterday therefore, about your partner being asked to go off 
H
for a cup of coffee by the nurse, is, you tell us, something your partner has told you about 
T.A.  REED 
Day 7 -  14
 & CO. 

---

A
only relatively recently.  Let us just examine that.  The picture is, is it, that just at the moment 
when you are about to speak to, or perhaps have even begun to speak to Dr Southall, your 
partner is asked by a nurse to go off for a cup of coffee. 
A 
Which I found, as you said, very odd. 
Q 
I was about to suggest it myself.  That did not happen, did it? 
A 
He told me that it did. 
B
Q 
I suggest to you that your partner was present throughout this encounter. 
A 
If he was present then he would be able to back up what I am saying about Professor 
Southall, but he obviously was not present. 
Q 
I am suggesting that he was present, and whether he backs up what you say remains to 
be seen.  There is no reason why, with you and your partner wanting to find out what was 
C
going to happen to your son, your partner, just at a crucial moment, should slip away for a 
cup of coffee, is there? 
A 
Maybe he felt that the doctor was going to say things that it would be better that my 
son did not hear.  Maybe that is why he thought the nurse said that to him, and I think that 
same thought went through my mind. 
Q 
You made a statement to the General Medical Council – I use the word “statement” 
D
deliberately – in November 2004, did you not? 
A I 
did. 
Q 
I think it might be helpful if you had a copy of this document in front of you so you 
do not just take it from me. 
A 
I do remember saying in that statement -- 
E
Q 
Just pause for a moment please.  I have a clean copy here which you can be shown.
(Document handed)  Just confirm, please, that it was made for the purposes of this hearing. 
A 
That is correct. 
Q 
If you look at the last page you will see your signature. 
A 
That is correct. 
F
Q 
And the date 22 November 2004. 
A 
It is not very clear, but I accept that. 
Q 
For my purposes for the moment, please, I want you to read through that where it is 
relevant, and I will suggest where it might be relevant in terms of the chronology.  Just read it 
through silently to yourself and I shall just ask you the question.  Take your time and begin, 
perhaps at paragraph 10.  (Pause for reading)
G
A 
Did you just want me to read 10 to 13? 
Q 
Paragraph 10 to 15 if you like, or 10 to 16. 
A 
(After a pause)  Yes. 
Q 
That document was written, as you have said, in November 2004.  It is almost exactly 
ten years after these events. 
H
A 
That is correct. 
T.A.  REED 
Day 7 -  15
 & CO. 

---

A
Q 
Can you just confirm this point, and that exercise simply goes to this point ---? 
A Yes. 
Q 
There is no suggestion in that statement that your partner was asked to leave for a cup 
of coffee during this encounter, is there? 
A 
No, because I do not believe that that was relevant to how Professor Southall spoke to 
B
me. 
Q 
In fact, on the contrary, the description you give, if you look at paragraph 13 in 
particular, and over the page, the rest of paragraph 13, you are describing the events by using 
the word “we” are you not?  That is you and your partner? 
A 
Yes, but I believe it was because we were initially there and maybe that is why 
I carried on using the word “we”, I do not know. 
C
Q 
The fact is that is the first time you have ever mentioned that your partner was not 
present during the time when you say Professor Southall was displaying anger.  The first time 
you said that was in your evidence yesterday, 12 years later.  Is that right? 
A 
I am not sure whether I had said it before, but I will accept that that is what you said 
because I do not recall when I said it to my solicitors, that I realised that my son’s partner was 
not there. 
D
Q 
You told your solicitor, have you? 
A 
I do not know.  Because to me this is a small, insignificant matter, it does not stick in 
my memory and some things are confusing. 
Q 
Just this question:  When did you tell your solicitor, if you did? 
A 
I do not know; I do not recall. 
E
Q 
Are you saying you do not recall if you ever have? 
A 
I believe that I must have spoken to them after I spoke to Mr Butler. 
MR TYSON:  My learned friend is aware that he is treading on extremely sensitive matters 
involving legal professional privilege. 
F
MR COONAN:  Maybe, but I am suggesting to you that this is the first time that this 
appeared in any document that I have seen. 
A 
It may have done, but I still feel that because of the time lapse there are things that 
I cannot remember about that day, but I do remember how Professor Southall spoke to me 
because it left a lasting memory. 
Q 
A lasting memory? 
G
A Yes. 
Q Okay. 
A 
One that I would hope to forget, but I cannot. 
Q 
Before leaving your partner, for the minute, where is he? 
A 
Where does he live, you mean? 
H
T.A.  REED 
Day 7 -  16
 & CO. 

---

A
Q Yes. 
A 
I believe he lives somewhere in Hampshire but I do not know exactly where. 
Q 
You do not know his address? 
A 
No.  He had contact with my solicitors to a phone number; I gave them his telephone 
number because I have contact with him through a telephone number. 
B
Q 
It is likely, of course, that your solicitors, Field Fisher Waterhouse, would have his 
address? 
A 
I do not know.  I do not know whether he took their address or whether they have his.
I do not know. 
Q 
Let us just move on to other matters.  You told us that these events were, in effect, or 
at least some of them, firmly etched in your mind? 
C
A Some 
parts 
are. 
Q 
You described it yesterday, or the process was that you looked back and got your head 
around it? 
A 
I think by that it means that …  When you are concentrating and trying to remember 
things there are other things that trigger your memory, and you remember things that you 
may not have remembered when you spoke about an occasion previously.  Is that how your 
D
mind works?  I do not know, but I believe that by really thinking and going through things 
that I was able to recall. 
Q 
You started the process of making a complaint to the GMC in I think 1997, did you 
not? 
A 
That is correct. 
E
Q 
You wrote a letter to the GMC and also again in July 1999? 
A 
I have written various letters to the GMC. 
Q 
As part of the obligation of disclosure which is on your solicitors, we have been able 
to see those letters.  All right? 
A Yes 
F
Q 
As you have already said to the Panel this morning, you made a statutory declaration? 
A 
That is correct. 
Q 
In July 2002? 
A 
That is correct. 
Q 
I am going to ask you, please, to look at a paragraph in that statutory declaration.  You 
G
will be handed a clean copy and it has been flagged up with a yellow sticker.  (Same handed)
Just before you open it up, Mrs D, you will see that on the first main page it sets out your full 
name and your address.   
“I solemnly and sincerely declare that in December 1997 and on 15 July 1999 I made 
a complaint to the GMC, which amongst other matters concerned Professor Southall, 
in the form of a letter of complaint the details of which are as follows…”, 
H
T.A.  REED 
Day 7 -  17
 & CO. 

---

A
and then you set out the details of your complaint? 
A 
That is correct. 
Q 
I want to take you, please, to paragraph 97, which is the page with the yellow sticker 
on.
MR TYSON:  Out of fairness to this witness she could read herself into this, perhaps starting 
B
at paragraph 94. 
MR COONAN:  Yes, of course.  Yes, just pick it up at paragraph 94 please.  You can read 
into that. 
A 
(After a pause)  Yes. 
Q 
Have you read paragraph 97? 
C
A I 
have. 
Q 
Can you just please read out for the Panel paragraph 97?  Take it slowly. 
A 
I am not allowed to use the names, am I? 
Q 
For these purposes I do not think there is an objection to using the first name. 
A
D
“Chris and I saw Professor Southall on the ward round on the morning of the 15th
January 1995.  Professor Southall was very abrupt and said that there was no such 
thing as ‘delayed allergic reactions.’  He said he wanted [Child H] to see an Allergist, 
namely a Professor Warner.  He said everything was normal.  [Child H] was not given 
a monitor and we were sent home thinking that everything was safe.” 
E
Q 
That is all you say about the incident?  Just pause for a minute. 
A 
Yes, that is all I said at that time. 
Q 
You are eager to say, but just pause for a minute.  In fairness to you, there was an 
error in the date.  That should be a reference to 15 December --- 
A 1994. 
F
Q 
-- as opposed to January 1995? 
A 
That is correct. 
Q 
Mistakes can be made about dates; I fully understand that.  The paragraph you have 
read out is really all that you said in this document about the incident that the Panel is 
concerned with.  Is that correct? 
A At 
that 
time. 
G
Q 
At that time, and the date again for us, please, at the end of the document? 
A 2004. 
Q 
You will see on the last page --- 
A 
2002, sorry.  4 July 2003. 
H
Q 
4 July 2002? 
T.A.  REED 
Day 7 -  18
 & CO. 

---

A
A 
That is correct. 
Q 
It finishes, if you look at paragraph 223: 
“I make this solemn declaration consciously believing the same to be true and by 
virtue of the provisions of the Statutory Declarations Act 1835”, 
B
and it sets out your signature.  The account you gave there in 2002 was even then eight years 
after this incident, was it not? 
A It 
was. 
Q 
Approximately.  You were no doubt assiduous to put into this document everything 
that you felt relevant to making a complaint against this doctor stick, were you not? 
A 
No, because as you can see, it was just a very brief account of that account with 
C
Professor Southall because my main concern was not how Professor Southall spoke to me, 
my main concern was the harm that he had done to my son, so I concentrated the complaint 
more on that rather than this aspect. 
Q 
Mrs D, I fully understand that you had complaints against Dr Southall and they are set 
out in this document.  I do not dispute that. 
A Yes. 
D
Q 
You brought legal proceedings, not in his name, let it be said, but against the Trust 
and various other agencies, have you not? 
A Yes. 
Q 
Not against him personally, but in relation to this situation in 2002, setting out in 
detail, I suggest, the nature of your complaints against him, all that you said is in relation to 
E
paragraph 97? 
A Yes. 
Q 
It may be self-evident but let us go through it.  There is no reference in that paragraph 
to Dr Southall being angry in the way in which he dealt with you and possibly your partner, is 
there? 
A 
Because I did not go into detail of that account in this statement. 
F
Q 
No reference to the tone of voice he was using? 
A 
Because I did not go into a complete account because I felt that the other concerns, 
especially to do with the harm to my son, was far more relevant than what was actually said 
to me. 
Q 
No reference at all to you feeling sick as a result of his conduct? 
G
A 
As I again say, it was not how I was treated at that time, it was my son. 
Q 
No reference to you being frightened by what he said to ask questions? 
A 
I reiterate that I did not go into detail because I felt that the other concerns were far 
more serious because they were due to causing harm to my son rather than how I was treated 
by Professor Southall. 
H
Q 
And no reference to Dr Southall being dismissive, waving, turning round? 
T.A.  REED 
Day 7 -  19
 & CO. 

---

A
A 
No, because I did not go into detail. 
Q 
You see, you have started the process of bringing complaints against this doctor, and 
if, in 2002, these matters that you described, if I may say so, graphically to the Panel 
yesterday, had made a lasting impression on you in 2002, they would have been no reason for 
you not to put it in this document, would there? 
A 
As I say, my main concerns were to the harm to my son caused by Professor Southall, 
B
not me.  It was only at a later date when I was aware that this was a serious concern 
according to the general medical practice in how patients are treated that I then went into 
more detail with this account, when I was asked to. 
Q 
You see, so that we have it absolutely clear, 2002 in the statutory declaration was 
indeed the first time ever you had complained about what I am going to call a “corridor 
incident”, is it not? 
C
A 
I am not too sure.  I cannot recollect when I did first talk about the corridor incident, 
because, as I said, my main concern was my son and not me. 
Q 
Whatever may have been your motivation, it may have other consequences, but so 
that there is no doubt about it, I am putting to you a positive suggestion that this was the first 
time you had made a complaint to anybody about what I am calling the “corridor incident”, 
eight years later? 
D
A 
It may have been, yes. 
Q 
It follows, does it not, that at the time you made no complaint to the nursing staff? 
A 
About how Professor Southall spoke ---? 
Q Yes. 
A 
No, because my main concern was my son. 
E
Q 
I just want to go through this, you see.  The Panel can make an assessment.  You did 
not make any complaint to the hospital about his conduct? 
A 
No, because I felt that that was irrelevant considering all the other concerns at the 
time. 
Q 
That may be, but if what you say is right as being an accurate assessment of what 
F
happened on that corridor in 1994, whatever may have been your other concerns – and I do 
not dispute them – you are going to complain about this doctor’s conduct if what you say is 
right as to the extent of it. 
A 
This was just a very brief account of the concerns. 
Q 
You did not complain to the hospital did you, that is the point, at any stage prior to 
2002? 
G
A 
Not about how Professor Southall spoke to me, no. 
Q 
You see, not only was there no reference to the corridor complaint in your letters to 
the GMC which were referred to on the first page of the statutory declaration, not only no 
reference there, but a complaint was made by you to the Trust in about 1999/2000, was there 
not? 
A 
I cannot remember all the dates because this has been such a complex history over a 
H
number of years. 
T.A.  REED 
Day 7 -  20
 & CO. 

---

A
Q 
Do you remember making a complaint to the Trust? 
A 
I do remember making a complaint, yes. 
Q 
I am suggesting to you that it was round about 1999/2000? 
A Right. 
B
Q 
So two years or may be three years – the precise time does not really matter – before 
this statutory declaration? 
A 
I would believe that I made a complaint to the Trust prior to the GMC or round about 
the same time as the GMC. 
Q 
But prior to the statutory declaration? 
A 
That is correct. 
C
Q 
Then we agree about that, and I am going to make this suggestion to you so that it is 
out in the open, that you made no complaint to the Trust in 1999/2000 about Dr Southall’s 
conduct in the corridor? 
A 
I did not, because my main concern was to keep my son safe and my main concern 
was the harm that Professor Southall was causing to my son.  They were my main concerns. 
D
Q 
I cannot put a precise date to you because I am not privy to correspondence you may 
have had with third parties, but round about 2000-ish you enlisted the support of Penny 
Mellor, did you not? 
A 
I did not enlist the support, and it was actually 1999.  I was given her name by 
somebody as just somebody to talk to because she was aware of other mothers that had been 
wrongly accused.  I did not need her support because I had already made my complaint to the 
GMC.
E
Q 
 This is the important point for my purposes.  If I could put it this way, Penny Mellor 
was on board before you made the statutory declaration, was she not? 
A 
She was, but I did not talk to her about my declarations or my statements, she was just 
purely somebody that I could talk to that was aware of what was happening at the Trust and 
with other parents.  At no time did Mrs Mellor have anything to do with any of my 
statements. 
F
Q 
I am going to suggest to you that your account that you have given to the Panel 
yesterday is exaggerated and it is exaggerated, in part at least, by the passage of time.  That is 
the way I am putting it to you? 
A 
I do not believe that it was an exaggeration. 
THE CHAIRMAN:  Mr Coonan, I would be looking to have a break shortly. 
G
MR COONAN:  Madam, I am almost finished.   
(To the witness)  One of the comments that you made about Dr Southall at that time was this.  
Can you just look at paragraph 16 please of the witness statement? 
A 
This?  (Indicated)
H
T.A.  REED 
Day 7 -  21
 & CO. 

---

A
Q 
Yes.  When you wrote this statement in 2004 – and I am going to quote from 
paragraph 16 – you said: 
“Throughout the latter part of the discussion I felt that Professor Southall was venting 
his hate towards me.” 
A 
I felt that the way he spoke to me that he did hate me.  I had no idea why he was 
B
talking to me in such a way, other than when you hate somebody, when you have antagonistic 
feelings towards them.  That is the impression that he gave towards me. 
Q 
You had met him briefly on one previous occasion and you described his conduct as 
very professional? 
A 
That is exactly how it was at that time. 
C
Q 
You saw him in the corridor and you felt at the time, you tell Field Fisher Waterhouse 
in 2004, that even then, in December 1994, that he was, to use your expression, “venting his 
hate”? 
A 
His attitude towards me in the corridor was very different to the first time that we saw 
Professor Southall. 
Q 
Again, there is no reference at all to this doctor venting his hate against you in your 
D
statutory declaration, is there? 
A 
No, because I elaborated because I was asked to make a statement on that incident, so 
I went into more detail. 
MR COONAN:   Thank you very much. 
THE CHAIRMAN:   Mrs D, we will take a break now.  You have been giving evidence for 
E
an hour and a half.  Mr Tyson may wish to ask you some more questions and the Panel may 
wish to ask you questions after the break.  We will break for twenty minutes.  I just want to 
remind you again that you may not discuss your evidence in the case. 
(The Panel adjourned for a short time)
MR COONAN:   Madam, I have no further questions. 
F
Re-examined by MR TYSON
Q 
I have got two areas I would like to ask you questions about.  Firstly, when you 
started your cross-examination you started indicating with your hands where the ward was in 
relation to the corridor, and I was just wondering whether on a bit of paper, if you have got a 
pencil---
G
A 
This is to the best of me trying to remember. 
Q 
Yes.  Could you use your best endeavours by writing it down, or drawing your best 
recollection of where the playroom was, the ward was and any possible corridor in between.
A 
(Witness drew diagram)  That is to the best of my recollection, my knowledge.  (Same 
handed to Mr Tyson)
H
T.A.  REED 
Day 7 -  22
 & CO. 

---

A
MR TYSON:   Madam, I am going to ask for some copies of that and I am going to ask for it 
to be C11. 
THE CHAIRMAN:   You have just answered my question.  Thank you.  (Long pause)
MR TYSON:   I apologise for the delay, I did not realise it would take so long to do a few 
photocopies.  (To the witness)  Do you have a copy of your original? 
B
A 
Yes, I have. 
Q 
Just to help us with the manuscript, does it say “Top room my son stayed on”? 
A 
That is correct. 
Q 
Then the other bit says “Open ward”. 
A Yes. 
C
Q 
Then the other bit says “Playroom” and the other bit says “Corridor”. 
A Yes. 
Q 
Just to help us, just prior to you seeing Professor Southall on 15 December 1994, had 
you been in the top room or in the playroom? 
A 
In the playroom. 
D
Q 
Was your son only in the top room overnight and otherwise spent his time in the 
playroom? 
A 
That is correct. 
Q 
Again, from memory, from which direction was Dr Southall and the accompanying 
doctors coming? 
E
A 
I do not recall which direction, but just that I saw them there.  I do not know whether 
it was at the beginning or the end of a ward round, I do not know. 
Q 
This was on what you understood was your last day? 
A 
That is correct. 
Q 
Why did you want to speak to Professor Southall? 
F
A 
Because we were in the playroom and we knew that we were waiting to see 
Professor Southall for him to discuss what was happening, because time was getting on and 
we did have quite a journey ahead of us, I came out of the playroom so that they could be 
aware that we were there because we were not in the room that I felt maybe that is where 
Professor Southall may have been heading to see my son and myself. 
Q 
Was there any other ward round with which you were involved with 
G
Professor Southall? 
A 
That was the only ward round. 
Q 
It was suggested to you that your account is one of exaggeration.  Have you 
exaggerated to the Panel that Professor Southall raised his voice? 
A 
I have not exaggerated, because to exaggerate I feel is very similar to lying and I have 
sworn on oath not to lie, or to tell the whole truth as far as I can recall. 
H
T.A.  REED 
Day 7 -  23
 & CO. 

---

A
Q 
Did you exaggerate to the Panel that he turned round to go with his hand being raised? 
A 
That is my recollection and I do not believe that I have exaggerated. 
Q 
Did you exaggerate when you told the Panel that you had no time to ask questions 
about the monitor? 
A 
That is correct, I felt that I was not able to ask any more questions, other than asking 
what was happening to my son the night before when the doctor was called.  I believe that 
B
that is the only question that I was able to ask. 
Q 
Did you exaggerate to the Panel when you described the tone of the way that you 
were being addressed in the middle of that conversation by Professor Southall? 
A 
I do not believe I did, because I felt that it was such a tone that that is why it has 
stayed in my memory. 
C
MR TYSON:   I have no further questions of this witness.  Thank you. 
THE CHAIRMAN:   It is now open to the Panel to ask questions.  Mr McFarlane is a medical 
member. 
Questioned by THE PANEL
D
MR McFARLANE:  Good morning.  I would like to take your attention first of all in file C2, 
behind tab 4(g), and we will take this slowly because it is to a particular point, and first of all 
can you turn to page 606, and there are a whole load of notes here which I understand were 
written by a Dr Suchal, who was the senior house officer, and these relate to the admission of 
your son to the North Staffordshire Hospital.  Now, on the photocopy you will see the copy 
of where the holes were for the filing system, and in the middle, between those two holes, on 
the right hand side is a line that says “given SMA”, with an arrow pointing to the right, and it 
E
then says “vomiting + faecal vomit”. 
A Yes. 
Q 
If you then go to tab (i), but keep your finger in this page 606, if you go to tab (i) on 
page 266, bottom paragraph, one line up from the bottom, it is written: 
 
“…that as a baby he had been given SMA and that this had produced faecal 
F
vomiting.” 
This reference I was reading to you was from a report that was prepared by Professor 
Southall.  Now, at the beginning of your evidence you told us that you were an SRN and an 
RSCN.
A 
That is correct. 
G
Q 
I am presuming that this history was obtained by Dr Suchal, the term “faecal 
vomiting” that he wrote down, which was then transferred by the Professor when he prepared 
his report.  Where did Dr Suchal get this term “faecal vomiting” from? 
A 
I believe that that was from me, because my son vomited quite a lot of times on that 
one occasion, and at that time he also did not open his bowels very much, it would be sort of 
ten days or longer, and, because he had vomited so much, what was coming up then was a 
browny colour. 
H
T.A.  REED 
Day 7 -  24
 & CO. 

---

A
Q 
Right.  I think you have been helpful.  What do you mean by “faecal vomiting”? 
A 
I believe that that is a term when it does come up from the bowel. 
Q 
Right.  I understand.  I mean, the thing that confused me, for me faecal vomiting is a 
condition whereby large bowel contents, i.e. faeces, are vomiting and represent a short circuit 
of the large bowel back up to the stomach, and that is a surgical emergency. 
A 
No, I do not believe that it was an emergency.  It was the fact that he had vomited so 
B
much I felt that there was nothing left to come up, but it was a brownish colour that was 
coming up. 
Q 
I think the correct term might be faeculent vomiting rather than faecal, but thank you 
for explaining that.  The next thing I would like you to do is to go to behind tab 6(b), to the 
letter, which has got page 1731 at the bottom, written by Professor Southall, and that was 
alluded to us by Mr Tyson.  Could you please advise us how many times was your son 
C
admitted to the North Staffordshire Hospital as a patient? 
A 
Just the one occasion. 
Q Only 
once? 
A 
That is correct. 
Q 
He was admitted under the care of Professor Southall? 
D
A 
That is correct. 
Q 
He was not admitted under the care of any other consultant? 
A 
No, he was not, no. 
Q 
I just find it very interesting, and I do not know if you might be able to help us, how 
the author of the letter can say: 
E
 
“My view is that they” – “they” referring to the special case files – “are part of ….. 
other hospital records rather than being directly related to his admission to the North 
Staffordshire Hospital under my care as consultant paediatrician.” 
Are you able to shed any light on that statement? 
A 
I do not understand exactly what Professor Southall meant by that.  I do not know 
F
whether he meant North Staffordshire, or other hospitals.  I do not know exactly how he 
could clarify that. 
MR McFARLANE:  Thank you very much indeed. 
THE CHAIRMAN:   Mrs Lloyd is a lay member. 
G
MRS LLOYD:  Good morning, Mrs D.  Mrs D, I just wanted to clarify one point of your 
evidence you gave this morning.  You were asked when was the first time you saw 
Professor Southall, and you said you first met him on 15 December 1994 in the corridor, and 
then later on, under cross-examination, you said that you had met him once before.  Could 
you just clarify that for me, please. 
A 
I thought that I was asked at the time about on a ward round.  I had seen him once at 
out-patients and once on a ward round, and then at a later date at the case conference, but at 
H
that date they were the only two times. 
T.A.  REED 
Day 7 -  25
 & CO. 

---

A
MRS LLOYD:  Thank you very much.  That clears that up.  Thank you. 
THE CHAIRMAN:   Mr Simanowitz is a lay member. 
MR SIMANOWITZ:  Good morning.  I want to ask a few questions just by way of 
clarification because I am not clear about certain things.  The first question I wanted to ask 
B
you was in your evidence, talking about your ex-partner, you said, and I appreciate this was 
speculation, maybe he thought that Dr Southall was going to say things that your son should 
not hear. 
A 
That is correct. 
Q 
So is it right that all three of you – you, your ex-partner and your son – went out into 
the corridor to where Dr Southall was? 
C
A 
I believe now that it possibly was just me that went out into the corridor, but at the 
time, because I did not sort of realise the implication of all the things relating to that ward 
round, I did not go into too much detail and I also did not sort of try to remember too much 
about it, because all that stuck in my mind was how Professor Southall spoke to me.  
Q 
So when you say you believe now, that is from things that have happened since?  It is 
not your memory of this occasion? 
D
A 
It is my memory, but I am trying to sort of remember everything of that account, and 
going over it in my head, that that is my belief, that I went out into the corridor so that we 
would not be missed. 
Q 
Thank you.  Now, I am trying to get a picture of what happened, because I think for 
me certainly it is not clear.  You went out and you stood in the corridor. 
A 
I believe, because I do not believe that I actually approached to speak to the doctors 
E
first because they were talking, they were discussing, and I believe that it is only right to 
stand back and wait for a doctor to then acknowledge that you are there, and I believe that 
that is probably what happened. 
Q 
Okay.  So then how did the conversation start, because in your evidence you 
suggested that Dr Southall said everything was normal, but that does not sound like the 
beginning of a conversation? 
F
A 
I cannot recall exactly how the conversation started because of the length of time.  
I can just remember aspects of that ward round that do stay in my memory. 
Q 
So he did not say, “What do you want?”, or, “Hello”, or anything like that? 
A 
I do not remember any of those phrases. 
Q 
You are quite clear that it was not you who initiated the conversation? 
G
A 
I do not believe so, but I cannot be absolutely one hundred per cent who did initiate, 
but I do not believe that I would have intervened when doctors were talking.  I would have 
waited for them maybe to glance at me or acknowledge me, and then, if it was me, I would 
have spoken, but I do not remember who initiated the conversation. 
Q 
You also said that, “Later he accused me of exaggerating my son’s condition”. 
A 
He did not accuse me at that date.  I was not aware at that time that that was 
H
Professor Southall’s view. 
T.A.  REED 
Day 7 -  26
 & CO. 

---

A
Q 
That was not in the conversation? 
A 
No.  I was not aware until two years later. 
THE CHAIRMAN:  I have a couple of questions that relate to the corridor incident, if I can 
put it that way.  You told us about the nature of the conversation.  Did you have any difficulty 
in understanding what Professor Southall was telling you in that intervention? 
B
A 
I was quite surprised that Professor Southall said everything was normal, and I was 
obviously confused because to me things were not normal.  The alarms were going off and 
my son was obviously unwell.  That is why I could not understand why he said everything 
was normal. 
Q 
So you understood what he was saying, but you did not understand the implications.  
Is that a fair way of putting it? 
C
A 
I could not understand how he could say everything was normal. 
Q 
You did not understand how he could say that? 
A 
That is right, because to my belief that is why I was there with my son in the first 
place, because everything was not normal. 
Q 
If you understand the difference then, you understood his words and what he appeared 
D
to be saying from his side, but it was the implications that flowed from that that raised more 
questions in your mind. 
A 
The questions flowed from when he said everything was normal, because he then did 
not clarify what was happening to my son to say this was normal because of this.  He gave no 
clarification whatsoever for just saying everything was normal.  When I spoke to him for 
clarification, that was when I believe he became angry and I was not able to ask any more 
questions.
E
Q 
To the best of your recollection did you ask a question saying what he meant by 
“normal”? 
A 
No, I do not believe I did use that phrase.  I believe I said what was happening to my 
son last night if everything was normal. 
Q 
Did you get an answer to that question? 
F
A No. 
Q 
What happened at that point? 
A 
I believe that is when Professor Southall became angry. 
Q 
What did he do then from your recollection? 
A 
From my recollection I may have said, “What was happening to my son?  Was it a 
G
delayed reaction?”  I do not know.  I may have done but I do not recall that, but then 
Professor Southall said that there is no such thing as delayed reactions in an angry tone and 
I felt he was dismissing me from asking any more questions. 
Q 
On the matter of the delayed reaction, was that in response to something because he 
perhaps would not have said that out of the blue.  You are recalling that those are words he 
said.
H
A That 
is 
right. 
T.A.  REED 
Day 7 -  27
 & CO. 

---

A
Q 
So how did it arise that he would have said that at all? 
A 
When we saw Professor Southall as an outpatient, I explained that my son had had a 
delayed reaction to his third immunisation. 
Q 
Then when you talked to him in the corridor, did it just come out of the blue, this 
further comment about there being no such thing as a delayed reaction? 
B
A 
I cannot be 100 per cent sure.  I could have said, “Was it a delayed reaction?”  I may 
not have said that, I do not remember.  All I remember is how Professor Southall spoke to 
me.  I do not remember everything I said at that time.  I may have said, “Was it a delayed 
reaction?” but I do not remember. 
Q 
Obviously something happened that caused him to make that remark as you recall it, 
but I appreciate you do not remember at this distance.  Can I also ask you, you obviously 
C
explained that you saw them in the corridor and you went to speak.  Was there an issue to do 
with privacy or confidentiality during the encounter in the corridor? 
A 
I am sorry, I do not understand. 
Q 
It has not formed part of your evidence or complaint but it is in fact mentioned in a 
head of charge about respecting privacy.  Was the fact that whatever was said in the corridor, 
was this an issue that you felt was to do with privacy, or was it simply the tone of his voice? 
D
A 
I think it was simply the tone and how he spoke to me. 
Q 
So you were not concerned that confidential matters were being spoken about in the 
corridor. 
A 
No, because from my recollection I do not remember seeing anybody else other than 
the people on the ward round. 
E
Q 
So that was not an issue? 
A 
No, and from my recollection the playroom was very quiet as well.  From my 
recollection we were the only people in there at that time. 
THE CHAIRMAN:  Thank you, Mrs D.  It is possible either counsel might have further 
questions arising from the Panel’s questions. 
F
MR COONAN:  No, thank you, madam. 
MR TYSON:  No, thank you. 
THE CHAIRMAN:  That means your evidence is complete and you may stand down. 
(The witness withdrew)
G
MR TYSON:  Madam, there is another document which I want you to have, and this will be 
C12.  To understand the context of this document you will need to look at D2.  (Document 
handed)  You may recall that in the course of cross-examination of Mrs H, my learned friend 
put in a document from Field Fisher Waterhouse acting on that occasion for Great Ormond 
Street and he made some comments to my client, Mrs H, indicating that Great Ormond Street 
were going to grant voluntary disclosure of all their notes.  You may recall Mrs H’s response 
H
that whilst that might have been the intention, there were missing notes from Great Ormond 
T.A.  REED 
Day 7 -  28
 & CO. 

---

A
Street and the letter, C12, is a letter from Field Fisher Waterhouse, acting in their role for 
Great Ormond Street, writing to Messrs Huttons on 7 October 1994.  Messrs Huttons were 
the solicitors for family H. 
The material parts read: 
“You are quite correct as regards the clinical notes disclosed with our letter.  It was 
B
made clear to the Solicitors previously acting for the H family that the medical notes 
prior to 1990 were lost.  This was acknowledged by them and we are enclosing a copy 
of their letter of 4 June 1991 for your reference. 
The originals have been missing since at least 1990 and have not been traced despite 
intensive searching at that time and subsequently.  However, the hospital has been 
successful in gathering together reports previous to that time and you will find 
C
included among your notes a report in respect of Child H’s admission in February 
1986 and one in respect of his admission in October 1988.   
We regret that we are therefore unable to offer any further assistance but trust that 
these summaries will be of use to you”. 
So C12 has to be read in the context of D2 and Mrs H’s answers about the fact that Great 
D
Ormond Street had lost the notes.  I am grateful to my learned friend for enabling me to 
produce at this time C12 to correct or deal with what the witness said, that there was a letter 
somewhere saying this. 
My next witness is Mrs M’s solicitor, who we sent away, and who has now come back.  In 
relation to this witness’s evidence I will be asking you, please, to look at C1, Tab 1 (gg).  
That is something called a facsimile transmission dated 23 April 1998. 
E
MRS ELINOR BETH PARRY, Sworn
Examined by MR TYSON
(Following introductions by the Chairman)
Q 
Could you give to the Panel your full names please? 
F
A Elinor 
Beth 
Parry 
Q 
What is your professional address? 
A 
39 to 41 Church Street, Oswestry, Shropshire. 
Q 
Are you a solicitor with the firm Longueville Gittins? 
A 
I am, yes. 
G
Q 
Have you worked for that firm since about 1986? 
A 
I have, yes. 
Q 
In early 1998 were you instructed by a lady that we call Mrs M, who had been served 
with an emergency protection order? 
A 
I was, yes. 
H
T.A.  REED 
Day 7 -  29
 & CO. 

---

A
Q 
Was that in relation to her youngest son, who we call either the youngest son or M2? 
A 
That is correct, yes. 
Q 
As a result that emergency protection order had the youngest son been taken away 
from the M family and placed in foster care? 
A 
Yes, the emergency protection order had been obtained ex parte and the child was 
immediately removed. 
B
Q 
You use the term “ex parte.”  There are a number of lay people in this room.  Does 
that mean without notice to the M family? 
A 
Yes, that is correct. 
Q 
Did you become involved in the matter subsequent to the emergency protection order 
being granted as Mrs M’s solicitor? 
C
A 
Yes, That is correct. 
Q 
In the preparation of the case did the court order a number of independent medical 
expert reports to be prepared? 
A Yes. 
Q 
Is it the case in care proceedings that sometimes all the parties instruct one particular 
D
expert or sometimes one or a number of parties instruct a particular expert? 
A Yes. 
Q 
It is also the case in care proceedings that for an expert to be instructed the court has 
to grant leave for that? 
A Yes. 
E
Q 
In this particular case was Professor Southall instructed on behalf of the local 
authority only? 
A 
That is correct. 
Q 
Was a further independent expert, Dr Black, instructed on behalf of all the parties? 
A 
Yes, she was jointly instructed expert. 
F
Q 
Was a third expert, Professor Stephenson, a consultant paediatrician, instructed by all 
the parties save the local authority? 
A I 
cannot 
remember. 
Q 
But you recall that there was a Professor Stephenson who did prepare a report? 
A Yes. 
G
Q 
Pausing there before we escape from the experts, do you recall that there was a doctor 
then known as Dr Solomon involved with the M family? 
A 
Yes, Dr Alison Solomon.  She is a child psychiatrist. 
Q 
You recall that she was a treating clinician? 
A Yes. 
H
T.A.  REED 
Day 7 -  30
 & CO. 

---

A
Q 
Due to the number of reports in the case, in her role as a treating clinician as opposed 
to an independent expert brought in from the outside? 
A Yes. 
Q 
There came a time that in the course of the proceedings where Professor Southall had 
been instructed by the local authority, he indicated that he would like to see your client and 
her husband? 
B
A Yes. 
Q 
Just pausing there for a moment, was Mr M represented by separate solicitors? 
A Yes. 
Q 
Can I ask you to look please at a bundle which we have called C1 and there should be 
a tab within C1, towards the back, headed (gg), which may or may not be open at the page in 
C
front of you, which starts with a fax from the local authority involved in this case? 
A Yes. 
Q 
Did you receive that fax, dated 23 April 1998, from the local authority involved in the 
case, which told you that Professor Southall would like to see your client and her husband as 
part of his assessment and gave a number of dates? 
A Yes. 
D
Q 
Going over the page to page 2, is this an attendance note of yours.  Did you speak to 
your client Mrs M on 23 April, trying to arrange the meeting with the timing and dates of the 
meeting with Professor Southall? 
A Yes. 
Q 
Turning over the page to page 3, you made an attendance on Mr McLaughlin.  Was he 
E
one of the solicitors involved in this matter acting on behalf of the local authority? 
A 
I believe so, yes. 
Q 
Does that indicate that your client was trying to contact her husband to see if he was 
going to the meeting with Professor Southall? 
A Yes. 
F
Q 
Over the page at page 4, again on 23 April, did you then speak to your client, and at 
item 5, she indicated that of the dates that had been offered on page 1, which was the Monday 
or the Wednesday, that she would prefer to go on the Monday? 
A Yes. 
Q 
At page 5 is there an attendance trying to deal with whether your client would get a 
travel warrant from social services to go to see Professor Southall at Stoke, and at page 6 
G
similar matters on 23 April, and did you then speak to your client (page 7) now on 24 April, 
telling her that the appointment was for Monday at eleven at Stoke and she should telephone 
Francine Salem to obtain a travel warrant?  Who is Francine Salem? 
A 
She was the social worker. 
Q 
It would appear that you got a fax in whilst you were speaking to your client on that 
occasion about the arrangements and on page 8 it appears that you sent a copy of that fax to 
H
your client on the 24th.  The letter of the 24th we see at page 9, which is a fax to your firm 
T.A.  REED 
Day 7 -  31
 & CO. 

---

A
from Mr McLaughlin, the solicitor at the local authority, giving details of how your client 
should get to Professor Southall, where his department was, and that your client should 
contact Francine Salem to arrange a travel warrant or, if possible, a family support worker. 
A Yes. 
Q 
Then, over the page did you get another fax about the arrangements indicating that a 
taxi had been arranged for her rather than a travel warrant and that taxi had been arranged by 
B
the social worker? 
A Yes. 
Q 
That, it would appear from the attendance notes and the correspondence, was the only 
documentation that you received or conversations you had with the local authority about this 
meeting.  Can you tell me this:  was there any indication prior to your client going up to 
North Staffordshire that the social worker would be actually present at the interview? 
C
A No. 
Q 
Then was your practice as a solicitor simply to deal with care work and family work? 
A 
Yes, I only dealt with family work. 
THE CHAIRMAN:  Mrs Parry, I wonder if I could ask you just to make sure you speak up.  
There is some difficulties with hearing at this end of the room.  Thank you. 
D
A 
Yes, I am sorry. 
MR TYSON:  In your experience at the time how usual or otherwise would it be for a social 
worker to accompany your client to see an independently appointed medical expert? 
A Very 
unusual. 
Q 
Had you come across it before this time? 
E
A 
I have no recollection of it taking place, no, nor subsequently. 
Q 
Did you attend that meeting that your client had with the doctor? 
A No. 
Q 
After that meeting were you subsequently contacted by your client? 
A 
Yes, I was. 
F
Q 
Did you see her to discuss the meeting that she had had with Professor Southall? 
A Yes. 
Q 
Did you make a manuscript note of that meeting that you had with Mrs M about the 
interview with Professor Southall? 
A 
Yes, I made an attendance note. 
G
Q 
If we look at page 13 to page 15, is that in your handwriting? 
A 
That is, yes. 
Q 
Is that a note you made whilst Mrs M was in the room with you? 
A 
Yes.  There may have been more in the note but that is all that is being put before me. 
H
T.A.  REED 
Day 7 -  32
 & CO. 

---

A
Q 
Did you subsequently dictate an attendance note relating to that meeting, which we 
see at pages 16 to 18? 
A Yes. 
Q 
Do we see on page 18 that the attendance took about an hour? 
A Yes. 
B
Q 
Mrs M was with you for about an hour and you took, as it were, two and a half pages 
of manuscript note, picking out aspects of that attendance? 
A Yes. 
Q 
Can we just go back to page 13, please, and can I seek to read it and you correct me 
where I have got it wrong.  Does it say: 
C
“Went in & found Francine was there, & I asked her what she was doing there. 
He kept saying to me I know this is going to be very painful as I have to ask Q’s 
[questions]
He got me 1st of all to draw a picture of the upstairs of the hse …”, 
D
and gives the address, 
“as he wanted to get it clear from my mind how could I see through from the toilet 
into the bedroom.” 
Is that your “how”? 
A Yes, 
correct. 
E
Q Then: 
“I did this, he wanted me to tell him where the position of the bed was before & after, 
how long the curtain rail was & how thick was, how it was fixed in.  I said it was 
screwed in.  He then wanted to know if it was my belt [as opposed to the eldest 
child’s].  I told him it was [the eldest child’s].  He insisted it was too.  I told him it 
F
was [the eldest child’s], asking me how many holes.  I told him I didn’t know [or 
don’t know] or what width it was.  He then x-examined me accusing me of lying that 
the pole didn’t break.  I answered them as best I could, he asked how I got on with 
Dora Black and asked if I could get my …”, 
and then I am struggling with the next word, Ms Parry? 
A 
Well, I cannot read it either, I am afraid.  It is “(something) at work.” 
G
Q 
Can we just keep a finger in there and go to your attendance note and look at page 17 
in the second paragraph, where it says: 
“He was asking how she had got on with Dora Black and asking how she could get 
her hands on drugs from work.” 
H
Then if we go back to page 13: 
T.A.  REED 
Day 7 -  33
 & CO. 

---

A
“…asked if I could get my (something) …”, 
and I was wondering if that word might be “hands” or whatever, whether it is elliptic for 
“hands on drugs”, which you subsequently dictated out. 
A 
Yes, because I would have dictated it straight away. 
B
Q 
So it may be that that is a shorthand for, “asked if I could get my hands on drugs at 
work.”
“I told him I wasn’t a nurse, asking me if I’d seen the anaesthetist saying I would 
know how to inject s’one. 
He said did I know no toxology report, he mentioned about [Mr M] going to prison 
C
after [something] assault. 
[Child M1] was cremated. 
He questioned me about the bullying, he said serious allg [allegation] … 
[M1’s] accident with scold”, 
D
I think that might be.   
“He was looking at Francine, who just stood there smirking.  He said if it can’t be 
proven.
He asked if I’d spoke to any of the other children about committing suicide.  I said no, 
he asked 
E
At end he said you don’t like Mrs Stones.” 
Just pausing there, was that the class teacher? 
A 
Yes, I believe so. 
Q 
“He only questioned ….. about [the youngest child] was about the bruise at 9 months 
F
old – I can’t remember. 
 
He said if nobody can prove that [the eldest child] did or didn’t kill himself through 
bullying.
 
He suggested that I kill him and that I either suffocated him, drugged him and then 
hung him. 
G
 
He eventually pressurised me. 
 
He said it was very” – is that “comments”? 
A 
I cannot read it. 
Q 
Over the page: 
H
T.A.  REED 
Day 7 -  34
 & CO. 

---

A
 
“…she’s been questioned by [the youngest child], he’s asking why is there a court 
hearing in May, and what happens after that, he’s saying he doesn’t seem to know that 
there is still an application for a care order, and is unhappy he hasn’t been told.” 
Then you dictated an attendance note.  How soon after seeing the client would you have 
dictated the attendance note? 
A 
Very soon after.  Within hours probably. 
B
Q 
We can see the dictation of that note starting at page 16.  You record that: 
 
“She was very upset ….. when she attended the interview with Professor Southall.
She went in and found Francine Salem ….. sitting there.” 
I do not know how much independent recollection you have got of this matter, Mrs Parry, but 
C
was she upset when she saw you? 
A 
I cannot remember, I am afraid.  It is a long time ago. 
Q 
Is your recollection of this matter principally based on the handwritten notes and the 
attendance note which I am about to take you to? 
A 
Well, I did recall, before seeing these notes, the incident, and that she was upset. 
D
Q 
You say that she was upset.  Do you recall what she was upset about? 
A 
She was upset because she was being accused of murder really, and she had gone to 
the interview expecting it to be a medical examination. 
Q 
Just going through your attendance note, your dictated attendance note on page 16: 
 
“She went in and found Francine Salem was sitting there.  When she asked her what 
E
she was doing there she said I am here on the same basis that another social worker 
was present with Dora Black.  She said well she was not there at any of the medicals 
when she spoke to Dora Black but she just shrugged her shoulders and stayed.” 
Just pausing there a moment.  “She just shrugged her shoulders and stayed”, is that in relation 
to what Francine did? 
A Yes. 
F
Q 
Now we are getting back to your client, Mrs M: 
 
“She said that throughout the interview Professor Southall was saying that he knew 
how painful these questions were. 
 
He asked only one question about [the youngest child] and that was something to do 
G
with an injury when he was 9 months old which she could not remember about. 
 
First of all he got her to draw a picture of the upstairs of the house [the address there 
given] as he wanted to get it clear in his mind how she could see from the toilet 
through to the bedroom.  She said that she did this. 
 
All his questions and investigations were about [the oldest child] and he wanted to 
H
know the position of the bed and where it was before and after, how long the curtain 
T.A.  REED 
Day 7 -  35
 & CO. 

---

A
rail was and how thick it was and where it was fixed in and how many screws were 
screwed in.  A lot of this she said she tried to reply as best as she could and he then 
started saying that it was her belt.  She said that she had never had a belt and she 
thought it was [the eldest child’s].  He asked her how many holes were in it and she 
did not know.  He wanted to know what width it was.  He was more or less cross 
examining her and accusing her of lying and that the pole could have broken with her 
weight and her son’s weight it would have been over 20 stone.  She said she answered 
B
the questions as best as she could and she said that she was not prepared to show how 
the belt was tied because of the continuing questions and telling her that her solicitors 
had improperly advised her.” 
Just pausing there.  Is that Professor Southall telling her that her solicitors had improperly 
advised her? 
A Yes. 
C
Q 
“He was asking how she had got on with Dora Black and asking how she could get 
her hands on drugs from work.  She said that he seemed surprised when she told him 
that she could not as she was not a nurse.  He seemed to think that she should know 
how to give injections but she said that she did not as she did not even watch the 
anaesthetist doing it as she was at the other end of the patient. 
D
 
He wanted to know if she knew that there was no toxicology report and she said that 
she did not. 
 
He had been cremated she told me. 
 
She was questioned about the bullying and throughout he seemed to look at Francine 
Salem who just sat there smirking.  He was telling her that it cannot be proven that 
E
she did not kill [the eldest child]. 
 
He also asked if she had spoken to any of the other children about committing suicide 
and she said that she said no but she remembered that [one of the children’s] mother 
came to her saying that he had just tried to commit suicide and insisted that she go 
back and when she went he said he had not. 
F
 
There were discussions about Mrs Stones and he accused her of killing [the eldest 
child] alright saying that she killed him either by suffocation or drugged him and then 
he eventually pressurised her into saying how the belt was tied and he said that it was 
very cleverly done. 
 
As far as Dora Black was concerned on reflection the interview went really well with 
her and Mrs Black’s view was that she would try her best for them.” 
G
Then you indicate that she said that the interview itself took about an hour with Mrs M.  You 
said that Mrs M was upset about the accusation that she had murdered the eldest child.  When 
she was with you, was she tearful? 
A 
That is what I cannot remember.  I cannot remember if she was crying. 
Q 
You can remember that she was upset? 
H
A Yes. 
T.A.  REED 
Day 7 -  36
 & CO. 

---

A
Q 
Following that interview did you write to the local authority about the presence of the 
social worker, going to page 19? 
A Yes. 
Q 
This is a letter by you to the local authority of 6 May 98, saying that: 
B
 
“Our client attended the medical appointment which was requested of her with 
Professor Southall and from our instructions it would seem that she has been 
subjected to this medical with your Social Worker Francine Salem being present.” 
Just pausing there a moment.  Have you any comment on the use of your word “subjected” 
there?  If you have not, do not worry. 
A 
It would have been because my client objected to it. 
C
Q 
“We should be grateful to receive a full explanation as to why this was the case. 
 
We also require full disclosure of the written notes that Francine Salem took 
throughout the medical interview. 
 
May we therefore please have your confirmation that these notes will be supplied 
D
within the next seven days.  May we also please have an explanation as to why our 
client was expected to attend for a medical and we were not notified that Social 
Workers would be present throughout taking notes.” 
Did you get a letter in response to that dated 13 May, we are now on page 20, from the local 
authority solicitor: 
E
 
“Thank you for your letter ….. 
 
I would first of all correct your assertion that this was a medical appointment with 
Professor Southall that your client attended.  As you are aware Professor Southall is 
one of the experts appointed by the Court and instructed by the Local Authority to 
prepare a Report and that indeed this was not a medical appointment but an 
interview.” 
F
Did you understand what the local authority was saying in that sentence? 
A 
No, I did not. 
Q 
“I understand from the Social Worker that she was requested to remain in the meeting 
by Professor Southall at his request.  I understand that your client did not object.  If 
you wish to have a formal explanation I can only suggest that you cross examine 
G
Professor Southall to explain why the Social Worker was required to sit in on the 
interview with your client.” 
Did you regard that as a proper explanation as to why the local authority social worker was 
present?
A 
No, I did not. 
H
T.A.  REED 
Day 7 -  37
 & CO. 

---

A
Q 
“With regard to the disclosure of the written notes I can confirm that the Social 
Worker did take 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.” 
Did you reply to that letter, page 21, on 15 May? 
B
A 
I did, yes. 
Q 
“Thank you for your letter ….. 
 
Our client does object to the Social Worker being present at a medical interview or 
whatever you may wish to call it. 
C
 
We consider that the notes taken by the Social Worker are within the ambit of 
documents to be disclosed and we seek these.  Will you agree to their disclosure 
within fourteen days?  If not we will seek directions from the Court for their 
disclosure. 
 
You should have now received from Messrs Wace Morgan Solicitors” – are those the 
solicitors acting for Mr M? 
D
A 
No, they were the solicitors representing the child. 
Q 
“…the report of Professor Stephenson.  When may we expect to receive the reports 
from Professor Southall and Professor Bentovin although are we right in our 
assumption that you are not instructing Professor Bentovin because of the joint 
instructions to Dr Black? 
E
 
We still await Dr Black’s report but have received a report from Dr Solomon…” 
Did you get a reply to that on 18 May 1998, which we have at page 22? 
A Yes. 
Q 
From the second paragraph, “I enclose a copy of the social worker’s notes”, and just 
turning over the page, is this the typescript document on pages 23-26 that you got? 
F
A 
I believe it is, yes. 
Q 
In fact we can see, by doing some minor detective work on the top right hand corner, 
the fax numbers, which seem to be consistent running through. 
A 
Yes, that is the fax number of my firm of solicitors. 
Q 
In that letter did it also confirm that Professor Bentovin was not being instructed by 
G
the local authority because in a sense they joined in the joint instruction of Dr Black? 
A Yes. 
Q 
Was there that discussion about the timing when Professor Southall’s report could be 
obtained?
A Yes. 
H
T.A.  REED 
Day 7 -  38
 & CO. 

---

A
Q 
Then did you see your client on 19 May, turning to page 27?  Do you have page 27 in 
the notes before you? 
A 
I do, yes. 
Q 
Was that “Consideration and reading the notes from---“ 
A 
Yes, I would have read the notes on 19 May. 
B
Q 
Yes.  These notes that we see on pages 28-29, just pausing there, would they relate to 
your two units reading the notes, or going to page 30--- 
A 
They would have related to the time when I saw Mrs M about them. 
Q 
If we go to page 30, do we see that you attended your client on 3 June for some 90 
minutes – which we see at page 32? 
A Yes. 
C
Q 
The manuscript notes that we have at pages 28 and 29 would be relating to that 
attendance on 3 June, would they? 
A Yes. 
Q 
You told us that the manuscript on page 28, where it says, 
D
“(1)  The belt description was correct.  I didn’t describe the pole as having 2 
brackets”,
does that arise out of consideration of what Miss Salem was saying in her note? 
A 
I believe so, yes. 
Q 
Then it says, 
E
 
“Doesn’t want to discuss the judgment”. 
By that time had there been a four-day hearing in front of His Honour Judge Tomkin which 
enabled the youngest child to come back home? 
A 
I have not got the file in front of me, but I suspect that that is the case, the child had 
been returned home at this stage. 
F
Q 
We know, because we have seen a document which is our C4, that the child was in 
fact returned on 10 March 1998, but I do not know at what stage thereafter you would have 
got a transcript of the judgment for you to go through with your client.  You discussed 
various other aspects of the case and the case preparation at page 28.  On 29, by that time it 
would appear that Professor Southall had produced a report and you say, on page 29, 
G
 
“Re Southall’s report, she didn’t like it”. 
A Yes. 
Q 
Is there then a comment on what Miss Salem’s report was saying? 
A Yes. 
H
Q 
Then we have, 
T.A.  REED 
Day 7 -  39
 & CO. 

---

A
“Re M1 speaking to the two boys who said M1 has said he was going to kill himself 
although she hadn’t spoken to them herself, merely wanted to make it clear she only 
found out about it on the day of the inquest”. 
Then it says, 
B
 
“We went to the handwritten notes”. 
Would those handwritten notes be the contact sheets? 
A 
They would be Miss Salem’s handwritten notes that she took at the time of the 
interview. 
Q 
Does it say, 
C
 
“We want the handwritten notes”? 
A 
Yes, we “want” the handwritten notes. 
Q 
Because hitherto you only had the typescript which we referred to earlier. 
A Yes. 
D
Q It 
continues, 
“Never told her about four occasions, about suicide threats, that’s not correct.  Also 
various statements which incorrectly translated or which she never said – she’s 
written things down as she wanted to hear them.  She never said she’d be pleased and 
talking about it if she cleared her name.  Many words are those of Professor Southall 
E
and not of Mrs M”. 
You deal with your attendance note which you made subsequent to this attendance, and you 
deal with matters that this Panel is concerned with in the second paragraph, 
“As far as the belt description is concerned in Francine’s notes apparently it was 
correct but she said that she did not describe the pole as having only two brackets as it 
F
had three brackets”. 
Then there are other matters relating to other aspects of the case.  Half-way down page 31, 
“As far as Professor Southall’s report was concerned she did not like it.  We started to 
go through it but it would seem pointless. 
G
She said that there were a number of mistakes which she did not like contained in 
Francine’s notes.  First of all, these were not verbatim and some of the information 
was incorrect.  It was also missing from what various people said. 
Re [the eldest child] speaking to two boys who said that he was going kill himself, 
although she had not spoken to these children herself, Mrs M wanted to make it quite 
clear that she only found out about it on the day of the inquest. 
H
T.A.  REED 
Day 7 -  40
 & CO. 

---

A
She wanted me to ask for the handwritten notes as she did not say that she had told 
[the lady there mentioned] on four occasions about the suicide threats and it was just 
not correct. 
There were various statements which were either incorrectly translated or which she 
never said and she had written them down on the statement which is on the file.  
Many of the words are those of Professor Southall and not Mrs M”. 
B
Do you see where it says, “she had written them down on the statement which is on the file”, 
can I ask you please to go to what I hope is going to be in the bundle at (aa)?  We have been 
looking at Section (gg).  Just glancing through that document, Mrs Parry, you will see that 
there is manuscript all over it, particularly on the third and fourth pages.  Mrs M gave 
evidence about this document and she indicated to us that this was her manuscript that she 
had written on these notes of Miss Salem, and that she had given the manuscript to you. 
C
A 
I am afraid I cannot help you.  I cannot remember. 
Q 
I do not want to lead in any way, but if we look at the bottom of page 31 again, back 
to your attendance note – this is in (gg) – where it says, 
“There were various statements which were either incorrectly translated or which she 
never said and she had written them down on the statement which is on the file.  
D
Many of the words are those of Professor Southall and not Mrs M”. 
A 
That would make sense, certainly. 
Q 
Lower down you record other matters relating to other reports that were there, in 31. 
A Yes. 
E
MR TYSON:  Madam, that is all I intend to ask this witness.  This may be a convenient time 
to break. 
THE CHAIRMAN:  I am not sure how long the cross-examination will take. 
MR COONAN:  Not terribly long, but there is one matter I want to raise with my learned 
friend about documents. 
F
THE CHAIRMAN:  Do you wish to do that in private? 
MR COONAN:  Certainly, yes.  We can discuss it and then continue with cross-examination 
after lunch. 
THE CHAIRMAN:  Very well. It is 10 minutes to one on my watch, so we will break until 
G
10 minutes to two.  Mrs Parry, I am sure you understand that, since you are on oath, you must 
not discuss your evidence or the case with anyone. 
(Luncheon adjournment)
H
T.A.  REED 
Day 7 -  41
 & CO. 

---

A
Cross-examined by MR COONAN
MR COONAN:  Mrs Parry, can I just ask a few questions, first of all, about the background 
leading up to the attendance by you upon your client?  If you cannot answer these questions, 
because I note that you have not got a file in front of you relating to this case, please say so. 
B
A 
Yes.  I have no file. 
Q 
Following the Emergency Protection Order, do you remember there being a case 
conference which you attended, and I will give you the date, on 9 February 1998? 
A 
No, I do not remember 9 February 1998, I am sorry. 
Q 
Again by way of background, do you remember when Mrs M had seen Dr Black, do 
C
you remember it being before 15 April 1998? 
A 
Without a file, I am sorry I cannot verify those dates. 
Q 
I do not want to be unfair.  I may be able to help you with a document that deals with 
that.  (Document handed)  Please look at that document.  My learned friend has seen it.  It 
comes from a file.  Does it appear to confirm that by 15 April Mrs M had already seen 
Dr Black? 
D
A Yes. 
Q 
Are you reading again from an attendance note of the form that the Panel have seen 
already? 
A 
Sorry, could you repeat that question? 
Q 
The file note is the same structure and layout as the forms that the Panel has seen 
E
already.
A Yes. 
Q 
Thank you.  That can be photocopied and handed to the Panel.  Mrs Parry, you do not 
have a file with you.  Can you help to this extent?  Did your firm cease to hold a file? 
A Yes. 
F
Q 
Did the file get transferred to another firm?  Is that what happened? 
A 
The file was collected by my client. 
Q 
And taken to another firm of solicitors? 
A 
I believe so, yes. 
Q 
So when you made your statement for the purpose of these proceedings, did you, as it 
G
were, chase after the file and extract the documents?  How did it work? 
A 
The documents were extracted for me. 
Q By 
whom? 
A 
The current solicitors, the General Medical Council solicitors. 
Q 
Do you know where the file is today? 
H
A 
No, I do not. 
T.A.  REED 
Day 7 -  42
 & CO. 

---

A
Q 
Just one other matter by way of background and again, if you cannot help me, please 
say.  Do you remember that attempts, as we have seen already, were made to get Mr M to 
come along to this meeting with Dr Southall? 
A 
From the notes referred to earlier on in my examination in chief, I think that was 
indicated.
B
Q 
Obviously Mrs M would know that attempts were being made for Mr M to come 
along as well. 
A 
Yes.  He was working away at the time. 
Q 
Did it come about that the very reason he could not come was because he was 
working away? 
A 
I cannot remember that, but that possibly was the case. 
C
Q 
Was a firm called A W Brown & Lloyd the firm of solicitors acting for Mr M? 
A Yes. 
MR COONAN:  Perhaps you could look at this document, and let me say straight away that it 
is in poor condition.  (Document handed) 
D
THE CHAIRMAN:  The document referred to a few moments ago has now been photocopied 
and distributed and will be D3. 
MR COONAN:  Mrs Parry, I have handed you a document bearing the name of that firm.  
Does it appear to say that the husband cannot come because of work commitments? 
A Yes. 
E
Q 
That is correct.  It does say that, does it not? 
A 
It does seem to, yes. 
Q 
Again, perhaps that might be photocopied and distributed.  Perhaps my learned friend 
could see it first. (Document handed)  This will be D4.  It is from Social Services files.  Can 
I move on, Mrs Parry, to the time when you did see Mrs M after her interview with 
Dr Southall?  I fully appreciate that the status or capacity in which you come before the Panel 
F
is to give evidence as to what Mrs M said. 
A Yes. 
Q 
On 27 April do you have any attendance notes of any meeting with her? 
A 
Is that the day she went -- 
Q 
To see Dr Southall. 
G
A 
You have the attendance notes that took place. 
Q 
I have to ask you that formally and I may well be anticipating your answer, but I need 
to ask it if only for the Panel to be aware of that fact.  What you are saying is that there is no 
attendance note in relation to a meeting on 27 April, or any attendance note of any telephone 
call by Mrs M to you on 27 April.  Look again in the section of the notes marked as (gg). 
A 
There is actually.  There is a reference to the fact that I spoke to him on 27 April by 
H
the “PS” on the letter of 27 April going out to her. 
T.A.  REED 
Day 7 -  43
 & CO. 

---

A
Q 
Yes, I want to ask you about that.  You have a postscript at the bottom of the letter on 
page 11? 
A Yes. 
Q 
But you have no attendance note which deals with the content of the telephone call? 
A 
Well, the letter of 28 April 1998, the subsequent letter marked page 12, indicates to 
B
me that she had phoned me and she had spoken about the appointment which upset her, 
because it says: 
“…I wish to discuss with you the interview which you had with Dr Southall and what 
we should do about it at this stage.” 
Q 
Yes.  Of course, I am not disputing for a minute she might have said that she was 
C
upset.  I am just concerned for the moment to establish that there is no note of what was 
causing her to be upset at that stage? 
A 
There is no note that I am aware of. 
Q 
What you have noted on page 12 on 28 April is that she telephoned your office 
requesting a copy of the post mortem report and a copy of the evidence from the inquest. That 
is what you say? 
D
A Yes. 
Q 
Again, I just want to establish the plain fact.  There is no attendance note prior to 29 
April which records that Mrs M was complaining that Dr Southall had accused her of 
murdering her child. Is that not right? 
A 
Yes, that is right. 
E
Q 
So the first time that we have Mrs M setting out what she says to you that Dr Southall 
said to her is on the 29th?
A 
As a written record, yes. 
Q 
There is no record, and I want to be clear about this.  Are you accepting that this is the 
first time Mrs M told you in any sense that Dr Southall had accused her of murdering her 
child, the 29th?
F
A No. 
Q 
When you say “no”, what are you saying “no” to? 
A 
I remember that she phoned me and it would have been late in the day, after the letter 
was going out on 27 April, and that is the reason why this letter has already been prepared by 
my secretary and we had to put a PS on it before it went out.  That would have been very late 
in on the day, probably just before 5 o’clock when the post had to go, and I remember that 
G
she was upset and I remember that she was stating the accusations. 
Q 
What, even then? 
A 
I do remember it because it was so odd. 
Q 
But there is no note of it? 
A 
There is no note of it, no, but at least nobody has produced the notes. 
H
T.A.  REED 
Day 7 -  44
 & CO. 

---

A
Q 
It was, if I may say so, eight years ago? 
A That 
is 
right. 
Q 
It may be that the Panel might be invited by Mr Tyson to rely upon your recollection 
of eight years ago that this lady made a complaint actually in a telephone call on the 27th that 
Dr Southall had accused her of murdering her child, do you see?  I am suggesting to you that 
at this stage you really cannot be sure that that is what she said.  Is that not right?  You cannot 
B
be sure now that she did actually complain in that phone call that Dr Southall had accused her 
of murdering her child? 
A 
I am fairly sure. 
Q 
You see, if she had made a complaint to you on 27 April, whatever time of the day it 
was, that Dr Southall had accused her only hours before the same day of murdering her child, 
you would have remembered that fact, I suggest, when you made your witness statement to 
C
Field Fisher Waterhouse in July of this year, would you not? 
A 
I had not seen the file when I was contacted by Field Fisher Waterhouse, but I 
specifically told them about the phone calls and I had that recollection which told them to go 
and hunt through the files. 
Q 
I am not disputing for a minute that you told the, in effect, to go and hunt through the 
files, and it would appear that they did and the product of their searches we have before us, 
D
the Panel have got, but I think in fairness to you, because it is an important or potentially 
important matter, that you have a look at how you put it in your witness statement you made 
earlier this year.  Is there a copy available?  I am told you may have seen it this morning. 
A 
I have left it upstairs.  (Copy handed to the witness)
Q 
Just to help you, I think if you look at the last page you will see it is dated 31 July of 
this year and signed by you, and just to help you on the topic we are discussing, it is 
E
paragraph 9, 10 and 11.  Again, please take a few minutes just to read that yourself silently.
(After a pause)  The first point I want to ask you about is that when you were being asked 
about these matters in July of this year – your recollection – you did not there say in terms 
that Mrs M had complained on the 27th in a phone call that Dr Southall had accused her of 
murdering her child, do you? 
A No. 
F
Q 
What you do recall is that Mrs M in the phone call appeared to be very upset.  That is 
how you remembered it? 
A Yes. 
Q 
That is paragraph 10.  In fact, I am going to read it out in fairness because it would be 
difficult for the Panel to follow otherwise.  Do you mind if I read it? 
A 
Not at all. 
G
Q Paragraph 
9: 
“I was therefore very surprised to be contacted by [Mrs M] on 27 April after the 
interview with Professor Southall.  She told me that Francine Salem, a Social Worker, 
had been present at the meeting which was a surprise to me.  I would not have 
expected a Social Worker to be present at a meeting with a medical expert.” 
H
T.A.  REED 
Day 7 -  45
 & CO. 

---

A
Paragraph 10: 
“From what I can recall [Mrs M] was very upset.” 
Paragraph 11: 
“On 28 April 1998 I wrote to [Mrs M] and asked her to make an appointment to see 
B
me as soon as possible to discuss the interview which she had had with Dr Southall 
and what we should do about it at this stage.  The reason I wrote this letter was she 
had phoned complaining about the meeting with Professor Southall.” 
That is the highest it is put, you see, by you, when you were asked to recall this in July of this 
year.  I am not disputing for a minute that she made a complaint about the meeting with 
Dr Southall.  That may well be true and you have recorded that, and I am not disputing that.
C
What I am focusing on is whether she complained at that time that Dr Southall accused her of 
murdering her child.  Do you not think you might have recorded that, first of all, and 
secondly, actually put it in the witness statement when you were being asked about it earlier 
this year? 
A 
All I can say is what I recollect.  I accept that it is not in the notes from the time and 
I have presumed that when I stated the reason I wrote this letter was that she had phoned 
complaining about the meeting with Professor Southall [it] was expanded in the later note. 
D
Q 
Does it come to this then, in fairness, that in terms of you recalling now the terms in 
which she made a complaint to you on the 27th, you cannot be sure? 
A 
No, I cannot be sure because it is not in writing. 
Q 
Mrs Parry, can I move on now, please, and seek your assistance with the longhand 
note on the 29th.   We can start this at page 13 of our bundle (gg).  You have very helpfully 
E
gone through this with Mr Tyson earlier and I am going to take you to the second page, page 
14.  You see just at the top of the page, the third line down in your writing: 
“He questioned me about the bullying, he said serious allg”, 
short for “allegation”, 
F
“to …”, 
and then it goes blank.  Again, do you think that is – and please look at the expanded dictated 
version at pages 16 and 17 if you wish – a reference to the teacher who is called Mrs S?  I am 
not going to use her name in the light of the context of this.  Mrs S?   
A 
(After a pause)  I am sorry, are you referring to page 17? 
G
Q 
You may well be right.  I am just asking for your view? 
A 
I am afraid I cannot help you. 
Q 
If you look at the next paragraph on page 14 of the longhand note: 
“He was looking at Francine, who just stood there smirking.” 
H
 Yes? 
T.A.  REED 
Day 7 -  46
 & CO. 

---

A
A Yes. 
Q 
Again, please forgive me if you think I am being pedantic.  In the typed version on 
page 17 you have Francine Salem sitting there. 
A Yes. 
Q 
I do not know, did she change her view?  Did she say she had stood at first and then 
B
did you then translate it as “sat”?  How did it come about? 
A 
I do not know, I am afraid. 
Q 
The next line is, in contra distinction, rather more important potentially for my 
purposes.  Look at page 14, the third line of the second paragraph.   
“He said if it can’t be proven.” 
C
Do you see that? 
A Yes. 
Q 
Look at page 17, the fifth block of text down please?  You see the sentence on the 
penultimate line of the fifth block: 
D
“He was telling her that it cannot be proven that she did not kill [her eldest child]”. 
Yes? 
A Yes. 
Q 
There is no “if” there? 
A No. 
E
Q 
You see, “if” reflects possibilities and options and scenarios, does it not, the word 
“if”?  Yes? 
A Yes. 
Q 
But your dictated note translates it as a positive assertion by Dr Southall to your client 
that as a matter of fact it cannot be proven that she did not kill her eldest son? 
F
A Yes. 
Q 
There is a difference, is there not? 
A Yes. 
Q 
What she actually told you as per the longhand note is couched in the conditional, 
“if”, and that is actually what she said, is it not? 
G
A 
That is what the handwritten … 
Q 
Yes, and if you drop down on page 14 to the block of text beginning, “He said”, it 
reads:
“He said if nobody can prove that [the eldest child] did or didn’t kill himself through 
bullying …”. 
H
T.A.  REED 
Day 7 -  47
 & CO. 

---

A
Looking at the typed text please that does not appear in the typed text, does it, the “if”? 
A 
I am sorry, which line of the typed text are you referring to? 
Q 
Anywhere in the typed text does that conditional, or option, or scenario appear? 
A 
No, I do not think so. 
Q 
What she was using, when she actually spoke to you, that you recorded, was indeed 
B
an “if”, in other words an option or a scenario or a possibility, was she not? 
A 
Well, all I can say is that these are notes, contemporaneous notes, and what is there is 
there.
Q 
So can you given an assurance, please, to the Panel that it was she who used the word 
“if”?
A 
I can only say that these were written down at that time as best as I could. 
C
Q 
As being a record of what she was telling you? 
A Yes. 
Q 
Now, can I just ask you to go back, please, to the typescript at pages 16 and 17, and 
I am just going to go through with you to highlight a number of features of this when you 
came to dictate it very shortly after the interview itself.  In paragraph 1 on page 16 you have 
D
recorded that Mrs M was asking Francine Salem what she was doing there. 
A Yes. 
Q 
In the fourth paragraph you have recorded that Mrs M was telling you that she (Mrs 
M) drew a picture of the upstairs of the house. 
A 
It would seem so, yes. 
E
Q 
Over the page at 17, on the second line, this is your dictated version, “He was more or 
less cross examining her”.  Was that an expression of your interpretation of what Mrs M told 
you about Dr Southall’s approach in the interview? 
MR TYSON:   It is only fair, as my learned friend has been very fair throughout, to compare 
both versions. 
F
MR COONAN:   I am going to. 
MR TYSON:   Rather than surprise her on one without telling her that there is another. 
MR COONAN:   I fully understand that, but perhaps I can be permitted to take my own 
course, and we will come to it.  (To the witness)  I just want to ask you, at this stage when 
very shortly after the interview the expression “more or less cross examining her” is used, 
G
and my enquiry of you, I hope fairly, is whether that was your impression, when you used the 
“more or less”, of how she was putting it to you? 
A 
I cannot help you, I am afraid.  I just do not know what was in my mind at that time. 
Q 
Because, and I think this is lying behind Mr Tyson’s intervention, if you go back to 
page 13, you see, about eleven or twelve lines form the bottom of page 13, in your writing, do 
you see the sentence, “He then [cross] examined me accusing of lying”, do you see that? 
H
A Yes. 
T.A.  REED 
Day 7 -  48
 & CO. 

---

A
Q 
That is how you noted it there, but when you dictate it it is now translated as “more or 
less cross examining her”, and I just wondered whether you could help the Panel as to how it 
comes that the second version is arguably rather more diluted, if I may say so, than the first?  
Can you help us at all? 
A 
 I am afraid not, save that it was a long interview and I doubt very much if I would 
have made it word perfect. 
B
Q 
I just wondered, you see, whether you have recorded here “more or less cross 
examining her”, what you have done is, as it were, recorded in the longhand note the gist of 
it, but then when you come to put it down in your typescript you have added in, as it were, a 
general feeling about it, and so it comes out as “more or less cross examining”;  do you think 
that is a possibility? 
A 
It is a possibility. 
C
Q 
I cannot remember whether Mr Tyson asked you about this, if so forgive me, but if 
you go back to the bottom of page 14, the last line, again it was you recording what Mrs M is 
telling you, “He said it was very” something – do you know what that word is? 
A 
I think it relates to the fact that later on in the typed version of events that it was very 
cleverly done. 
D
Q Right. 
A 
I think that relates to that comment. 
Q 
For that, if you go to page 17, to the penultimate block of text, and you see on the last 
line you have recorded her saying that “he”, that is Dr Southall, “said that it was very cleverly 
done”.
A Yes. 
E
Q 
No doubt you used your best endeavours to record really that which she was saying, 
and it comes out as a comment “very cleverly done”? 
A 
It would seem to from the dictation. 
MR COONAN:   Forgive me one moment, Mrs Parry.  (Pause)  Thank you very much, that is 
indeed all the questions I ask. 
F
Re-examined by MR TYSON
Q 
You were asked by my learned friend about the telephone conversation you had had 
with Mrs M on the afternoon that she had seen Professor Southall.  I noted and wrote down 
you said, in answer to that question, “I remember she was upset and I remember she was 
saying that the accusation about the murder even then”, and then I noted you said, “it was so 
G
odd”.
A Yes. 
Q 
Does the fact that you regarded that accusation as being so odd assist in your 
recollection as to whether she made that comment and made that accusation in that telephone 
call?
A 
Yes, I took the telephone call very seriously, but it was so late in the day that we 
H
could not do anything about it. 
T.A.  REED 
Day 7 -  49
 & CO. 

---

A
Q 
I know it was late in the day and you did not note it, or we have not seen a note, but 
I am not asking about whether you made a note of it; what I was seeking to say was whether 
as the accusation was so odd, to use your words, does that assist as to whether she did in fact 
make that accusation on that evening? 
A 
Well, there was no written note of it, so it is very difficult for me to say outright that it 
took place regardless, but my recollection of that phone call was that she was very upset and 
B
she had briefly told me what went on with serious allegations being made against her. 
MR TYSON:   I have got no further questions. 
THE CHAIRMAN:   Mrs Parry, it is possible that the Panel may have some questions for 
you.  Mr McFarlane is a medical member of the Panel. 
C
Questioned by THE PANEL
MR McFARLANE:  Good afternoon, Mrs Parry. Thank you for coming.  Can I take you to 
page 14 and your handwritten note.  I must say the standard of your handwriting is far better 
than mine.  I want to look at the very last word on that page, “he said it was very”, are you 
able to decipher what that word is? 
A 
I am sorry, no. 
D
Q 
I mean, I do not claim to be a graphologist, or anything else like that, but when 
I looked at it I thought it might have said “convenient”.  Do you have any views on that? 
A 
No, not really, I am sorry, I just cannot make it out at all. 
Q 
That is okay.  Right at the very beginning you said that it was quite unusual that the 
social worker was at the meeting with Dr Southall which was attended by Mrs M, and that 
E
you did not know that this was going to happen prior to the meeting.  If you had known that 
the social worker was going to be at the meeting, would you have attended the meeting also? 
A Probably, 
yes. 
Q 
Thank you.  You have obviously spoken to Mrs M on the telephone and face to face 
on a number of occasions.  Seeking your own professional opinion, did you think that Mrs M 
was prone to exaggeration from time to time? 
F
MR COONAN:   I think this is a difficult question to put, and I, with great respect to 
Mr McFarlane, I am not sure she is in a position to answer that. 
MR McFARLANE:  Thank you.  I withdraw the question and I stand corrected. 
MR TYSON:   Well, you have only been corrected by one.  In my submission, you are 
G
permitted to ask, but the weight of the answer is a matter which you, the Panel, have got to 
consider later.  Mr McFarlane laid the trail saying that she knew this woman, and here is a 
professional witness who has seen a number of her clients, and lawyers tend to have a view of 
their clients, and in my submission the witness is allowed to deal with the answer, but bear in 
mind that this lady is not, as it were, a psychiatrist of whatever, the answer can be taken with 
such weight as is necessary, but it does not stop the answer being given to, in my submission, 
a legitimate question. 
H
T.A.  REED 
Day 7 -  50
 & CO. 

---

A
MR COONAN:   Well, I maintain my objection, I am afraid.  Insofar as lawyers may have 
views of their own clients, one is tempted to say, well, it might veer towards one particular 
view of one’s clients.  It is a line of questioning which could be applied to many, many 
witnesses, and in my submission it really is not appropriate that that question be put.  There is 
very little weight, if any, that could be attached to the answer in any event. 
THE CHAIRMAN:   We have differing views here, Mr McFarlane, and if you are seeking an 
B
answer to the question, and continue to do so, I will ask the Legal Assessor to advise us on 
how we should proceed. 
MR McFARLANE:  I should be most interested to learn the learned Legal Assessor’s 
opinion, please. 
THE CHAIRMAN:   Thank you. 
C
THE LEGAL ASSESSOR:   A question such as this, if put to an expert in the field, for 
example a psychiatrist, may well have some weight and indeed some relevance, but a 
question to a witness who is not in that specialist field, asking whether in her opinion 
somebody is prone to exaggeration would, I would advise the Panel, be unhelpful to say the 
least.  Of course, a witness is entitled to express an opinion, but this could be applied to any 
witness in regard to an assessment of any other person.  In those circumstances, my advice to 
D
the Panel would be that this question, although on the face of it it could be said to be an 
allowable question, would be in these circumstances inappropriate, and my advice would be 
that it should not be pursued.  I should also say that of course it is really a matter for the Panel 
to assess in the long term whether they find the witness to be somebody who has exaggerated 
in the circumstances that have been put to her. 
THE CHAIRMAN:   Mr McFarlane, are you content, or would you like the Panel to retire to 
E
discuss it? 
MR McFARLANE:  I am on this occasion happy to stay corrected, I wish to withdraw the 
question, and I have no further questions to ask.  Thank you. 
THE CHAIRMAN:   Mr Simanowitz is a lay member of the Panel. 
F
MR SIMANOWITZ:  Good afternoon, Mrs Parry.  In addition to being a lay member of the 
Panel, many years ago I was in fact a practising solicitor, and I just wanted to ask you a bit 
about these two versions of your notes, given my recollection of my own practice.  If you are 
taking notes from a client, and the client is speaking very quickly and you want to get on, you 
make, and I think you used the term “as best as I could”, and then when you come to dictate 
it, is it right if it is not long after that you may have a better recollection of some things, and a 
worse recollection of others, so you get your dictated note in as best a form as you can?  Is 
G
that the way you would proceed? 
A 
Yes, that is the way I proceeded. 
Q 
So that sometimes the dictated note is a better version, but if in the written note it is 
clear then you go by the written note? 
A Yes. 
H
T.A.  REED 
Day 7 -  51
 & CO. 

---

A
Q 
So when you get on page 14 this word which could variably be deciphered as 
“comments” or “convenient” or whatever, you made a quick note, and when you came to 
dictate it you record that it was cleverly done? 
A Yes. 
Q 
Thank you.  You had made the arrangements for your client to attend the meeting 
with Dr Southall.  What did you understand the purpose of that meeting was? 
B
A 
My recollection, and I stand to be corrected, was that Dr Southall had already 
prepared an earlier report for the ex parte order that was made before the case started. 
It was really so that he could alter his opinion which he had given earlier on.  Without the file 
I cannot really state specifically what the report was and what the specific instructions to him 
were.
Q 
I understand that.  Can you say as much as whether you understood it was going to be 
C
a medical interview about medical matters? 
A Yes. 
Q 
Did you understand it to be about anything else? 
A No. 
Q 
I want to come to the evidence you gave about Mrs M being upset.  Your first answer 
D
to Mr Tyson was, “I cannot remember whether she was upset when she saw me”.  I made a 
note of that.  Then when you were asked further you said, “I did recall before seeing these 
notes that she was upset”.  I am not sure whether there is an inconsistency there or not.  Do 
you recall when she came to see you that you saw her and she was upset? 
A 
Yes, she was upset, but what I cannot remember is whether she was crying. 
MR SIMANOWITZ:  I realise you said that later, but in fact you had said before you could 
E
not remember.  But it clarifies that for me, thank you.  Those are all my questions. 
MRS LLOYD:  Good afternoon, Mrs Parry.  Mrs Parry, we have had lots of references in 
your evidence and have of course seen the documentary evidence of the written notes and the 
typed notes you made of your meetings with Mrs M.  I wanted to ask you, you actually 
became involved with Mrs M in 1998 and I believe her son died in 1996.  Apart from her 
recalling the details of the meeting with Dr Southall, how were you first made aware of M1’s 
F
death? 
A 
I recall Mrs M came to see me almost on the day that her second child was removed 
from her, so I was probably made aware of it then. 
Q 
On page 12 of (gg) there is a letter from you to Mrs M dated 28 April which refers to 
her requesting a copy of the post mortem and a copy of the evidence from the Coroner’s 
inquest.  Could you just clarify for the Panel why they were being requested the day after she 
G
had the meeting with Dr Southall? 
A 
I suspect that this letter would have been dictated well before the 27th.
Q 
Are you saying that she would have asked for those prior to her meeting with 
Professor Southall? 
A Probably, 
yes. 
H
T.A.  REED 
Day 7 -  52
 & CO. 

---

A
Q 
You said that you probably learnt about M1’s death when Mrs M came to see you 
about the removal of M2.  Were you aware that the case had been closed by the police at that 
time? 
A 
I cannot remember if it was closed. 
Q 
Could you elaborate on that?  Was there an ongoing investigation? 
A 
I have not got the file, but it may have been re-opened, this care case. 
B
Q 
Finally, your typed attendance notes on pages 16 to 18, did Mrs M ever see these for 
verification of their accuracy? 
A I 
cannot 
recall. 
Q 
Would it be normal practice to show these to clients or to send a client a copy? 
A 
It is certainly my normal practice at the moment, but I am not sure about at the time. 
C
THE CHAIRMAN:  There are no further questions from the Panel, Mrs Parry, but it is 
possible that either counsel may have something arising out of them. 
Further cross-examined by MR COONAN
MR COONAN:  Just one short matter arising out of the questions put by Mrs Lloyd.
D
Mrs Parry, you were asked by Mrs Lloyd to look at page 12, about the request for a copy of 
the post mortem report and a copy of the evidence from the Coroner’s inquest, and you said, 
as I recall it, that this would have been dictated before the interview. 
A 
It may have been, yes. 
Q 
Again, I do not want to be mischievous; I just want to be as accurate as possible, but 
the second part of that letter, if that is right, how do the last three lines fit with that? 
E
A 
Because my secretary would have added another paragraph on.  If she had had tapes 
from a previous phone call from Mrs M from a few days before, then I would say , “Add a 
paragraph on”, so she would alter the letter. 
Q 
I think the point I am making is this.  When one is trying to look at the structure of 
how things work here, even relying on normal practice or best practice and so forth, there is 
an awful lot of speculation as to what happened when, is there not? 
F
A Yes. 
Q 
That is fair, is it not? 
A Reasonably 
so, 
yes. 
Q 
Because if you look back at page 11, and that is dated 27 April, Mrs M has actually let 
you have a psychology report and you tell her, as of 27, that you have actually got the post 
G
mortem of the inquest asking her if she wishes to have copies.  So that is on the 27th.
A Yes. 
Q 
It remains actually that we simply do not know how the letter dated 28th comes to be 
structured, do we? 
A No. 
H
T.A.  REED 
Day 7 -  53
 & CO. 

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A
Further re-examined by MR TYSON
MR TYSON:  I want to put two matters arising out of Mrs Lloyd’s questions.  Firstly, the 
matter that my learned friend picked up.  Looking at the letter on page 11, written the day of 
the interview, do you note the last paragraph, 
 
“I hope the taxi came for you for the appointment at Stoke-on-Trent”. 
B
Would that indicate to you one way or the other whether that part of the letter, as opposed to 
the postscript, was written before you knew what happened at Stoke-on-Trent? 
A 
Yes, it must have been. 
Q 
Dealing with another aspect arising out of Mrs Lloyd’s questions, that was whether 
the police re-opened the matter, could you look, please, in the same bundle at the tab after 
C
your evidence, which is (gg), at (jj)?  Could you just read that for a moment.   
A 
The letter of 3 December? 
Q 
Yes.  (Pause for reading)  Have you absorbed that? 
A Yes. 
Q 
Does that assist your memory as to whether there was a re-investigation and the 
D
results of the re-investigation or review? 
A Yes. 
MR TYSON:  I have no further questions of this witness and perhaps she can be released. 
THE CHAIRMAN:  Thank you, Mrs Parry.  That completes your evidence and you may be 
released from oath. 
E
(The witness withdrew)
MR TYSON:  Madam, I am going to call the Head of Administration at the Royal Brompton 
Hospital, who is Mr John Chapman.  For the information of the Panel, he dealt with two of 
the complainants, Mrs A and Mrs H.  he dealt with the providing or otherwise of their records 
from the Brompton point of view.   
F
I am grateful to my learned friend who indicates that I can lead this witness.  You will be 
receiving in relation to this witness some more material to put into your bundles, which were 
not in your bundles when I opened this case because, as I kept on saying, I needed more 
discussion on the question of accessibility before I dealt with it.  My instructing solicitor 
understands these bundles better than I and she is not here at the moment.  Perhaps we could 
break now to give us time to discuss these things. 
G
THE CHAIRMAN:  Yes, the Panel would like to take a break.  We will take 15 minutes. 
(The Panel adjourned for a short time)
MR TYSON:    Madam, perhaps I can explain my new witness and also get you to put some 
of the material into your bundles.  As I say, he is the Head of Administration at the Royal 
H
Brompton and NHS Trust.  He is going to produce a huge amount of documentation relating 
T.A.  REED 
Day 7 -  54
 & CO. 

---

A
to his side of dealings with the requests by Mrs H and Mrs A, ultimately for the whole of the 
SC file, if I can put it that way.  It is going to take some time and I do not say it is going to be 
the most interesting bit of evidence that I am going to call in the course of these proceedings, 
but could you have in your background that I will be producing in the course of the hearing a 
spreadsheet which puts together in chronological form the requests from Mrs A and Mrs H, 
and the other side of the coin, what Mr Chapman was doing.  I hope that will assist the Panel 
and give you a chronology. 
B
At the moment this witness will produce a mass of documentation.  Can I ask you, first, to 
look please at your C2 file, Section 3?  In Section 3 there will be a Tab (a) and I am going to 
give you a Tab (b) and Tab (c) to insert before Tab (d) that you have already. 
In relation to Patient H, could you go before Tab 3 but in the same bundle, and I am going to 
give you a new Section (l), (m) and (n) to put just before (o).  (Documents handed) 
C
Madam, I now call John William Chapman.  Again, I am grateful to my learned friend that he 
permits me to lead this witness through the documentation. 
JOHN WILLIAM CHAPMAN, Affirmed
Examined by MR TYSON
D
(Following introductions by the Chairman)
Q 
Could you give to the Panel you full name, please? 
A 
My full name is John William Chapman. 
Q 
What is your professional address? 
A 
My professional address is the Royal Brompton and Harefield NHS Trust, which is 
E
located at the Royal Brompton Hospital, Sydney Street, Chelsea, London. 
Q 
Are you the head of administration at the Royal Brompton and Harefield NHS Trust? 
A 
Yes, I am. 
Q 
Did you start work at the National Heart and Chest Hospital Special Health Authority, 
as it then was, which included the Brompton, in September 1987? 
F
A 
Yes, I did. 
Q 
So you started at the Brompton, albeit under a different label, in 1987 as director of 
planning and administration? 
A 
Yes, that is true. 
Q 
Then did you remain in that role until March 1994 and then in April 1994 did the 
G
Royal Brompton become an NHS trust and your title was changed to director of 
administration? 
A Yes. 
Q 
Then in April 1998, on the merger of the Brompton NHS Trust with the Harefield 
NHS Trust, did you become head of administration of the conjoined trusts? 
A 
Yes, I did. 
H
T.A.  REED 
Day 7 -  55
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A
Q 
So you have been staying on the same site, as I understand it, doing more or less the 
same job but with a number of different titles? 
A 
Certainly since 1994, yes. 
Q 
Since 1994 have your responsibilities included legal services within the Trust?  
A Yes. 
B
Q 
Do you manage all clinical negligence and personal injuries against the Trust? 
A 
Yes, I do. 
Q 
Do you liaise in that respect with solicitors and with the National Health Service 
Litigation Authority? 
A 
I do now and I have done since the NHS Litigation Authority was formed in 1995. 
C
Q 
I am going to ask you about a patient at the Brompton who we know as Child A.  
I think that you are familiar with the family that I am referring to? 
A 
Yes.  I have had conversations with the child’s mother. 
Q 
Did that child, Child A, undergo investigations at the Brompton in 1987 when 
Dr Southall was a senior lecturer and honorary consultant? 
A 
Yes, and there are medical records relating to the child’s treatment at the Royal 
D
Brompton Hospital. 
Q 
Can I ask you please to look at a document which may not be before you, and that is 
C5.  Just to assist you, Mr Chapman, the vast majority of C5 is something known as an SC 
file.  Did you, in the course of your involvement in these two cases, ultimately come to hear 
about what an SC file was?  I am asking you globally, but I can take you to the 
documentation in due course. 
E
A 
I came to certainly be aware of what an SC file was and I was certainly aware what it 
was in and around October 2003 when I learned about it from a solicitor employed by another 
Trust.
Q 
Have you actually ever seen an SC file? 
A 
No, I have not.  I have seen certain papers which were purported to have been in an 
SC file, but I have never seen an SC file myself. 
F
Q 
I am going to take you to various documents within Child A’s SC file just to help us 
with some history.  Can I ask you please to look at page 97 in that SC file? 
A 
Yes, I have it before me. 
Q 
Are you aware that in August 1997 the A family wrote to the Brompton Hospital 
requesting medical notes held at the Brompton and in particular requesting, as you see 
G
towards the end of the second paragraph, a copy of the reports made after the MMR scan 
performed on Child A in February 1987? 
A 
I must say I am not aware of that.  I was not even employed by the National Heart and 
Chest Hospitals SHA on 26 August 1987.  I was working my notice with another employer at 
the time. 
Q 
But you are aware that this letter was written? 
H
T.A.  REED 
Day 7 -  56
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A
A 
I have never seen it.  I was not involved with the disclosure of the medical records of 
Child A until December.  I believe it was December 1994. 
Q 
You indicate that you are aware that a request was made in 1987? 
A 
I am aware that there were requests for disclosure of the child’s records, yes, which 
were dealt with by my predecessor.  
B
Q 
If I can deal with it globally, are you aware that in 1987, following advice that was 
received, no disclosure was made at that time? 
A 
That is difficult to say.  This is a long time ago and I was not there.  I am aware that 
there were requests, I believe from the family and three previous solicitors before the 
solicitors I became involved with actually requested the medical records from the Trust 
solicitors. 
C
Q 
Let us get it, to be fair to you, to when you became involved, Mr Chapman.  We can 
put away C5 for a moment then and turn to another bundle which hopefully is in front of you, 
which is C2, section 3, tab (b). 
A Yes. 
Q 
Page 1 is a letter written by the firm of solicitors there mentioned, Thomson Snell & 
Passmore, to Norton Rose, dated 15 December 1994.  Are you aware that Thomson Snell & 
D
Passmore were then representing the A family? 
A Yes. 
Q 
And that Norton Rose were your solicitors for the Brompton? 
A Yes. 
Q 
Did you receive that letter from your solicitors, which set out, as it were, a shopping 
E
list of material that was required by Thomson Snell & Passmore? 
A 
Yes, it specifies eight items. 
Q 
It specifies eight items, and also looking for better copies of some medical records? 
A Yes. 
Q 
Did the items 2 and 3 contain both a request for the report of the MRI scan and the 
F
scan itself? 
A Yes. 
Q 
And the report for the NMR scan and the scan itself? 
A Yes. 
Q 
Just to cut matters short, did it turn out eventually that those were one and the same 
G
thing? 
A 
Yes, it did.  Yes, magnetic resonance. 
Q 
Did you make inquiries arising out of that letter to find the various items in that letter 
and did you write to your solicitor contact at Norton Rose on 18 January 1995? 
A 
Yes, I did. 
H
Q 
Which we have at page 3.  Did you point out in the second paragraph of that: 
T.A.  REED 
Day 7 -  57
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A
“As it happens I do not have many of the documents they are seeking.  I do possess 
images from magnetic resonance scans that were undertaken … and these are 
enclosed with this letter and the medical notes.” 
You did not possess matters relating to the CT scan or the barium swallow? 
A That 
is 
right. 
B
Q 
You also made comments about the electrocardiogram reports, indicating at that time 
your understanding that this was a test not undertaken at the Royal Brompton? 
A 
Yes, that is right. 
Q 
Similarly, with electroencephalogram reports, EEG reports, you also indicated that 
your understanding was that those were not undertaken at the Royal Brompton? 
C
A Yes. 
Q 
Also, as part of the shopping list you were asked for all tapes showing multi-channel 
recordings? 
A Yes. 
Q 
Is it true that at that time you had no idea what a multi-channel recording was? 
D
A 
No, I did not. 
Q 
Did the multi channel recordings appear in the Brompton notes at that time? 
A 
I believe there were references there to what recordings were undertaken, yes. 
Q 
Was it your understanding that there were several reports on the tapes, but not the 
tapes themselves? 
E
A 
Yes, that is what I am referring to. 
Q 
Did you then receive a letter, which we have at page 5, passed to you by your 
solicitors from Thomson Snell & Passmore, apologising for their misunderstanding in respect 
of MRI and NMR scans and setting out what they were looking for in relation to the multi- 
channel recording? 
A Yes. 
F
Q 
As a result of the matter about multi-channel recordings, did you then write to 
Professor Southall, who by that time had left your hospital, on 22 March, which we have at 
page 6? 
A 
Yes, that is my letter. 
Q 
Perhaps dealing with the earlier matters which you were not able to deal with earlier, 
G
do you say in the second paragraph: 
“For more than two years it was contended that insufficient information had been 
given by the solicitors … to comply with legal rules relating to the disclosure of 
medical records”, 
and thus the records were not disclosed until April 1993? 
H
A 
That would have been adduced from the clinical investigation file. 
T.A.  REED 
Day 7 -  58
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A
Q 
Then you indicate that in December 1994 another firm of solicitors had been 
instructed, and that is Thomson Snell & Passmore? 
A Yes. 
Q 
You set out at the bottom of the paragraph that they are seeking copies of the 
recordings made on the dates there mentioned of the breathing patterns, oxygen saturation 
B
and heart rate patterns and the like.  Then you say over the page: 
“The medical records contain only reports of the recordings and I enclose copies.  
I have been informed that you may have some records in your possession at the 
University of Keele relating to the treatment and care of certain children in Royal 
Brompton Hospital.” 
C
Can you recall now what was the nature of your information that medical records relating to 
Brompton children had been taken to Keele? 
A 
I believe, from what I can recall, that the information either came from the medical 
records manager who was guiding me at the time, as I had only been in that post for around 
nine months or so, or from the previous litigation manager, who had taken on another role in 
the hospital, that there were records retained in other parts of the hospital that were not in the 
main medical records department and therefore that I should check to make sure that there 
D
was a full disclosure.  I cannot say for certain who it was.  I think in all probability it was the 
medical records manager who had been in post quite a long time by then, but I cannot be 
absolutely certain now. 
Q 
Were you surprised at the possibility that some of the medical records relating to 
children at the Royal Brompton should be at the University of Keele? 
A 
I do not know whether I can say I was surprised.  I certainly knew that some 
E
departments had records and retained them outside the main medical records library, where 
the bulk of the records were certainly kept, and that practice continues even today. 
Q 
I think the question I asked you is were you surprised that the records had been taken 
out of the hospital? 
A 
It is really difficult now to say I was surprised at the time, I have to say. 
F
Q 
You wrote to him, as we have seen, and you also wrote to your solicitor on the same 
day, 22 March, at page 8, and you say that you had re-examined the content of the medical 
records and confirm that there are written reports of this multi-channel recordings, and that 
you had made enquiries in the medical records library for additional records and “have been 
informed that there are no further documents relating to the treatment of [Child A] at Royal 
Brompton”. 
A Yes. 
G
Q 
However, you had been informed that when Dr Southall had left he took with him 
certain records. 
A 
Yes, I had been informed, yes. 
Q 
Then did you receive a letter from Professor Southall, page 9, which said that he had 
looked through the records and had identified – this is when he was at the North Staffordshire 
H
T.A.  REED 
Day 7 -  59
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A
Hospital – and had identified six multi-channel physiological recordings and indicated to you 
that these recordings might be slightly difficult to put on to paper form? 
A Yes. 
Q 
Did you receive a letter meanwhile on 4 May from your solicitors enquiring whether 
you had heard from Dr Southall, and informing you that an affidavit might have to be 
prepared:
B
 
“If he does not have the records in his possession, then I will need the information 
I requested from you ….. I would appreciate a note on the various searches and 
investigations carried out and a list of the people you spoke to, in order to confirm in 
the affidavit that we cannot trace the records.” 
A 
Yes, this is putting me on notice effectively. 
C
Q 
Yes.  By this stage, in view of the enquiries made by TSP, was it clear that there were 
medical records, but they were not actually in the Brompton Hospital?  Taking you back to 
page 8, your response at that time in March was that there were no further documents relating 
to the treatment at the hospital. 
A Yes. 
D
Q 
So you had been put on notice. 
A Yes. 
Q 
Then on 7 June did you write to your solicitors, page 11, and indicated that you had 
written to Professor Southall, in the first paragraph, and then in the second paragraph 
indicated that you had received a response from Professor Southall about the six multi-
channel physiological recordings, and in the third paragraph indicating that you had made a 
E
number of calls to Professor Southall, and setting out the difficulties about storage of paper 
copies of the information that you wanted. 
A Yes. 
Q 
Were you subsequently advised by your solicitors that if Thomson Snell & Passmore 
did not have the paper, they would like the actual physical tapes. 
A 
The original tapes, yes. 
F
Q 
Did you then ask Professor Southall for those physical tapes? 
A Yes. 
Q 
Then did Thomson Snell & Passmore come up in July, page 14, with further matters 
arising out of their study of the clinical records, which they had been provided with, 
identifying what appeared to them to be some further gaps? 
G
A 
Yes, that is right. 
Q 
Going to page 17, meanwhile did you get a letter from Professor Southall indicating 
that he had sent the original tapes to the solicitors?  
A 
Yes.  This is a copy of a letter he had written to Norton Rose. 
H
T.A.  REED 
Day 7 -  60
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A
Q 
Then did you write, page 18, in July to Professor Southall relating to the gaps that had 
been identified by Thomson Snell & Passmore, asking for his assistance broadly to fill in the 
gaps? 
A Yes. 
Q 
Did you indicate under number 1 that the medical records department had informed 
you that there were no temporary records created for Child H between the dates in question? 
B
A 
Yes.  I would have seen the medical records manager and asked her about it, and she 
would have, I am certain, checked and told me that there was no temporary record. 
Q 
Then did you on the same day inform your solicitors, page 19: 
 
“I have enquired in the Medical Records Department to see if for some reason a 
temporary medical record was created ….. but have [found] that there is none.  I will 
C
therefore ask Professor Southall to confirm [those matters].” 
A Yes. 
Q 
Then in August did you write to your solicitors, giving them information about the 
status of Dr Southall at any given time within the hospital and dealing with whether he had 
status to admit patients under his own name? 
D
A 
Yes, that is right, yes, and the source of the information was largely Professor 
Denison.
Q 
Yes.  When you had written to Professor Southall in July, on page 18, asking for, as it 
were, any further records that he was holding in relation to this Brompton patient up in North 
Staffordshire, did you get the letter, which we see at page 22, from Professor Southall on 15 
August 1995? 
E
A Yes. 
Q 
Did that indicate to you that: 
 
“We always kept our own medical records for all the special cases that we dealt with 
at the Brompton”. 
F
A Yes. 
Q 
Did the expression “special cases” have any meaning to you at all at that time? 
A 
Not at the time, no. 
Q 
Then he indicates that he has arranged for something to be photocopied and enclosed 
with this letter, and we see a document at page 23, which is a list.  Was that a list compiled by 
G
you? 
A 
Yes, it is. 
Q 
That sets out the documents that you received from the Professor at the time. 
A Yes. 
H
T.A.  REED 
Day 7 -  61
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A
Q 
That is all I want to deal with about Patient A.  Can I come, please, to your dealings 
with Patient H, and I would ask you to look at the same file that you have in front of you at 
section 2, under tab (l). 
A 
Yes, I am ready. 
Q 
Did the hospital receive a letter dated 16 June 1994 from the solicitors Hutton’s, 
setting out the name of their clients, who we know as the H’s? 
B
A Yes. 
Q 
In particular, Child H, who is the third person there mentioned. 
A Yes. 
Q 
Setting out various allegations, for instance on page 2 in the middle paragraph, setting 
out allegations that: 
C
 
“Our clients consider that there was negligence in the treatment [Child H] received at 
Great Ormond Street Hospital, Royal Brompton Hospital and University Hospital of 
Wales ….. We are instructed on behalf of our clients to bring a claim for damages 
against Great Ormond Street Hospital, Dr David Southall [in person]” and your 
hospital, amongst others. 
D
A Yes. 
Q 
Was there a request on page 3 for medical records, in the third paragraph on page 3: 
 
“Accordingly, we request you to produce to us all surgical, nursing ….. records” and 
the like. 
E
A Yes. 
Q 
Did that firm of solicitors helpfully schedule the material that they were in fact 
seeking, which we see at page 6? 
A Yes. 
Q 
To put it broadly, it appeared to be a lot, if I can put it that way? 
F
A 
It is certainly exhaustive. 
Q 
Dealing with, picking it up at (5), the admitting doctor’s notes, in-patient medical 
notes, out-patient medical notes, the nursing kardex at (11), investigations thereafter, 
correspondence at (20), so clinical correspondence they were also looking for. 
A Yes. 
G
Q 
If you look at (23) over the page. 
A Yes. 
Q 
Have you come across a request such as that before, for the doctor’s own files relating 
to treatment of the patient and the type of treatment generally? 
A 
Possibly.  I cannot for certain say, but I took this to be a standard letter that a firm of 
solicitors would write to any hospital requesting medical records.  I have certainly received 
H
similar schedules from other solicitors over the years. 
T.A.  REED 
Day 7 -  62
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A
Q 
You got the usual consent, page 8.  Did Child H undergo investigations at your 
hospital in September 89 and March 1990? 
A 
Yes.  There is a set of medical records relating to the treatment of the child. 
Q 
So you got this letter in 1994 from those solicitors, and did you on the same day 
contact your solicitors Norton Rose, page 9? 
B
A 
Yes, I did.  That was the standard procedure in the hospital at the time, that letters for 
action in relation to written proceedings would be sent to the Trust’s solicitors. 
Q 
Dealing with the bottom paragraph on page 9, did you ask Norton Rose to act, and 
you say the letter seeks disclosure and you confirm that the medical case notes and 
correspondence with the local authority were in your possession and you had taken 
appropriate steps to comply with the investigations and the X-rays. 
C
A 
Yes, that is right. 
Q 
Did you review those medical records and meet with your solicitors shortly after, in 
late June, and give your solicitors a copy of all the medical records? 
A 
Yes, I did.  I met them on 28 June. 
Q 
Following that meeting on 28 June, did you then write to Professor Southall on 1 
D
July? 
A Yes. 
Q 
Informing him that you had received the correspondence and that a claim was being 
brought against him personally, and that you held medical records but none of the 
correspondence that you were also asked to provide, and the last three lines: 
E
 
“I write to ask therefore that if you possess a file within the Academic Department of 
Paediatrics ….. with such correspondence would you please send it me as soon as 
possible.”
A 
Yes, that is right. 
Q 
Were you chased by your solicitors as to whether you had a response from Professor 
F
Southall?
A 
Are you referring to JC5 on page 13? 
Q 
No.  I am referring you to the fact that you wrote to Professor Southall on 1st July, as 
we see at page 11. 
A Yes. 
G
Q 
Could you go then please to Tab (n)?  Is this a letter to your solicitors, Norton Rose, 
dated 18 July? 
A Yes. 
Q It 
says, 
“Thank you for your letter of 14 July in which you have informed me of the outcome 
H
of a conversation with the solicitor at Hutton’s who is pursuing action for damages 
T.A.  REED 
Day 7 -  63
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A
arising from alleged negligence…After our meeting on 28 June I wrote as agreed two 
letters to Professor Southall at the Academic Department of Paediatrics in North 
Staffordshire Health Centre in respect of H and his parents.  I enclose copies of both 
letters.  To date he has not replied”. 
A 
Yes, there was one letter concerning Child H, the other letter related to another child. 
B
Q 
Thank you.  That is mid-July, and then in August, page 12, did you get a letter for you 
to deal with from the H’s solicitors indicating that they had issued an application to the court 
for the documents? 
A Yes. 
Q 
Were you written to by your solicitor at page 13 in September 1994, giving you 
advice from your solicitors as to whether there should be disclosure or not? 
C
A That 
is 
right. 
Q 
We see the brunt of the advice at the bottom of page 13, 
 
“I think the court would order pre-action discovery”. 
A 
Yes, that is right. 
D
Q 
There is a suggestion that voluntary disclosure should be given, at the top of page two 
of that document.  Were you asked to confirm, at the end of the first paragraph, 
 
“Please confirm that the hospital has no other documents”? 
A Yes. 
E
Q 
Did you reply to that letter at page 15, the letter to your solicitor agreeing that there 
should be voluntary disclosure of the documents in the possession of the hospital relating to 
this child?  That is in the second paragraph. 
A Yes. 
Q 
Then dealing with matters in the various schedules attached to the parents’ 
F
application, setting out exactly what they want, as it were, a further shopping list, if I can put 
it that way, do you deal with the matters requested under various of the schedules, including 
clinical research protocols and Ethics Committee Guidance and the like? 
A 
Yes, minutes of meetings of the Ethics Committee, yes. 
Q 
And things like that. 
A Yes. 
G
Q 
Over the page, in relation to the sixth item of the schedule, did you have no 
correspondence between the hospital and the local authority there mentioned, and did you 
indicate that you had written to Dr Southall asking for the file in relation to that matter? 
A 
Yes, and had written previously. 
Q 
Yes.  Were you then informed by your solicitors that voluntary disclosure would take 
H
place despite the fact that there were various missing matters? 
T.A.  REED 
Day 7 -  64
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---

A
A Yes. 
Q 
About a year later, page 18, were you made aware that the H family had decided to 
discontinue their action? 
A 
Yes, that is right. 
Q 
We see that at 15 September 1995, at page 18, 
B
“We are writing to inform you that we have lodged Notice of Discontinuance at the 
court”.
A Yes. 
Q 
So you had provided such documents as you were able to provide, but the action went 
C
no further. 
A 
Yes.  The court was actually keeping us informed over those nine months of the 
proceedings that were taking place and subsequently being adjourned, and at times also 
Norton Rose would telephone me to tell me what was taking place as well. 
Q 
Can I move on from 1995 to 2000?   Can I ask you, please, to look at the next tab, 
which is Tab (m)?  You see that that is a letter, I think we heard in evidence, from Mrs H to 
D
you.
A 
It is signed by Mr and Mrs, but yes. 
Q 
Can you recall that you received that letter? 
A 
I did receive it, yes. 
Q 
Had you had a telephone conversation with Mrs H? 
E
A 
Yes, I had had a telephone conversation with her. 
Q 
We need not go into what was in the telephone conversation, but did she enclose the 
document that she had been talking about and you did not know what she was talking about 
in actual fact?  Did she enclose that document on the same page as this? 
A 
Yes, that is right. 
F
Q 
In the course of the conversation, can I ask you this, had she drawn your attention to 
the fact that in the top right hand corner of the document, she had found something which she 
called an “SC number”? 
A 
Yes, she did.  I did make a record of that conversation. 
Q 
Was she asking you in that conversation, before she sent you this, what an SC number 
was? 
G
A 
I believe so.  I would like to refer to the file note but I am fairly certain that she did 
ask me what the SC number stood for. 
Q 
Would that be in your own files? 
A 
I did send it to Field Fisher Waterhouse.  They asked me for it, but it is in my files. 
Q 
Whilst that is being looked for, your recollection is, and you have a note to that effect, 
H
that some time prior to you getting the letter that we see at Tab (m), you had had a 
T.A.  REED 
Day 7 -  65
 & CO. 

---

A
conversation with Mrs H and one of the matters that she had brought up was the question of 
broadly, “What was an SC file?” 
A 
Yes, that was one of the matters.  
Q 
As a result of that telephone conversation and that subsequent note that you got from 
Mrs H, did you reply to her, going back to the previous section, which we see at page 19? 
A 
Yes, I wrote to her.  That was in response to another conversation. 
B
Q 
Can I pick it up?  You are answering various of her queries. 
A Yes. 
Q 
Can I pick it up in the last paragraph on page 19?  It says, 
“When you wrote to me you also enclosed a copy of a report on respiratory recordings 
C
dated 27 September 1989.  This includes Child H’s hospital registration number and 
another SC number ‘2026’.  I am sorry to say that I do not know what this number 
refers to”. 
A Yes. 
Q 
The letter continues, 
D
“You confirmed to me that it is not child H’s registration number at Great Ormond 
Street”.
A 
Yes.  I probably asked her if it could be. 
Q 
Until 16 May 2000, Mr Chapman, were you aware of SC files or SC numbers? 
E
A 
I had seen SC numbers but I was not aware of SC files. 
Q 
As Head of Administration at your hospital, do you feel you should have been aware 
of SC files being held, or files being held on patients of yours in order to comply with your 
statutory obligations about disclosure of records? 
A 
I was not responsible for the operation or management of the medical records 
department.  I was remote from that. 
F
Q 
So you cannot answer. 
A 
I cannot answer the rest of it, no. 
Q 
Did you then, in July – page 21 – send her a copy of such notes that were held on the 
child at the Royal Brompton Hospital? 
A Yes. 
G
Q 
Can I ask you, please, to look within Tab (k), which is earlier on in this bundle?  That 
brings us forward from 2000 to 2002, and can I ask you to look at page 19?  When it says 
there in the first paragraph, 
 
“I wrote in my letter of 16 May I did not know what SC2026 refers to”; 
H
T.A.  REED 
Day 7 -  66
 & CO. 

---

A
bearing in mind I have just been referring you to a letter of  16 May 2000, should we read 
into that 16 May 2000? 
A 
I think that is right. 
Q 
It is page 19 in the next tab.  Do you see that? 
A Yes. 
B
Q 
At the bottom of page 19 you say you do not know what SC2026 refers to. 
A Yes. 
Q 
So when you are writing in 2002, should we take the reference in the last sentence of 
the first paragraph, 
 
“I wrote in my letter of 16 May”, 
C
to mean 16 May 2000? 
A 
Yes.  I did say in the next sentence, 
 
“as far as I have been able to establish in the past two years”. 
Q 
Yes, and then you set out your understanding since that date, as it were. 
D
A Yes. 
Q You 
say, 
“SC2026 appears to have been applied by the Department of Paediatrics (Clinical 
Physiology) of which Dr David Southall was head until July 1992.  It appears only on 
reports by this Department.  I can see no other use of the reference in any other 
E
documents in Child H’s medical notes.  It does not feature in any of the social 
Services documents so I am certain it does not refer to ‘social care’. 
A Yes. 
Q 
Can you help us with the reference to “social care”? 
A 
I think that one of the points going through my mind at the time was whether or not it 
F
was a social services reference. 
Q 
Did you go on to tell Mrs H, in the middle of the next paragraph, 
“The NHLI Academic Department undertakes medical education and research into 
heart and lung disease in infants and children.  My enquiries in the Academic 
Department of Paediatrics for further records of Child H’s treatment and care revealed 
G
nothing.  I concluded that Dr Southall could have taken further records to North 
Staffordshire Hospital.  Your letter informs me that your enquiries to North 
Staffordshire Hospital found that Professor Southall held a file about Child H there”. 
A Yes. 
Q 
We heard from the lady yesterday and she produced the letter from the North 
H
Staffordshire Hospital indicating the discovery of the SC file 2026 in that case.  Just one last 
T.A.  REED 
Day 7 -  67
 & CO. 

---

A
matter in relation to your evidence.  I would like you to look at page 21 in Tab (k).  This is a 
letter from the Director of Service Improvement at the North Staffordshire Hospital NHS 
Trust.  I do not know if you have seen that before so perhaps you would just read it to 
yourself, and then I want to ask you one question about it.  (Pause for reading) 
A 
Yes, I have read it. 
Q 
Are you aware that after June 2002 any further material was sent by the North 
B
Staffordshire back to your hospital? 
A 
No, I was not. 
Q 
Has there been? 
A 
I do not know. 
Q 
One last matter, is it right that you very helpfully came today with a huge amount of 
C
original files, which I see are by your right knee?  Is it right that you have kindly permitted 
both Professor Southall’s barrister and myself to look at those overnight if we have to? 
A 
Yes.  I have no objection.  I will leave them here. 
MR TYSON:  Madam, on that rather informal note, can I say that, subject to anything that 
I see if and when I have an opportunity of looking at those files, that concludes my 
examination in chief.  I am perfectly happy for my learned friend to cross-examine, if he 
D
would like to cross-examine on the same proviso that he would also like to look at the 
original material in those files. 
THE CHAIRMAN:  Are you saying you would like to return to us with questions for the 
witness if that becomes necessary? 
MR TYSON:  I do not know because I have not been able to go through the exercise of going 
E
through the enormous amount of files that this witness has brought.  I hope that I do not have 
to, but I am leaving open the possibility that I do. 
MR COONAN:  Madam, I was well aware that these files existed today because I was shown 
them at 20 minutes to two.  When I say I was “shown” them, I was shown the fact that there 
was a pile of them and both Mr Tyson and I became aware of the fact that they were there, 
but neither of us have had an opportunity of actually looking at them.  The Panel have already 
F
heard Mr Chapman – it is no criticism of him – refer to these as file note conversations.  
I have not seen those and I think that, out of an abundance of caution if nothing else, I ought 
to have a look at the files to see if there is any material which sheds any light on the issues 
which are presently before the Panel.  I ought to do that, in fairness to Dr Southall, and 
indeed, frankly, in fairness to the shape and content of my cross-examination do that before 
I even cross-examine.  I think that, if I may say so, I would wish to hear if there is to be any 
more examination-in-chief before I cross-examine, so I am inviting Mr Tyson to look at these 
G
documents before I cross-examine. 
THE CHAIRMAN:  Mr Tyson? 
MR TYSON:  That is a very fair invitation for my learned friend to make.  I do not think 
I can read all those documents in the time that we have available before we have to rise 
tonight.
H
T.A.  REED 
Day 7 -  68
 & CO. 

---

A
THE CHAIRMAN:  I am suggesting, if this course of action is acceptable, then the Panel 
would rise now till tomorrow morning.  Is that acceptable to both of you that we should 
proceed that way? 
MR TYSON:  Highly acceptable. 
MR COONAN:  Madam, it is; it is indeed.  Can I just say at the moment that I do not have a 
B
great deal to ask Mr Chapman, so he should not, I think – if I can say this through you, 
madam – worry unduly about getting to his board meeting at 12 o’clock.  Obviously, one 
does not know what is in Pandora’s Box, but subject to that we will try with expedition to 
make sure he is away. 
THE CHAIRMAN:  It would appear to make sense that we rise now and that will give you 
the opportunity to peruse the documentation.  Is there still a request for an early start?  I think 
C
it was mentioned earlier. 
MR COONAN:  Could I just make this observation?  Of course, Mr Tyson would prefer, 
I am sure, to look at these files, and it would seem sensible at least for him to look at them 
first.  That may take a little time.  We would then have to look at them after he has, together 
with Ms Ellison.  I, for my part, am in your hands.  If you wish to sit earlier to morrow 
morning, then so be it. 
D
THE CHAIRMAN:  The answer to that is the Panel is willing to listen to a request, but we 
would normally sit at 9.30 unless requested otherwise, either to sit earlier or later. 
MR TYSON:  My request is 9.30. 
THE CHAIRMAN:  Is that acceptable to you?  Would that give you both time? 
E
MR COONAN:  I support Mr Tyson. 
THE CHAIRMAN:  Does that give you time to look at the documents?  If you have not had 
enough time you can apply for more time at 9.30. 
MR COONAN:  I am very grateful.  We will make time and try and do it.  If there is a real 
F
problem we will let you know. 
THE CHAIRMAN:  Thank you.  We will rise now and we will reassemble at 9.30 tomorrow 
morning.  Mr Chapman, I should remind you that you are now on oath and remain on oath 
overnight, so you must not discuss your evidence in the case with anyone. 
THE WITNESS:  I understand that, Chairman, and thank you. 
G
(The Panel adjourned until 9.30 a.m. on Wednesday, 22 November 2006)
H
T.A.  REED 
Day 7 -  69
 & CO. 

---

GENERAL MEDICAL COUNCIL
FITNESS TO PRACTISE PANEL (PROFESSIONAL CONDUCT)
Wednesday 22 November 2006
44 Hallam Street, London, W1W 6JJ
Chairman:   
  
Dr Jacqueline Mitton 
Panel Members:
Mrs Leora Lloyd 
Mr Alexander McFarlane 
Dr Sameer Sarkar 
Mr Arnold Simanowitz 
Legal Assessor:   
Mr Robin Hay 
CASE OF: 
SOUTHALL, David Patrick 
(DAY EIGHT)
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 JOLLIFE 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
MR JOHN WILLIAM CHAPMAN, Re-called 
 
Examined by MR TYSON, Continued 
 
 
  1 
 
Cross-examined by MR COONAN   
 
 
  2 
 Re-examined 
by 
MR 
TYSON 
    23 
 Questioned 
by 
THE 
PANEL 
    28 
 Further 
re-examined 
by 
MR 
TYSON 
   31 
APPLICATION TO ADMIT EVIDENCE   
 
By MR TYSON 
 
 
 
 
 
33 
 By 
MR 
COONAN 
     37 
 ADVICE 
FROM 
LEGAL 
ASSESSOR 
  40 
 
DECISION 
 
 
 
 
 
 
41 

---

A
THE CHAIRMAN:  Good morning.   Mr Tyson, you thought you had probably finished your 
examination in chief, but you then had some documents to read. 
MR TYSON:  Yes, madam, I believed I had.  As ever there was an opportunity to think about 
something overnight and I asked my learned friend whether he would permit me to ask one 
more question. 
B
MR JOHN WILLIAM CHAPMAN, Re-called
Examined by MR TYSON, Continued
MR TYSON:  Mr Chapman, what I am going to do is ask you to look, please, at the bundle, 
C2 in the first lot of tabs under (k), and within (k) at page 19. This was a letter that we looked 
at yesterday, a letter from you to Mrs H dated 22 April 2002.  You indicate in that letter that 
C
you had already written to Mrs H in May 2000 indicating you did not know what SC 2026 
was.
A Yes. 
Q 
Later on in that letter you indicate that you have done two more years research and 
found that that was a file number used by Dr David Southall until July 1992.  In the third 
paragraph you indicate that your inquiries in the Academic Department for Paediatrics – was 
D
that the Academic Department for Paediatrics at the Brompton? 
A 
Yes.  It was on the Royal Brompton Hospital site. 
Q 
…for further records of Child H’s treatment and care revealed nothing. 
A Yes. 
Q 
You were asked, both in the case of A and in the case of H to produce records prior to 
E
2000 because the parents of those children had requested them.  Is that right? 
A 
I believe so, yes. 
Q 
And yesterday we went through each of the requests in both cases. 
A Yes. 
Q 
If you did not know that there was an SC file in either of those cases, would that help 
F
you as to whether you would be able to produce the SC file in response to those requests? 
A 
Can I make sure I understand what you are saying?  If I had or had not known? 
Q 
If you had no knowledge that there was an SC file, which is what you indicated in the 
letter I have shown you, how would that assist you in locating all the medical records in 
response to a request by the parents via their solicitors? 
A 
I had written to Dr Southall at the time to ask him if he had any records.  I had 
G
conducted searches in the medical records department.  I had conducted searches in the 
hospital elsewhere.  I had also asked the National Heart and Lung Institute itself if there were 
any records and I had asked in the Academic Department of Paediatrics, which by 2002 was 
the responsibility of another head. 
Q 
None of those inquiries revealed the existence of a separate file called the SC file. 
A 
That is true.  They all said to me that they had no records of an SC file or SC records 
H
themselves. 
T.A.  REED 
Day 8 -  1
 & CO. 

---

A
Q 
Thus, were you able to produce the SC file in relation to the solicitors’ requests? 
A 
No, I never produced an SC file to the solicitors and I can verify from what you 
showed me yesterday when you directed my attention to an SC file, I never found or had 
produced for me any such file. 
Q 
Indeed you had never seen one until yesterday. 
B
A 
I had never seen one, that is correct. 
MR TYSON:  Thank you. 
Cross-examined by MR COONAN
MR COONAN:  Mr Chapman, on the last point – we will come back to tracing matters 
C
through in a minute – the plain fact is that at the time you were doing the search for the SC 
files they were in fact in Stoke, as we now know. 
A 
I was searching for more than an SC file.  I was also searching for additional records 
because the solicitors who acted for the parents we have been talking about had actually said 
to us that they believed there were missing records. 
Q 
They may say they believed there were missing records. 
D
A 
I verified there were none so far as they related to national Health Service Royal 
Brompton records. 
Q 
Absolutely.  I am not suggesting that there were records that you had overlooked.
I am suggesting that the records in fact were in Stoke. 
A 
I had written to Stoke to ask if there were any records. 
E
Q 
Yes, but how Stoke managed it is a matter for Stoke.  I am dealing with the fact that 
the practical reason why you could not find the material is because, as a matter of fact as we 
now know, it was in Stoke. 
A 
Yes, but I had a duty to look. 
Q 
Can we just go back, please, to deal with each of these two children and pull together 
some of the milestones because, speaking entirely for myself, sometimes it is a little difficult 
F
to see how everything interlocks.  Let us take Child A first, but perhaps I may say in passing 
thank you for letting us have a look at the documents and it may be that I shall need to refer 
you to one or two of them.  Right? 
A Yes. 
Q 
In respect of Child A there were, in reality, two periods, first of all 1987 to 1994 and 
the second period 1994 and thereafter.  That is a convenient way of dividing it, is it not? 
G
A 
In that way, yes.  I would actually subdivide the second period into three. 
Q 
I am trying to keep it as simple as possible.  The first period 1987 to 1994, there was 
an initial request for the records in 1987 by Child A’s parents. 
A 
Yes, I think I was directed to that yesterday, to a letter that pre-dates my employment. 
Q 
Yes, it is C5, page 97.  That was the first request, and it might be helpful to turn that 
H
up again because there is a particular reference I need you to look at.  I know this is before 
T.A.  REED 
Day 8 -  2
 & CO. 

---

A
your time, but Mr Tyson asked you to look at it and I will do the same.  It is page 97.  This is 
the first request addressed to the Brompton by the parents for the notes and I take you to the 
latter part of the second paragraph, last four lines, 
“We also request a copy of the report made after the NMR scan performed on Child A 
on 10 February 1987 at the special unit adjacent to the Brompton Hospital under 
instructions from the Brompton team”. 
B
So there was a specific request as far back as 1987 for the NMR report, as it was then called. 
A Yes. 
Q 
I do not know if you can help with this, did the hospital at about that time have what 
is called a PAS? 
A 
A patient administration system, yes. 
C
Q It 
did? 
A 
It did have a patient administration system.  As to whether it had modules, for 
example imaging modules, I cannot be certain of, but it had a patient administration system. 
Q 
So there was an outstanding request.  We know from Mrs A’s evidence that a 
significant number of solicitors were instructed by her sequentially in order to attempt to 
D
obtain the records. 
A Yes. 
Q 
And they did not succeed.  We know that.  You accepted that. 
A 
I would accept that, although my knowledge of those three previous attempts is 
relatively cursory, although there is documentation in the file. 
E
MR COONAN:  There is one document I would like you to look at in the file.  You will find 
it, I think, in your first volume.  It is a letter to the Brompton dated 25 September 1987.  Let 
us see if you can locate it first.  It is from Norton Rose. 
THE CHAIRMAN:  Is this in a bundle before the Panel? 
MR COONAN:  Not yet.  I want Mr Chapman to identify the document and then we can 
F
circulate it.  Do you have that document? 
A 
Is it dated 25 September 1987? 
Q 
Yes.  It is from Norton Rose to Miss Karen Turner.  It has been photocopied so it can 
be distributed.  (Document handed)  It will be D5.  As you said yesterday, Mr Chapman, 
Norton Rose were the Brompton Hospital’s solicitors as far back as September 1987. 
A 
Yes, and before that. 
G
Q 
And before that. 
A 
Long before that. 
Q 
It is a letter referring to the A family’s request for medical notes.  The writer refers in 
the second part to the legal position in relation to wardship proceedings, but can I ask you 
please to look at the last four lines of that second paragraph, 
H
T.A.  REED 
Day 8 -  3
 & CO. 

---

A
“As I said in my earlier letter, Mr and Mrs A would not be entitled to apply for pre-
action discovery in the usual way because this is not a personal injury or medical 
negligence case.  In any event, the records should only be handed over to medical, 
legal or other professional advisers”. 
Then at the bottom of the page, 
B
“My advice, therefore, is to withhold the records and to wait until a decision 
concerning disclosure if any, is made by the Judge. 
 
I enclose herewith a draft letter to Mr and Mrs A”. 
Over the page we find the draft letter, drafted from the solicitors.  In the middle paragraph it 
says,
C
“Medical records within the NHS remain the property of the Secretary of State and 
not of the individual doctor or patient.  Access to such records is limited and they are 
usually only disclosed to an applicant’s legal advisers and any other medical or 
professional advisers in certain circumstances. 
We do not believe that our clients [the Brompton] are under a duty to disclose the 
D
records in this case and have advised them accordingly”. 
That is, as a matter of historical record, the position being taken by the Brompton’s legal 
advisers.  Is that right? 
A 
Yes, that was their advice. 
Q 
Mr Chapman, can you just help me about another aspect of this.  Leaving aside 
E
wardship, which is a wholly separate jurisdiction, the jurisdiction in relation to pre-action 
disclosure in a personal injury or medical negligence claim is a separate jurisdiction as 
regards disclosure of documents, is it not? 
A 
Yes.  It has changed considerably since that time. 
Q 
You anticipated my next question.  In the 1980s and 1990s – we can take this quite 
broadly – the ability of claimants, as they are now called (plaintiffs at the time) to obtain 
F
disclosure in medical negligence actions or personal injury actions was, certainly from the 
standpoint of plaintiffs and their advisers, extremely restricted, was it not? 
A 
I would not entirely agree, if I may say so, because the Access to Health Records Act 
came into operation.  The Act was 1990 and health authorities, health organisations were 
encouraged to help people to have access to their clinical records.  There were caveats; there 
were certain restrictions. 
G
Q 
It is the caveats and restrictions, if I may say so. You, wearing your, as it were, 
defendant’s hat may take one view, another person wearing a claimant’s hat may take a 
wholly different view, but the fact is during that period, as this letter indicates, the law and 
procedure at various times indeed restricted disclosure of medical records either to the legal 
advisers or, as the letter indicates, to the nominated medical expert? 
A 
Yes, but that changed in a case, I believe against Wandsworth Health Authority. 
H
T.A.  REED 
Day 8 -  4
 & CO. 

---

A
Q 
Indeed it did, but there were, as you have said, changes during the period, changes in 
philosophy and thinking, not just by the defendant’s advisers ---? 
A No. 
Q 
-- but by the courts? 
A 
Yes, and subsequently through the reforms instituted by Lord Woolf. 
B
Q 
Absolutely, the Woolf reforms, of course, coming into operation in 2000? 
A 
Yes, with the protocols for pre-action discovery. 
Q 
None of that existed prior to then? 
A 
That is true, not at this time. 
Q 
If we are speaking generally, of course, one has to add into the equation the 
C
experience and expertise of solicitors involved, or the lack of it? 
A Yes. 
Q 
That is fair, is it not? 
A 
Yes, I would say so, and indeed for claimants and others who wished to access health 
records.
D
Q 
Certainly, in those early days there was not the specialisms residing in claimants’ 
solicitors as there is now, as a general observation? 
A 
I agree completely. 
Q 
Which was a matter of great concern to a large number of people? 
A Yes. 
E
Q 
The result of the advice adopted by the Brompton at that time really led to a position 
whereby these notes – what I am going to call the main library notes – were not actually 
handed over until 1993? 
A 
I believe that is right, bearing in mind that I did not have any responsibility before this 
until 1994. 
Q 
Mr Chapman, I am not suggesting you did, so do not feel defensive about it. 
F
A 
Right.  Thank you. 
Q 
It was before your time, but it is a matter that falls within the gaze of the Panel and 
therefore I must deal with it as best I can.  The policy adopted by the Brompton was not to 
disclose until an affidavit was sworn by Norton Rose in 1993, and we see that at 3A(c) in tab 
2.
G
THE CHAIRMAN:  Could you possibly just repeat that reference? 
MR COONAN:  Yes, it is bundle C2, tab 3(b).  I am sorry.  In fact, can you just go back,  
Mr Chapman, to tab 3(a) and it is the third document in.  You see an affidavit there? 
A Yes. 
Q 
We see the date of the affidavit on the top right-hand corner? 
H
A 
28 January 1993. 
T.A.  REED 
Day 8 -  5
 & CO. 

---

A
Q 
That affidavit, if you look at the second page, represents, does it not, a sea change in 
the attitude of the Brompton to the disclosure of the main library file? 
A 
Can you direct me again? 
Q 
Yes, in the middle paragraph, paragraph 3 on the second page of the affidavit.  Just 
read it quickly. 
B
A 
Yes, I see where you are referring to now. 
Q 
It represents a sea change in the Brompton’s attitude to the disclosure of the main 
hospital file? 
A Yes. 
Q 
If we now move into tab (b), and if you go please to the first document, there should 
C
be a letter dated 15 December 1994 from yet another firm of solicitors, Thomson Snell & 
Passmore (I am going to refer to them as TSP).  We see there an acknowledgement in the 
second paragraph that the notes and records then held by the Brompton were disclosed early 
in 1993? 
A Yes. 
Q 
So it follows that, in accordance with the admission and concession in the affidavit by 
D
the Brompton, that disclosure then took place? 
A Yes. 
Q 
Just keeping the letter of 15 December 1994 open, it follows, looking at that 
document, that the main library file itself was incomplete in terms of disclosure, was it not? 
A 
Yes, in the whole or the entire sense, yes.  Some of these records would have been 
held outside, scans for example. 
E
Q 
Absolutely.  Leave scans to one side for the minute because we have a particular 
interest in scans.  We see the other elements which these solicitors are saying, in effect, 
“Look, you gave us disclosure of the main library file in early 1993.  It is now 15 December 
1994 and we are wiring to you because we have noticed that there are omission and gaps 
even in the main library file”? 
A Yes. 
F
Q 
But that in itself is not a problem, is it?  These things do happen. 
A Yes, 
indeed. 
Q 
Because there are outlying documents and you have very often got to go to the 
outlying departments to get hold of the records? 
A 
As I alluded to yesterday in answer to a question. 
G
Q 
Indeed you did.  One of the specific matters that the solicitors wanted was the report 
relating to the MRI scan, and they duplicate the request, but we know what they are talking 
about? 
A Yes. 
H
T.A.  REED 
Day 8 -  6
 & CO. 

---

A
Q 
It is not surprising, is it, that they were requesting that MRI scan, because from the 
main library file disclosure there is a clear reference to the existence of such a report.  Could 
you look at tab 3(e) at page 13? 
A Yes. 
Q 
Mr Chapman, this is a photocopy in our bundle of what is actually in the main library 
file? 
B
A 
Yes, there is a written note. 
Q 
There is a written note and any solicitor looking at this document would see 
immediately that there is a reference to an MRI having been carried out? 
A Indeed. 
Q 
And, indeed, in particular as well, a reference to the fact that an EEG was done? 
C
A Yes. 
Q 
That also is referred to, I think, in that request.  However, staying with the MRI for a 
minute, a clear reference to the report and at the bottom of the letter, if you go back to
15 December 1994, a specific request for the tapes showing multi-channel recording? 
A Yes. 
D
Q 
Again, if we can just deal with the multi-channel recordings, there are clear references 
in the notes, in the main library notes, to the fact that such were carried out? 
A Yes. 
Q 
So it is not surprising that any solicitor, if he is doing his job properly, is going to ask 
for the tapes? 
A I 
agree. 
E
Q 
We have two matters of particular importance.  I am going to deal with the multi-
channel recordings topic first, with your help, and then we will deal with the MRI.  Matters 
that follow are taking place under your watch, if I can put it that way? 
A All 
right. 
Q 
What you do, perfectly naturally, is to write to Dr Southall on 22 March 1995 and you 
F
will find that at tab 3(b) at page 8.  It is your JC file? 
A Yes. 
Q 
Page 8 at the bottom of the same tab, 3(b). 
A 
It is page 6.  Page 8 is my letter to Norton Rose. 
Q 
You write to Professor Southall and you say two things on the first page.  First of all, 
G
you rehearse some of the history in the first paragraph.  You explain to him, in effect, the 
reasons why disclosure had thus, up to 1993, not been granted? 
A Yes. 
Q 
So you were filling him in as to the background.  I take you to the last three lines of 
the first paragraph: 
H
T.A.  REED 
Day 8 -  7
 & CO. 

---

A
“On their advice [that is Norton Rose], disclosure of the records was resisted since the 
solicitors acting for [Child A] did not specify the nature of allegations relating to his 
treatment which would justify pre-action discovery of the records.” 
A Yes. 
Q 
That is a clear reference at that time to the operation of the Rules of the Supreme 
B
Court? 
A Yes. 
Q 
You were probably familiar with them at that time, were you?  Order 24, Rule 7A? 
A 
No.  To be frank, I probably was not.  I had only been in post nine months, so I was 
not familiar with the Rules of the Supreme Court.  I was, however, familiar with Hall v 
Wandsworth.
C
Q 
Then in the second paragraph again you continue the history: 
“For more than two years it was contended that insufficient information had been 
given by the solicitors acting for [Mr and Mrs A] to comply with the legal rules 
relating to the disclosure of medical records.” 
D
Then right to the point, over the page, you say to Dr Southall: 
“I have been informed that you may have some records in your possession at the 
University of Keele relating to the treatment and care of certain children”, 
and note the plural there, 
E
“in Royal Brompton Hospital.  If you have the recordings requested by the solicitors 
acting for [Child A] in your possession, would you please send them to me.” 
That was 22 March.  Four weeks later, if you turn on to page 9, Dr Southall responds directly 
to the point, does he not? 
A Yes. 
F
Q 
In that letter he says: 
 
“I have looked through the records and identified 6 multichannel physiological 
recordings that we performed ….. because of storage, we destroy the paper version 
and retain only the taped version.” 
That was in April.  If you turn on, please, to page 13, he having explained what the position 
G
is, you then ask him for the actual tapes. 
A Yes. 
Q 
That request is made by you about two and a half months after you get this first letter. 
A Yes. 
Q 
I am not criticising you, I am just remarking on the fact that there is a two and a half 
H
month gap, and you ask him for the actual tapes on 5 July 1995, because in the body of that 
T.A.  REED 
Day 8 -  8
 & CO. 

---

A
letter we know that it was 5 July, or thereabouts, that you wrote to Dr Southall because you 
say to Norton Rose, “I enclose a copy of a letter that I have written to him”.  I do not think we 
have that particular letter in the bundle, but it does not matter, the fact is that it is recorded 
that you requested the actual tapes. 
A Yes. 
Q 
Then if you move on to page 17, on the documents we have got it would appear it is 
B
round about a week later, and I stress that, only a week later, Dr Southall actually discloses 
the actual tapes to Norton Rose on 13 July. 
A Yes. 
Q 
Now, once the tapes are in the hands of Norton Rose, Norton Rose then have an 
obligation, do they not, pursuant to that agreement and concession in the affidavit, to disclose 
those tapes--- 
C
A 
Yes, to Thomson Snell & Passmore. 
Q 
Absolutely, to Thomson Snell & Passmore, acting on behalf of the A family, and that 
is therefore something that Norton Rose should have done at that time. 
A Yes. 
Q 
As far as you know they did? 
D
A 
As far as I know, yes.  I have heard nothing more from Norton Rose about it. 
Q 
Therefore, as far as you know, Norton Rose gave them to Thomson Snell & 
Passmore, and if you look at the documentation a minute, so that in effect Thomson Snell & 
Passmore, acting on behalf of Mr and Mrs A, we can say that Mr and Mrs A were, to all 
intents and purposes, in possession of the tapes? 
A 
Yes, through their solicitors, yes. 
E
Q 
Through their solicitors.  If you turn on to page 18, six days after Dr Southall has 
given Norton Rose the tapes, six days later, you ask him a number of specific questions 
arising out of the medical records. 
A Yes. 
Q 
I am not concerned about those because they do not appear of themselves to be of any 
F
direct relevance, but you raise the question within that letter to Dr Southall as to whether or 
not there are any other documents, I think is a fair way of putting it?  Is that fair? 
A 
Yes, I had asked--- 
Q 
So it is a global invitation or request of Dr Southall whether there are any other 
documents. 
A 
I am referring in particular to possible medical records, medical notes, clinical notes, 
G
anything else. 
Q Anything 
at 
all. 
A Yes. 
Q 
Right.  That is on 19 July.  So we can take it therefore that in this chronology that is 
the first time that he has been requested for that material. 
H
T.A.  REED 
Day 8 -  9
 & CO. 

---

A
A 
Yes.  The inquiry was directly related to the reference from Norton Rose through 
Thomson Snell & Passmore that there were no entries in the medical records for thirteen 
days.
Q 
Absolutely, but whether it was expressed or implied, it was a clear invitation for 
Dr Southall to respond as to whether or not there were other records. 
A 
Was there anything else. 
B
Q 
Absolutely.  Within about four weeks, this is July, we have, if you turn on to page 22, 
Dr Southall responding to that letter of 19 July, and he tells us, if you look at the document, 
in terms: 
 
“We always kept our own medical records for all the special cases that we dealt with 
at the Brompton”. 
C
All right – point one? 
A Yes. 
Q Point 
two: 
 
“I have arranged for these” – that is in relation to Child A – “to be photocopied and 
D
enclosed with this letter.” 
Then he goes on to deal in the rest of that letter with the specific points raised in your letter of 
19 July.  Again, I do not think we need to bother about those specific points.  There are two 
matters I would like you to look at.  First of all, he is declaring there, “We always kept our 
own medical records for all the special cases that we dealt with”, and he is in fact enclosing 
photocopies of Child A’s special cases file with the letter. 
E
A Yes. 
Q 
Those documents came to you. 
A They 
did. 
Q 
If we turn to page 23, right through to 49, right? 
A Yes. 
F
Q 
There are two things:  pages 24-49 represent the documents that Dr Southall sent by 
way of a photocopy. 
A 
Yes, seventeen documents as I categorised them. 
Q 
On page 23 is a list that you made. 
A 
Yes, that is right. 
G
Q 
One of the matters that appeared on the list was item 8, which is the MRI imaging 
report.
A Yes. 
Q 
Of 11 February 1987, which, if you keep your finger on that and turn on to page 37, 
you see a copy of the report, is that right? 
H
A 
Yes, signed by two consultants. 
T.A.  REED 
Day 8 -  10
 & CO. 

---

A
Q 
Yes.  So a photocopy of the MRI report has arrived in your hands following a request 
first made by you on 19 July for records to Dr Southall. 
A Yes. 
Q 
It is in your hands in August of the same year. 
A 
Yes, that is right. 
B
Q 
Of course, what you do with it is, if I may say, correct, because you send those 
documents, do you not, to Norton Rose? 
A 
I did, yes. 
Q 
So there is no doubt about it, did you send to Norton Rose pages 24-49? 
A 
I would have done, yes, and I would be certain they arrived, because if any were 
C
missing I am absolutely confident that Norton Rose would have contacted me. 
Q 
They are an efficient firm? 
A Yes. 
Q 
Now, if you go, please, to tab 3(a), the last document in tab 3(a). 
A 
The last letter, 6 October? 
D
Q 
That is right, 1995.  Now I think we in effect complete the audit trail.  You send those 
documents to Norton Rose, and Norton Rose on 6 October write to Thomson Snell & 
Passmore dealing with a number of specific matters raised which I am not concerned about, 
and I go, please, to the final paragraph: 
 
“Finally, please find enclosed further records relating to the treatment and care of [A] 
E
at the ….. Brompton ….. which our client has just received from Professor Southall 
who had taken them with him to North Staffordshire Hospital.” 
A Yes. 
Q 
In fact, I am not quibbling too much, but it may have been they were in your hands in 
August, but be that as it may the important point is that Norton Rose send those documents to 
F
Thomson Snell & Passmore. 
A 
Yes, clear from the letter they were sent. 
Q 
So Mrs A, through her solicitors, has had this material, including the MRI film report 
since October 1995, yes? 
A 
Yes, from the letter, yes. 
G
Q 
Now, there is one other dimension to the MRI position I would like you to deal with.
I think just shortly before this hearing began you were contacted by Field Fisher Waterhouse 
in respect of Child A in connection specifically with the MRI report and the MRI films 
themselves, is that right? 
A 
Can you show me the reference, please? 
Q 
Yes.  I am going to give you a letter, with a clip of correspondence attached to it, 
H
which is dated 9 November 2006, which was disclosed to us by Field Fisher Waterhouse.  So 
T.A.  REED 
Day 8 -  11
 & CO. 

---

A
perhaps, please, you can just identify it and then it can be distributed.  Just have a look at the 
clip behind. 
A (Same 
handed)  Yes. 
MR COONAN:   Perhaps that could be distributed, please.  (Same handed)
THE CHAIRMAN:   This will be D6. 
B
MR COONAN:  Mr Chapman, as we see in the first paragraph of this letter you were asked 
by Field Fisher Waterhouse to search for the original MR image and the original report. 
A Yes. 
Q 
And of course the report is the same report that I have just been dealing with, with 
your assistance. 
C
A Yes. 
Q 
Then you say you have searched for the original MR image and the report – that is the 
original report presumably. 
A Yes. 
Q 
In the MRI department, the X-ray department and the records department.  You say 
D
that you have been unable to find them and believe, from what others have told you, that the 
MR image and the report – that is the original report. 
A Yes. 
Q 
Were destroyed, “most probably when the original medical records of Child A … 
were transferred to optical disc format.”  Can you help me as to when that would have been?  
Was it before your time? 
E
A 
No, it was not before my time. 
Q 
Take your time. 
A 
All right.  (After a pause):  My memory is very, very vague; it was some time in the 
1990s, possibly around 1999, maybe 2000, when there were too many records being held in 
the medical records department and the decision was taken to transfer to optical disc format. 
F
Q 
Up until 2000 or whenever it may have been – and I understand the problems about 
the lapse of time – the original report was, your understanding is, in the hospital, ready there 
to be handed over if anybody had asked for it. 
A Yes. 
Q 
You go on to deal with connected but slightly different aspects.  You say that you: 
G
“do not recall and have no evidence of any conversation with Mrs A this year or in 
any previous year about the MR image.” 
Is that still your recollection? 
A 
Yes, it is. 
H
T.A.  REED 
Day 8 -  12
 & CO. 

---

A
Q 
Your files contain only two letters from Mrs A to you, July and September 2003 and a 
note of a telephone conversation in October 2003.  “She did not raise the issue of the MR 
image in the letter or in the conversation.”  You go on: 
“I am further certain that having signed a witness statement on 7 November 2005 
about Child A I would have written a file note of any subsequent conversation with 
Mrs A.” 
B
Does that still remain your view? 
A 
Yes, that is still my view, yes. 
Q 
Again, just to complete one other aspect of the audit trail, looking in your litigation 
files you can say that Norton Rose returned the original medical records of Child A to you in 
February 1995 and the original MR scan in March, presumably of the same year. 
C
A Yes. 
Q 
As you say, having sent a copy to TSP, the solicitors who represented Mrs A at that 
time. 
“I would have returned the original medical records and the MR scan to the Medical 
Records Department.  Norton Rose informed the Trust on 25 March 1996 that legal 
D
proceedings had ended.” 
They had been abandoned, is that right? 
A 
Yes, it is. 
Q 
Abandoned by Mr and Mrs A. 
A 
Yes.  There is a letter in the litigation file to support that. 
E
Q You 
say, 
“I have no evidence from that date that the original medical records or the original 
MR scan was sent to any other solicitors and although I contacted the NHS LA and 
another firm of solicitors who represented them in July 2003 after Mrs A had written 
to me the focus of the enquiry then was on the completeness of the medical records of 
F
Child A and one of Professor Southall’s clinical trials and not on the existence of the 
MR scan.” 
A That 
is 
right. 
Q 
Just to complete what you say in the letter, I take you to the last paragraph, please, on 
the first page.  You say, as you have just told us, 
G
“… the medical records of Child A had been transferred to an optical disc.  The 
medical records department informs me that it would not have been possible to copy 
the scan image to a … disc and so long as the report of the scan was either in the 
original medical records or on the X-ray module of the hospital patient administration 
system …” 
H
That is the PAS computer system. 
T.A.  REED 
Day 8 -  13
 & CO. 

---

A
A 
That is the new, the current PAS, not the one that was in operation in 1987. 
Q 
I will come back to that in a minute if I may, but thank you for that.  You go on to 
say:
“… the original scan image would have been destroyed with the original medical 
records.” 
B
Mr Chapman, you dealt with that a few minutes ago in your evidence, is that right? 
A Yes. 
Q 
You go on to say: 
“The report of the scan on Child A is on the X-Ray Module of the hospital PAS.
C
I enclose a copy of the MR attendance record and the report. 
I believe the only potential source for the actual image of the MR scan today would be 
TSP, assuming they have retained their copy of the medical records which Norton 
Rose disclosed to them.” 
To complete the correspondence, over the page in the clip, taking you to the second page and 
D
the third page, we see in that particular format the report of the MRI. 
A Yes. 
Q 
This print-off took place when, Mr Chapman? 
A 
Are you referring to the last two pages? 
Q 
Yes, I am. 
E
A 
Either on 9 November or the day before. 
Q 2006. 
A 
I printed the first page marked “Attendance Record” because I have that level of 
access to the imaging module of the PAS.  My personal assistant obtained the second copy 
from the magnetic resonance department; I do not have that level of access to the report itself. 
F
Q 
The point is that in the computer system of the Brompton there is to this day the MRI 
report.
A Yes, 
there 
is. 
Q 
And there has been all this time has there not? 
A 
I cannot in truth say whether there was under what we call the prime computer system 
before the current system was installed around 1990.  I do not know whether there was an 
G
imaging module of the old computer system, but at some point the report would have been 
typed into the imaging module of the current patient administration system. 
Q 
It must have been, must it not, because if the document, as we know, a copy and 
another document were in the documents kept in Stoke by Professor Southall, it is difficult to 
see how the Brompton got this material on its computer, do you follow? 
A 
Yes, I follow that. 
H
T.A.  REED 
Day 8 -  14
 & CO. 

---

A
Q 
So the inference must be that it has been there all the time in one form or another? 
A 
Can I slightly qualify that? 
Q 
Yes, of course. 
A 
From my recollection of disclosing medical records, magnetic resonance images are 
sometimes put into the original medical record and are not retained in the MR department, 
but at some point, I would agree with you, if it came to destroying the original records, 
B
destroying the image, a copy would have had to have been made and could then have been 
sent to the MR department to enable it to be inputted into the X-ray module. 
Q 
I follow.  That is in relation to the scan. 
A 
No, it is in relation to the report. 
Q 
Either way, the hospital in one form or another, the Brompton, has had the 
C
information which we are now seeing throughout this period. 
A 
Yes, I think I would agree. 
Q 
Thank you very much, that is all I need to establish.  Having carried out that exercise 
the trail – if I can, I hope, not exaggerate – really went dead from 1995 to 2003. 
A 
Yes, we heard nothing. 
D
Q 
You heard nothing, so there were no requests, the action had been abandoned in 1996 
and then suddenly in 2003 Mrs A, acting in person, not through solicitors, is that right? 
A 
That is right.  Can I just go back to what you said?  You said “abandoned” – in fact 
that file which you have seen was archived and I had to retrieve it in 2003. 
Q 
There we go, it was filed away, you thought it was all over and you could tie the pink 
ribbon round it. 
E
A 
So to speak. 
Q 
And put it to one side, yes? 
A Yes. 
Q 
She then made a renewed request to you for, she believed, outstanding notes, is that 
right?
F
A Yes. 
Q 
Again, we can take this reasonably shortly, but you sent her directly a copy of what 
had been sent to TSP in 1995. 
A 
That is right, clinical notes generated from the optical disc.. 
Q 
Let us just be clear about that.  Did you send her in 2003 a copy of the material that 
G
Norton Rose had sent TSP in October 1995? 
A 
No, I would have sent her what existed on hospital computer system on the optical 
disc.
Q 
That would have included, would it not, the MRI report? 
A 
Yes.  It would have included the MRI report if it had been transferred to the optical 
disk.
H
T.A.  REED 
Day 8 -  15
 & CO. 

---

A
Q 
It follows, does it not, that in so far as she is saying to this Panel that she never had 
the MRI and never had documents from Dr Southall on stoke, the problem lies or would 
appear to lie with TSP. 
A 
Yes, I did direct her to TSP too in one of my letters. 
Q 
Indeed you did, because that is where the audit trail stops. 
A 
Yes, that is where we believe it ended, yes. 
B
Q 
Can I just complete this part, please, by seeking your confirmation that you do not 
have on your file any letter or request from TSP saying, in effect, “Where is the MRI?” 
A 
No.  I never had a letter directly from TSP at all.  The communication was between 
the solicitors, not with me. 
Q 
If TSP had asked Norton Rose, “Where is the MRI?” Norton Rose would have 
C
referred it to you. 
A 
They would have referred it to me. 
Q 
But you never had any such request. 
A 
No, I have never had a request. 
Q 
That completes Child A.  Can I turn to Child H, please?  You will have to turn in C2 
D
back to Tab (l).  You should see the name “Huttons” in the top right. 
A 
Yes, I have that, a letter dated 16 June 1994. 
Q 
For our purposes this represents the first request for the notes by solicitors acting for 
Mr and Mrs H, Huttons, and I think these events again happened under your watch. 
A 
Yes.  I had been in post barely three months then. 
E
Q 
Following that request in June, you wrote to Dr Southall on 1 July.  If you turn to 
page 11 you summarise in the first paragraph the nature of the allegation being made to assist 
Dr Southall with the background. 
A Yes. 
Q 
In the last paragraph you in effect come to the point and you say at the bottom of that 
paragraph,
F
“I write to ask therefore that if you possess a file within the Academic Department of 
Paediatrics in the North Staffordshire Hospital Centre with such correspondence 
would you please send it to me as soon as possible”. 
I just note there that you refer to “such correspondence”. 
A Yes. 
G
Q 
That is correspondence involving the County Council. 
A Yes. 
Q 
There was at that stage a query, was there not, about whether or not Dr Southall was 
going to in effect be a defendant in the proposed proceedings. 
A 
That is right, yes. 
H
T.A.  REED 
Day 8 -  16
 & CO. 

---

A
Q 
So in so far as there was a question mark over that, this of course being the mid-
1990s, but even so there was a question mark over whether or not he would be a defendant, 
despite the concept of Crown indemnity. 
A 
This pre-dates what we call NHS indemnity. 
Q 
Absolutely.  It pre-dates the operation of the NHS indemnity. 
A 
Yes, and the NHS litigation authority. 
B
Q 
So in those circumstances it would not be surprising if Dr Southall then had to 
consider his own position and seek advice. 
A 
No, that would be right. 
Q 
To seek advice from his own defence organisation. 
A Yes. 
C
Q 
Such advice would cover a question of the disclosure of any records that he might 
hold.  That would be perfectly understandable, would it not? 
A 
Yes, it would be.  It is fairly much the same position now when doctors receive claims 
from patients who they care for privately. 
Q 
I think in your file there is a letter from yourself to Dr Southall dated 4 January 1995.
D
Would you like to look at your actual file?  It is in Volume 1.  I am going to ask, first of all, 
that you identify it and then the Panel will receive a copy suitably redacted for anonymity 
reasons.
A 
This is the letter dated 4 January 1995, JC/emw, is it? 
MR COONAN:  That is correct.  Perhaps that can be distributed.  (Document handed) 
E
THE CHAIRMAN:  This will be D7. 
THE WITNESS:  My letter actually refers to three claims from three different families. 
MR COONAN:  Indeed it does, and we have anonymised the names of anybody else in that 
document.  So we are just dealing with H.  It is 4 January 1995.  You refer to a letter of 28 
November.  Just pausing there, during this period, you having written first of all to 
F
Dr Southall in July 1994, there was quite clearly communication between you and 
Dr Southall. 
A 
Yes, that is right. 
Q You 
say, 
“In my letter of 28 November 1994 I wrote to say that I would seek advice from our 
G
solicitors, Norton Rose, on your view that further action on your part in relation to 
legal proceedings by the H family should be continued either through the hospital or 
the solicitors. 
I have been informed that Norton Rose have spoken to Mrs Jones, your personal 
assistant, about the matter.  They [Norton Rose] have now advised me that we should 
wait to see how proceedings develop, and in particular whether fully pleaded cases 
H
arise, before making a decision on appropriate representation for you”. 
T.A.  REED 
Day 8 -  17
 & CO. 

---

A
Then at the bottom it says, 
“Full particulars of the claim have not so far been issued, nevertheless they continue 
to advise that you should obtain advice from your medical defence organisation 
because you are cited as a separate defendant”. 
B
So at that stage Dr Southall had been cited as a defendant, and therefore his actions, as you 
would expect, are going to be the subject of advice and guidance by those who advise him.  Is 
that right? 
A Yes. 
Q 
So far as the trust is concerned, the trust policy, following advice from your solicitors 
Norton Rose, was really a “wait and see” policy. 
C
A 
That is correct. 
Q 
I just want to step back slightly.  In September 1994, slightly before this letter, the 
trust, the Brompton, had voluntarily disclosed such notes as were then in existence at the 
Brompton.   
A 
That is right.  The trust was advised by Norton Rose to agree to voluntary disclosure. 
D
Q 
That is correct.  Dr Southall was not the only other defendant or potential defendant at 
that time, was he? 
A 
No, I believe there were five in total. 
Q 
It is correct, is it not, that although the Brompton decided to embark on voluntary 
disclosure in September 1994, the other defendants did not? 
A 
That is correct. 
E
Q 
So the other defendants, following advice, decided not to and to just to sit back and 
disclose nothing. 
A 
Yes, so far as I know.  I can only speak actually for one other defendant with whom 
I had a conversation who told me that that was their position. 
Q 
Was one of the defendants the Great Ormond Street Hospital? 
F
A 
May I refer to the bundle? 
Q 
By all means. 
A 
I see nothing in the originating application to cite Great Ormond Street as a defendant. 
Q 
Were Field Fisher Waterhouse acting for a particular party at that stage? 
A 
Can I go back to the file because I recall a letter from Field Fisher Waterhouse. 
G
Q 
Would you like to look at a letter dated 14 July 1994 from Norton Rose to you? 
A 
Yes.  On the second page there is a reference to Great Ormond Street in the second 
paragraph.
Q 
I am going to ask that this letter be produced in a moment, but just to introduce it, can 
you help the Panel, please, were Field Fisher Waterhouse then acting for Great Ormond 
H
Street? 
T.A.  REED 
Day 8 -  18
 & CO. 

---

A
A 
Can I refer to the file again because I do recall a letter from Field Fisher Waterhouse?  
Yes, dated 28 June, 1994, “We act for the Great Ormond Street Hospital”. 
MR COONAN:  There we are.  I was correct in my understanding.  With that background, 
Field Fisher Waterhouse acting for Great Ormond Street, Great Ormond Street now being a 
cited defendant, could I invite a copy of the letter of 14 July 1994 to be produced and again 
suitably redacted?  (Document handed) 
B
THE CHAIRMAN:  This will be D8.  Mr Coonan, I am conscious of the fact that we were 
told that Mr Chapman had to leave at some point. 
MR COONAN:  I have almost finished – I say “almost”; very shortly.  Mr Chapman, this 
letter is dated 14 July 1994 and you say in the first paragraph that you had had contact with 
Huttons acting for the H family. 
C
MR TYSON:  It is not a letter from him.  It is a letter to him. 
MR COONAN:  Yes, from Norton Rose.  The solicitors summarise the position and the 
allegations and in effect analyse again the same position in the second paragraph on the first 
page.  Then on the second page, in the second paragraph – the first one for our purposes has 
been blanked out – 
D
“I have spoken to Field Fisher Waterhouse regarding disclosure of their documents in 
the H case.  They have decided that they will give voluntary disclosure but only in 
relation to documents which stemmed from Great Ormond Street.  They have copies 
of documents from other parties but have decided not to disclose those.  I think this is 
a sensible course of action and I would suggest that we do the same”. 
E
Then it goes on to deal particularly with the legal aspect of this.  In the last paragraph Helen 
Morgan says, 
“At our meeting, you said [that is you] that you would be writing to Dr Southall to 
check whether he had copies of [blank] medical records if, in fact, the hospital does 
not have them.  Have you had any luck in tracing them?” 
F
So the position appears to be in 1994 that Field Fisher Waterhouse, acting for Great Ormond 
Street, for their own reasons were deciding to withhold from voluntary disclosure copies of 
documents from other parties in the medical records. 
A 
Yes, that is what they were saying, or what is being reported by Norton Rose. 
Q 
So anything that does not stem from Great Ormond Street, do you read that as 
meaning documents coming in, copies of documents between third parties, they are going to 
G
withhold? 
A 
Yes, that would be my understanding. 
Q 
The trust solicitors thought that that was a sensible course of action. 
A 
That is what they said. 
Q 
The “wait and see” policy continued, did it not, with this result, that the action against 
H
these five defendants was discontinued by the H family on 15 September 1995? 
T.A.  REED 
Day 8 -  19
 & CO. 

---

A
A 
There is a notice of discontinuance, I believe. 
Q 
And that is the date. 
A 
Yes.  I recall the date quite well because I had a conversation with the solicitor in 
Norton Rose informing me that there was going to be an application by another party to 
discontinue proceedings and the other defendants were to agree to it. 
B
Q 
So far as you were concerned at the trust, that was the end of that. 
A 
Yes, that is right. 
Q 
During this period which begins in June 1994 and ends in September 1995, we see 
that there is the one letter to Dr Southall requesting documents. 
A 
That is right, yes, one letter. 
C
Q 
One letter set against the backdrop of a policy of “wait and see” coupled with him 
going to seek advice from his advisers. 
A That 
is 
right. 
Q 
Then five years later, in 2000, the matter springs into life again.  Mrs H, in person, 
writes to you and in the letter she encloses a document which is headed, “report”, is that 
right?
D
A 
Yes.  Do you wish to direct me to it? 
Q 
I do not think we need to go to it.  I can summarise it. 
A 
This was raised yesterday. 
Q 
I can summarise it and then I will ask you questions.  She encloses a report and the 
report is on recordings which had been carried out on Child H. 
E
A Yes. 
Q 
And that document was in the main disclosure which you had voluntarily engaged in 
back in 1994. 
A Yes. 
Q 
So in that disclosure a report bearing an SC number? 
F
A That 
is 
right. 
Q 
She had known about that, and so had the solicitors acting for her back in 1994? 
A 
Yes, I think that is right. 
Q 
Your reply, please.  Can we look at a letter dated 16 May 2000.  It is in tab (l) at page 
19.  The first part of the letter I need not trouble you with, but towards the bottom of the 
G
page:
“When you wrote to me you also enclosed a copy of a report on respiratory recordings 
dated 27th September 1989”, 
and again that just summarises the matter I have just reminded you of.  Is that right? 
A Yes. 
H
T.A.  REED 
Day 8 -  20
 & CO. 

---

A
Q 
Then you observe: 
“This includes [Child H’s] Hospital registration number and another SC number 
‘2026’.  I am sorry to say that I do not know what this number refers to.” 
That was how you put it in May of 2000.  You had seen by this stage, in general terms, SC 
numbers, had you not? 
B
A 
Yes, they were in other medical records as well, yes. 
Q 
When you say “other medical records” you are talking here generally, not just about 
either Child A or Child H? 
A 
No, I am talking about others.   
Q Others? 
C
A Yes. 
Q 
So we are talking about the main library hospital medical records? 
A 
Perhaps I should have qualified what I have just said.  In a certain number of others, a 
limited number. 
Q 
That is fair enough, but in the main library hospital medical records? 
D
A Yes. 
Q 
You have seen them before and you say to Mrs H, “Well, I do not know what this 
number refers to.”  It may be  – and I am not criticising you, you understand – that you did 
not make the link, because if you now turn to tab 3(b) at page 22 --- 
A 
Is this the letter of 15 August from Dr Southall? 
E
Q 
That is right.  Just pause until the Panel catch up.  It is the letter of 15 August.  Again, 
this is not a criticism, but it may be you did not make the link, but Dr Southall had told you in 
August 1995 that they always kept their own medical records for all special cases that they 
dealt with at the Brompton? 
A 
Yes, but he does not tell me how they were categorised. 
Q 
Certainly, and again it is not a criticism but there are these two matters.  On the one 
F
hand, the Brompton knew about the SC numbers and he had, in effect, told you (that is you, 
never mind other people) of the existence of the special cases.  When you wrote this letter on 
16 May that we have just been looking at, did you at that stage then think of writing to 
Dr Southall and saying, “What does this number refer to?”? 
A 
No, I did not.  I did not. 
Q 
But you could have done? 
G
A 
I suppose so, yes, but I had no reason to.  It did not occur to me that I should have 
written or I might have written to Dr Southall. 
Q 
It is not a criticism.  I am just establishing the fact. 
A 
Clarifying the circumstances. 
H
T.A.  REED 
Day 8 -  21
 & CO. 

---

A
Q 
Yes, just establishing the fact that out there, available, was the ability to clarify, but 
that step was not taken.  In any event, what you did do was to send Mrs H a copy of all the 
notes held at Brompton that she had had before, in 1994? 
A 
Her solicitors had had before, yes. 
Q 
For these purposes I am using “solicitor” and “client” in the same breath.  Okay? 
A Yes. 
B
Q 
You sent her the same documents that her solicitors had had in 1994.  Had you ever 
had a query by the solicitors back in 1994 as to what the SC file number stood for?  
A 
No, I had not.  I had no query either directly from Huttons, who as you know wrote 
originally to the hospital, or through Norton Rose. 
Q 
The last matter.  Since 1995, of course, we – and I use that compendiously; those who 
C
operate professionally in the medico legal field, and I include you – of course have had to 
operate in a new culture, which is the culture emanating from the NHSLA? 
A Yes. 
Q 
The NHSLA in effect determines, in general terms, the approach to be adopted by 
individual Trusts – again, I hope I am not going to be accused of exaggerating – on just about 
everything?  Is that right? 
D
A 
(No audible response)
Q 
Again, maybe that is a bit mischievous, but on many, many aspects of litigation the 
NHSLA determines how it is to be conducted? 
A 
Yes, I agree with that.  There is an amount of latitude given to Trusts to manage 
litigation themselves though, but it determines the rules. 
E
Q 
But nothing like the latitude that the Trust had before 1995.  Would you agree with 
that?
A 
Yes, I would. 
Q 
Because there is a centralised body that deals with these matters now and when you 
say that they lay down the rules, they establish the rules or approaches or policies in relation, 
amongst other things, to disclosure? 
F
A 
Yes, indeed.  There is an advice note from the NHS Litigation Authority specifically 
about disclosure and openness. 
Q 
I think it really comes round to what you were saying earlier.  There has been a 
gradual change about the approach to be adopted reflecting the period during which the 
NHSLA has been bedding in since 1995? 
A 
Yes.  I would say the bedding in period was really 1995 to 2002 and much, much 
G
tighter control by the NHS Litigation Authority since then. 
MR COONAN:  Mr Chapman, thank you very much indeed.  You have been very helpful. 
MR TYSON:  Can I ask about the witness’s arrangements before I ask any questions? 
THE CHAIRMAN:  I was going to suggest that I think the Panel might, as an absolute 
H
minimum, need a five-minute comfort break at this time. 
T.A.  REED 
Day 8 -  22
 & CO. 

---

A
MR TYSON:  I have a number of questions I need to ask this witness.  Can I just ask him 
about the practical arrangements?  (To the witness)  You have a board meeting, so I 
understand?
A 
Yes, we do, at 2 o’clock. 
Q 
At 2 o’clock? 
B
A Yes. 
Q 
How long will the board meeting go on for? 
A 
Probably three hours, maybe three and a half. 
Q 
When do you have to leave this building in order to go to that board meeting? 
A 
I should really be there three-quarters of an your beforehand, at 1.15, so I would 
C
probably have to leave at 12.15, 12.30. 
MR TYSON:  Madam, I do have a number of questions of this witness. 
THE CHAIRMAN:  I think my question now is this.  I have no idea how many questions the 
Panel has, but is your questioning likely to take a quarter of an hour? 
D
MR TYSON:  I can finish my questioning within his time-scale. 
THE CHAIRMAN:  I think what is in my mind is whether we should take a proper break 
now or whether things are so desperate we should just take a short break, a very short break. 
MR TYSON:  For ten minutes as opposed to 20 minutes? 
E
THE CHAIRMAN:  Let us split the difference.  I think the minimum break we can take, by 
the time we have actually got downstairs and come back, would be about fifteen minutes, so 
can we agree on that?
MR TYSON:  Yes. 
(The Panel adjourned for a short time)
F
THE CHAIRMAN:  As soon as you are ready, Mr Tyson. 
Re-examined by MR TYSON
Q 
Towards the end of your cross-examination you were asked about the input of the 
National Health Service Litigation Authority on disclosure of medical records.  It is right, is it 
G
not, that in relation to Child A and Child H the disclosure was dealt with under the pre-
NHSLA era? 
A 
Yes, it was. 
Q 
So the NHSLA does not apply to the cases under consideration by the Panel? 
A 
That is correct. 
H
T.A.  REED 
Day 8 -  23
 & CO. 

---

A
Q 
You were dealing with this matter when you and your solicitor had control of the 
disclosure process? 
A 
That is right, yes. 
Q 
You were asked in relation to Child A and the MRI scan in particular and you 
acknowledged that the parents were asking for that MRI scan as early as August 1987? 
A Yes. 
B
Q 
You noted that?  
A 
Yes, from the letter. 
Q 
From the letter, and that in January 1993 disclosure took place in relation to the 
records for Child A of all that you had.  Is that not right? 
A January 
1993. 
C
Q 
Yes.  We can see that from the affidavit from Miss Minter that we have looked at in 
relation to that child? 
A Yes. 
Q 
I can take you back to that. 
A 
No, now that you have mentioned her name I am content to say yes. 
D
Q 
That was an affidavit that indicated that medical and nursing notes should be 
disclosed, but not matters relating to any correspondence with the local authority? 
A 
Yes, that is right. 
Q 
Medical and nursing notes in that context included, did it not, all the matters which 
one would find in the hospital records, such as clinical notes, nursing notes, results of 
E
investigations and the like? 
A 
Yes, and correspondence. 
Q 
And correspondence, including clinical correspondence? 
A Yes. 
Q 
So if there was an MRI report in the hospital notes in January 1993 that would have 
F
been disclosed? 
A 
That is correct. 
Q 
But as we know, and perhaps I can take you to tab 3(b) in front of you in bundle C2, 
page 1, notwithstanding disclosure in January 1993, that disclosure did not include, as we can 
see on page 2, the MRI report? 
A 
Yes, item 3. 
G
Q 
As you said, it would have been disclosed had it been in the notes in January 1993? 
A Yes. 
Q 
It was discovered it was not there in December 1994 and you are asked about it.  Can 
you go to page 3, please, which is your letter to Norton Rose.  In the second paragraph you 
indicate, four lines in: 
H
T.A.  REED 
Day 8 -  24
 & CO. 

---

A
“As it happens I do not have many of the documents they are seeking.  I do possess 
images from magnetic resonance scans that were undertaken on [Child A] and they 
are enclosed with this letter and the medical notes.” 
You did not then have the report? 
A 
No, I have referred solely to the scan, the image. 
B
Q 
Turning to page 8, in March 1995, you say in the second paragraph: 
“I have made enquiries in the medical records library for additional records and have 
been informed that there are no further documents relating to the treatment of [Child 
A] at Royal Brompton Hospital.” 
Would that include that, having made your enquiries, there was still no MRI report? 
C
A 
Yes, I am prepared to say that, yes. 
Q 
Would you go to page 10?  Were you asked by your solicitors two things:  one, a 
chasing letter to Dr Southall about these matters, and also that you should make a note, 
“…on the various searches and investigations carried out and a list of the people you 
spoke to, in order to confirm in the affidavit that we cannot trace the records.” 
D
A Yes. 
Q 
The record that by that time you still could not trace was the MRI report? 
A Yes. 
Q 
Would you go to page 18?  This is the letter described by my learned friend as the 
E
“anything else” letter because we can see that at the bottom of paragraph 1 you are asking 
Dr Southall for anything else, effectively? 
A Yes. 
Q 
At page 19 did you report back to your solicitors and in the middle of the main 
paragraph you have inquired in the medical records department to see if, for some reason, a 
temporary medical record was created at the time, and have been informed there is none? 
F
A Yes. 
Q 
So you had made even further enquiries and is it right that you did not come up with 
the MRI report? 
A 
Yes.  I specifically remember that inquiry too. 
Q 
So you initially gave disclosure in January 1993 and still by two and a half years later 
G
you still did not have the MRI report? 
A 
That is right, yes. 
Q 
You were asked about document D6, which is the letter you subsequently--- 
A 
I am sorry, could you repeat the reference? 
Q 
Yes.  You were given an individual document, which is D6, which is the letter that 
H
you wrote to Field Fisher Waterhouse on 9 November.  Do you have that?  
T.A.  REED 
Day 8 -  25
 & CO. 

---

A
A Yes. 
Q 
Before I ask you questions on this, were you aware that the original of the MRI report 
was subsequently found in one of Dr Southall’s special case files? 
A 
I was aware that – I cannot say whether it was original because I do not have the 
original;  the original would have been signed in ink by the two consultants, and I cannot 
recall whether it was the original or whether it was a copy--- 
B
Q 
I am putting to you as a statement of fact, and I can prove it if necessary, can I suggest 
to you (and I can prove it) that the original of the MRI scan, the one with the original 
signatures, was in fact subsequently found in one of Dr Southall’s special case files. 
A All 
right. 
Q 
Let us take that as a given. 
C
A Yes. 
Q 
Thus, in that context one has to look at your second paragraph of the letter of 9 
November, and you say: 
 
“My Personal Assistant and I searched for the existence of the original magnetic 
resonance ….. image and report yesterday in the Magnetic Resonance Department, 
D
the X-Ray Department and the Medical Records Department at Royal Brompton 
Hospital.  The outcome I am very sorry to say is that we have been unable to find 
them”. 
So you could not find the original? 
A 
I could not find the original.  I had a duty in response to the inquiry to search for the 
original as I was asked to provide the original. 
E
Q 
Yes.  You say that you believe, from what others had told you, that it would have 
been destroyed. 
A 
If the original had been returned to us, and I have said that the image and the report 
were returned by Norton Rose, then subsequently they were destroyed, and that information 
was given to me by the Medical Records Department. 
F
Q 
I suggest to you that that is--- 
MR COONAN:   I am sorry, but this is amounting to cross-examination of his own witness. 
MR TYSON:   I accept that that was an inappropriate start of this question.  Another 
alternative, is it not possible, that the original remained in Dr Southall’s special case file? 
G
MR COONAN:   I mean, he has given the evidence based on what he was told, and anything 
else now is tantamount to cross-examination. 
MR TYSON:   Well, I will move on from that subject.  The point has been made.  You deal 
subsequently in that letter about what had come back to you from Norton Rose in February 
1995, and this is in the penultimate paragraph of the first page.  That paragraph, on a re-
reading of it, does not refer to the report, does it? 
H
A 
No, I have not referred to the report. 
T.A.  REED 
Day 8 -  26
 & CO. 

---

A
Q Merely 
the 
scan. 
A The 
scan. 
Q 
The tracing of the matters in the computer system that you subsequently carried out 
that you were asked about, did that reveal the original written report? 
A No. 
B
Q 
You were asked about Child H, and in particular you were taken to tab 2 at (l), and 
within it to page 11, and you taken to the request that you made on 1 July 1994, at the bottom 
of that, to a request you were making of Professor Southall for any further file. 
A Yes. 
Q 
You were also taken, I believe, to the next tab which was (n), if you look at (n). 
C
A Yes. 
Q 
This is a letter that you subsequently wrote to your solicitors indicating in the first 
paragraph that you had written to Professor Southall, and you say, “To date he has not 
replied”.
A Yes. 
D
Q 
Did you get any reply at all from Dr Southall to that request for information relating 
to another file? 
A 
No, I did not. 
Q 
You were taken to a letter, an individual letter, at D7.  It is an individual document 
that you were given in the course of being cross-examined, which we have as D7, which is a 
letter from you to Professor Southall dated 4 January 1995. 
E
A 
This must be it. 
Q 
Yes.  You were given it, I hope, and I will give you a copy.  (Same handed)
A Yes. 
Q 
One question arising out of this letter:  did this letter relate to the question of who 
should represent Professor Southall, or is it a letter that relates to disclosure? 
F
A 
Sorry, could you repeat the question? 
Q 
Yes.  The question is this:  did this letter relate to the question of representation of 
Professor Southall, or did it relate to the question of disclosure? 
A 
It is about representation. 
Q 
Thank you.  Again, dealing with the H matter, you were asked by my learned friend 
G
whether the Trust in that case had given disclosure in September 1994 and you confirmed 
that it had. 
A Yes. 
Q 
That disclosure would have included the normal kind of disclosure in these cases, 
which would have included such records that you had of clinical notes, nursing notes, 
correspondence, and the results of investigations? 
H
T.A.  REED 
Day 8 -  27
 & CO. 

---

A
A 
Yes, it would have included all that and indeed more, everything that they requested 
in the schedule for the Royal Brompton Trust as a defendant – schedule 2, I believe.
MR TYSON:   Thank you.  I have got no further questions, but you may be asked some 
questions by the Panel. 
THE CHAIRMAN:   It is possible that the Panel has some questions now for you, 
B
Mr Chapman.  Mr Simanowitz is a lay member of the Panel. 
Questioned by THE PANEL
MR SIMANOWITZ:  Good morning, Mr Chapman.  I just have one very simple question 
about clarification.  In the letter D6, which you wrote to Field Fisher, there are two references 
to the MRI.  In the second paragraph you refer to an original MR image, and in the fourth 
C
paragraph you refer to an original MR scan.  Are those two the same thing? 
A 
Yes, they are. 
MR SIMANOWITZ:  Thank you. 
THE CHAIRMAN:   Mrs Lloyd is a lay member of the Panel. 
D
MRS LLOYD:  Good morning, Mr Chapman.  I have just got a couple of questions for you.
Could you tell the Panel whose responsibility do you believe it was to have informed the 
medical records library or yourself that a special case file existed on patients at the Royal 
Brompton? 
A 
I think it would have been the department concerned. 
Q 
When you say “the department concerned”, could you be a bit more specific, please? 
E
A 
I think it would have been Professor Southall’s academic department. 
Q 
A similar question, but again for clarity, given the role you have;  whose 
responsibility do you believe it was to have informed yourself or the medical records 
department that a special case file on patients of the Royal Brompton Hospital existed at the 
North Staffordshire Hospital? 
A 
That is difficult to answer because the file is at another Trust, but I believe the Trust 
F
could or should have informed either the medical records department or the Chief Executive. 
Q 
Again, when you say “the Trust”, it is an inanimate object, could you be a bit more 
specific?
A 
North Staffordshire Hospital Trust. 
MRS LLOYD:  Thank you. 
G
THE CHAIRMAN:   Mr McFarlane is a medical member. 
MR McFARLANE:  Good morning, Mr Chapman.  Following on from Mrs Lloyd, I have 
two questions.  Does the Royal Brompton Hospital have a policy of allowing records to be 
transferred from the Royal Brompton to other hospitals? 
H
T.A.  REED 
Day 8 -  28
 & CO. 

---

A
A 
It has a records management policy and a records management strategy, and that does 
have references to disclosure of records to other organisations, and indeed transfer or dispatch 
of medical records to other organisations. 
Q 
When did this come into force? 
A 
1999, to my knowledge.  It came as a consequence of National Health Service 
guidance to health organisations, and came out as a result of a Department of Health strategy 
B
about retention, storage and indeed destruction of medical records. 
Q 
Prior to that time what was the policy of the hospital? 
A 
There was an earlier policy, I believe it dated from 1981, but I have very little 
knowledge of the contents, and indeed I never saw it until a few years ago when I was asked 
to disclose it to an inquiry. 
C
Q 
So if you saw it a few years ago, could you let us know what it said? 
A In 
1981? 
Q Yes. 
A 
I could not actually, on the knowledge I have here. 
Q 
One further question:  could I please take you to the letter which you have entitled 
D
“JC5”, which is found at C2 3(b), page 8, which is the letter that you wrote on 22 March 1994 
to Norton Rose Solicitors. 
A 
Could I just look it up, please? 
Q 
By all means.  It is in bundle C2, under tab 3(b), page 8. 
A Yes. 
E
Q 
You have been taken to this document on a couple of occasions.  If you take the 
second line in the second paragraph, and you say, “…and have been informed that there are 
no further documents relating to the treatment of [Child A]”, if I look at the three words “no 
further documents”, does this refer to paper-based records only, or does it include data held 
on a computer system in electronic format? 
A 
That refers to documents in paper format. 
F
Q 
Paper format only? 
A 
Paper format only. 
MR McFARLANE:  Thank you very much indeed.  No further questions. 
THE CHAIRMAN:   I have a question.  Finally, at some point in your cross-examination, 
you told Mr Coonan in one way or another Brompton has had the MRI scan one way or 
G
another throughout the period, and you said, “I agree”.  Now, was the period there the whole 
period in question from the point when the MRI scan was done to the present day, if you 
like? 
A 
The original scan was disclosed to Norton Rose, they returned it in March 1995, the 
hospital then retained it until it was destroyed, and I was asked when it might have been 
destroyed, I could not be exact, but I thought 1999/2000. 
H
Q 
Did your comment refer to the report on the scan? 
T.A.  REED 
Day 8 -  29
 & CO. 

---

A
A 
No, I was referring to the scan. 
Q Thank 
you. 
A 
I am sorry, the scan was destroyed and the original report has been destroyed, but the 
report has actually been transferred to the imaging module of the current system, the PAS. 
Q 
This is where I am feeling confused, because if the report is now on your computer 
B
system you must have got it from somewhere to get it onto the computer system.  We have 
been told by Mr Tyson that the original report was elsewhere and has now been recovered, 
but does that imply that the Brompton Hospital had a copy of that report somewhere? 
A 
The hospital must have had a copy in order to be able to transcribe it onto the imaging 
module of the PAS. 
Q 
It must have had a copy, but nevertheless there were times when you were searching 
C
for that document --- 
A 
And I could not find it. 
Q 
You could not find it. 
A Yes. 
Q 
But the later evidence suggests that it was nevertheless somewhere in the Brompton 
D
Hospital.
A Yes. 
Q 
But whatever the Brompton Hospital had, it was a copy, we understand, but you 
cannot demonstrate that. 
A 
I cannot give you an explanation as to what happened to it within the Royal Brompton 
Hospital after Professor Southall sent a copy to me which I copied on to Norton Rose.  It was 
E
then, I think, put into the medical records and then destroyed. 
Q 
I am now confused again.  Is it possible that it got into the Brompton computer 
records via a copy that had come from Professor Southall? 
A 
It is possible, but I cannot explain it and I cannot say for certainty.  Whatever 
happened, one way a copy did reach the medical records, the X-ray department acquired it 
and transcribed it. 
F
Q 
Can I go back then, can you not be sure that a copy existed at the Brompton 
throughout that period? 
A 
No, I cannot be sure, I certainly could not find it. 
Q 
Is it possible that the explanation for it appearing on your present computer records is 
that since the period when you could not find it a copy has been made of the original and has 
G
reappeared? 
A 
That is possible, yes. 
Q 
That is possible. 
A 
That could be possible, yes. 
Q 
And you cannot say either way. 
H
A 
No, I cannot, no. 
T.A.  REED 
Day 8 -  30
 & CO. 

---

A
Q 
Thank you very much.  Dr Sarkar has thought of a question. 
DR SARKAR:  I now have a question arising from madam chairman’s question.  Is it 
possible that the computer printout of the MRI report which you dug out of the computer was 
actually inputted at the time of writing the report way back in 1987, or did they not have 
computers at that time? 
B
A 
I cannot answer that because I was not at the Royal Brompton Hospital at that time, 
and I do not know for certainty whether or not there was even an imaging module of the old 
patient administration system to enable it to have been actually inputted.  What I have 
established actually since I wrote this letter is that the imagine department is still backloading 
old X-ray and imaging reports onto the new module. 
Q 
So it will be safe to assume that they were not inputted to the computer at that time, in 
C
1987.
A 
I have no information to say that it was on the original patient administration system 
simply because I do not know whether there was an imaging module at that time. 
Q 
Would you agree that if they had an imaging module and the report was directly 
inputted before making a proper readable copy, then the Brompton would have had the report 
at all material times. 
D
A 
Yes.  Given what I know of the two consultants who signed it, I would feel fairly 
confident that they would have done it, yes. 
Q Thank 
you. 
THE CHAIRMAN:  That appears to complete the Panel’s questions but it is possible that 
either counsel might have questions arising from those questions. 
E
MR COONAN:  No, thank you very much. 
Further re-examined by MR TYSON
Q 
You were asked two questions by Mrs Lloyd and the first related to whose 
responsibility it was to tell the medical records department at the Brompton that a different 
F
file was being kept, and you answered that. Then you were asked whose responsibility it was 
to say that the file had been taken to North Staffordshire and was at another trust; the answer 
you gave was that the trust could and should have informed the medical records department 
at the Royal Brompton.  Would your answer be any different if the trust at North 
Staffordshire was itself unaware that there was a special case system? 
MR COONAN:  Again, I do object to this.  This is wholly hypothetical and it is tantamount 
G
to cross-examination. 
MR TYSON:  It is not tantamount to cross-examination, it arises directly out of a question 
that Mrs Lloyd asked, it follows directly from the answer that he gave and it was not 
presented in a leading fashion. 
MR COONAN:  I maintain the objection. 
H
T.A.  REED 
Day 8 -  31
 & CO. 

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A
THE CHAIRMAN:  The Legal Assessor may have a view that would help the Panel on this. 
THE LEGAL ASSESSOR:  In ordinary course such a question would amount to cross-
examination of the witness and of course counsel cannot cross-examine his own witness, but 
as it has arisen from a question from a Panel member in the circumstances I would advise the 
Panel that the question is permissible. 
B
THE CHAIRMAN:  I will just check with the Panel that they accept that.  The Panel accepts 
that advice so we will regard the question as permissible. 
MR TYSON:  I do not know whether you can remember the question, or do you want me to 
repeat it? 
A 
I would be grateful if you could repeat it. 
C
Q 
You were asked by Mrs Lloyd whose responsibility it was to tell medical records at 
the Brompton that the SC file or a file had gone to another hospital, and you answered that 
that Trust should have informed medical records.  My question was this: would your answer 
be any different if you were aware that that trust itself had no knowledge of these SC files? 
A 
If that trust had no knowledge of the existence of the files I do not see how it could 
have informed the Royal Brompton and Harefield Trust that the file existed there. 
D
Q 
If the only knowledge of these SC files at that new trust was Dr Southall and his 
department, whose responsibility was it to tell the Royal Brompton that that file had been 
transferred from the Brompton up to North Staffs. 
A 
If I may go back slightly to one question before that, I was, I recall, asked who should 
have told the trust management that the files or records were being transferred; my answer is 
no different. 
E
Q 
Just remind me what the answer is. 
A 
What I said was that if the files located within Royal Brompton Hospital were being 
transferred elsewhere, the head of department – and I was asked who that was and I gave the 
answer, Professor Southall – should have informed the trust. 
Q 
You were asked by Mr McFarlane about whether there was any policy prior to 1999 
about the transfer of records to another hospital, and you indicated that there was a policy in 
F
1981.  Two questions arise out of that: firstly, could you send, having given your evidence, a 
copy of that policy to Field Fisher Waterhouse and I will ensure that it is distributed 
appropriately; secondly, from your memory of that document did it require agreement or 
consent of the Royal Brompton to take a file out of the Royal Brompton to another hospital? 
A 
I do not know.  I have never read that original policy in any great detail.  I was asked 
to disclose it to another inquiry and that is when I became aware of it. 
G
Q 
I have no further questions arising out of Panel questions, thank you. 
THE CHAIRMAN:  Thank you very much for coming, Mr Chapman.  That now completes 
your evidence, you are no longer on oath, you may stand down and I think you are probably 
in quite good time for your meeting. 
A 
Thank you very much, madam chairman. 
H
(The witness withdrew).
T.A.  REED 
Day 8 -  32
 & CO. 

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A
MR TYSON:  I now have an application which I seek the determination of the Panel upon.  It 
is an application pursuant to section 116 of the Criminal Justice Act 2003 that I can read the 
evidence of Mr H as opposed to calling him as a live witness.  The reason for that is that 
under the section, which I will take you to in a minute, it is permitted because he is unwell.  
Because he is unwell I ask that I can read his evidence rather than call him. 
B
Section 116 of the Criminal Justice Act says: 
 “In criminal proceedings a statement not made in oral evidence in the proceedings is 
admissible as evidence of any matter stated if …” 
Three matters have to be fulfilled. 
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“Oral evidence given in the proceedings by the person who made the statement would 
be admissible …” 
The first category therefore is if he came along and gave the evidence would that be 
admissible evidence, and the answer is yes to that.  So hurdle one is carried.  Hurdle two is:  
“The person who made the statement … is identified to the court’s satisfaction.” 
D
Hurdle two is crossed.  Hurdle one is can he give admissible evidence?  Yes.  Hurdle two is 
can he be identified?  Yes.  Hurdle three is any one the five conditions mentioned in 
subsection (2) is satisfied, and the condition that I rely on is set out in subsection (2)(b): 
“That the relevant person is unfit to be a witness because of his bodily or mental 
condition.”
E
There are, therefore, three hurdles that I have to jump over: one, can he give admissible 
evidence?  Two, can he be identified?  Three, is he unfit to be a witness because of his bodily 
or mental condition? 
In those circumstances it is open to the Panel to take this evidence and there is a major matter 
that you have to take into account: firstly, whether it is admissible, which I say it is, and, 
secondly, what weight you give to the evidence bearing in mind that part of it may be 
F
challenged.  The question of weight does not affect the question of whether you can receive 
it, the question of weight comes into having received the evidence what value do you give it, 
it not having been cross-examined. 
There is guidance given on that and I refer, in shorthand, the learned Legal Assessor to 
paragraph 11-18 where it says effectively that the jury should be warned about the weight to 
be given.
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“… the strength of any warning is to be decided on the basis of the facts of the 
individual case, the issues and the significance of the statement in the context of the 
case as a whole, the jury should be warned, especially in a case where the evidence in 
the statement is disputed, that in assessing the weight of the evidence they should take 
account of (a) the fact that, unlike evidence given orally in court, it will not normally 
have been given on oath … (b) the fact that it has not been subject to cross-
H
examination, and (c) the circumstances in which the statement was made, particularly 
T.A.  REED 
Day 8 -  33
 & CO. 

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A
if it is apparent that it was made for the purposes of pending … judicial proceedings, 
or of a criminal investigation.” 
The fact that it may have – and I have to accept probably will have – less weight because it 
will not be cross-examined upon should not, in my submission, affect the question about 
whether you receive it in the first place.  My application here is whether you should receive it 
in the first place, and it does tick all the boxes – if I can put it that way – that you should 
B
receive it in the first place. 
I rely on two matters in respect of the evidence that this witness is unwell.  The first bit of 
evidence you heard from my client when she gave evidence, and I refer in particular to the 
transcript that we have of Day 6, page 34 at B where I asked Mrs H what was wrong with her 
husband.  I said: 
C
“ I just want to ask you something completely different, Mrs H, and that is about the 
state of health of Mr H.  Is he able to come to give evidence? 
[A] No. 
[Q] 
What is wrong with him? 
[A] 
My husband had an emergency quadruple heart bypass in 1998.  Three of the 
bypasses have failed.  He has chronic angina and the stress of coming here would be 
D
too much, and the stress of the video link would have been too much for him as well.  
He could not have handled it.  He tells me with angina pain you cannot concentrate on 
anything else and so his doctor considered it, as he did, too stressful.  I am not going 
to lose my husband to something like this.  He is the father of my four children and 
his health is more important.” 
You will see the reference to what his doctor said, and can I hand out, please, to the Panel the 
E
copies of the letter from the general practitioner dated 24 August 2006? 
THE CHAIRMAN:  That will be C13.  (Document C13 distributed).
MR TYSON:  This is a letter from Dr Upton, who is a personal GP at the practice.  It is dated 
24 August 2006, and relates to this hearing, as we see.  It is to the General Medical Council, 
“Professor Southall re Mr H”, and says, 
F
“Mr H came to see me today and informed me that you require medical evidence that 
he suffers with ischaemic heart disease and angina of effort.  This I can confirm and 
I feel that the stress of appearing at the hearing would exacerbate his angina”. 
That is direct advice, in my submission, from the patient’s GP, that the stress of appearing at 
the hearing would exacerbate his angina.  In my respectful submission, faced with that letter, 
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coupled with the evidence of Mrs H about matters of stress, then I would submit that these 
abundant grounds show that I have crossed over hurdle three; namely, that the relevant 
person is unfit to be a witness because of his bodily condition.  In those circumstances it 
follows automatically that not only should you admit the witness statement, to be read, but it 
is essentially your duty to admit it because I have ticked all the boxes, if I can put it that way. 
There are three other subsidiary matters.  The first subsidiary matter is that in discussing this 
H
matter with my learned friend, he indicated that he may be relying on Section 123, but in my 
T.A.  REED 
Day 8 -  34
 & CO. 

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A
submission Section 123 has absolutely no relevance to the issues which you have to consider.
What Section 123 is headed is, “Capability to make statement”.  Section 123 says, 
“Nothing in section 116 [the section I have just referred to] makes a statement 
admissible as evidence if it was made by a person who did not have the required 
capability at the time when he made the statement”. 
B
There is no suggestion that Mr H is incapable by reason of his mental state of making a 
statement; merely that he is not in a position to come here to give evidence.  We are given 
further guidance in subsection (3) of what “capability” means.  It says, 
“For the purposes of this section a person has the required capability if he is capable 
of (a) understanding questions put to him about the matters stated, and (b) giving 
answers to such questions which can be understood”. 
C
So it is clear that “capability” appears to refer to mental capability in understanding questions 
and giving answers, and that is not the issue in this case. 
There is also two questions of a residual discretion which you have in any event to admit 
matters, which arise if I cannot go through the front door.  The first residual area of discretion 
you have is given to you by Section 114 of the Criminal Justice Act.  Section 114(1) says, 
D
“in criminal proceedings a statement not made in oral evidence in the proceedings is 
admissible as evidence of any matter stated if, but only if”, 
then for my purposes it gives two examples, 
“(a) any provision of this Chapter or any other statutory provision makes it 
E
admissible” – 
that is Section 116.  Secondly, it gives a further provision, 
“if the court is satisfied that it is in the interests of justice for it to be admissible”. 
That is my residual argument.  First of all, you should admit it because Section 116 covers 
F
the point directly.  My subsidiary submission is that you should admit it in any event because 
the court is satisfied that it is in the interests of justice that it be admissible.  In subsection (2) 
you are given guidance to take into account the following factors in deciding whether or not it 
should be admitted in the interests of justice.  It goes from (a) to (i), and factor (a) is how 
much probative value the statement has in relation to the matter in issue.  I would submit that 
it has great probative value in relation to the matter in issue. 
G
Secondly, (b), what other evidence has been or can be given on the matter?  The other 
evidence, of course, is Mrs H’s, but Mr H, I would submit, would corroborate what Mrs H is 
saying.  Then (c), how important the matter or the evidence mentioned is in the context of the 
case as a whole.  I submit it is important evidence because it goes directly to the heads of 
charge relating to Mrs H, which include the matters set out in Appendix One, and the matter 
related to any discussions about when the child was an in-patient; whether there was any 
discussion about a local paediatrician being involved, which goes directly to the specific 
H
heads of charge relating to this patient. 
T.A.  REED 
Day 8 -  35
 & CO. 

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A
Then we have (d), where we look at the circumstances in which the statement was made.  The 
statement was made in preparation for these proceedings and it has the usual health warning 
at the end of it, indicating, as is right, 
“I understand that my statement will be used as evidence for the purpose of a hearing 
before the General Medical Council’s Fitness to Practise Panel and for the purpose of 
B
any appeal, including any appeal by the Council for the regulation of healthcare 
professionals”.
It continues, 
“I am unable to give evidence in person or by video link due to health reasons.
I believe the facts stated in this witness statement are true”. 
C
So it is both a declaration or statement of truth and he signs it, and he also indicates that he is 
unable to give evidence in person.  So that covers the circumstances there.  Under (e) how 
reliable the maker of the statement appears to be.  That is a matter you will have to assess and 
I cannot make any submissions on that save to say that he is the husband of Mrs H. 
Under (g), whether oral evidence of the matter stated can be given and if not, why not.  The 
D
oral evidence cannot be given because he is too unwell to give it.  Under (h), the amount of 
difficulty involved in challenging the statement, and I accept that that is a point in that my 
learned friend cannot cross-examine.  But that is always the case when a written statement is 
admitted and, as I keep saying, that goes to weight and not to admissibility. 
Under (i), the extent to which that difficulty is likely to prejudice the party facing it.  As this 
witness is saying much the same as Mrs H says, in my submission, my learned friend will not 
E
be prejudiced to a significant extent because one can take the questions that he will put to 
Mrs H and assume that he will put them to Mr H.  You will recall that Mrs H was extremely 
firm on the issue that there was never any discussion by either Dr Samuels or Dr Southall 
about a local paediatrician being involved in any aspect of her child’s care. 
MR SIMANOWITZ:  I am sorry to interrupt, but I think you went from (e) to (g). 
F
MR TYSON:  Heading (e) was how reliable the witness was; (f) was how reliable the 
evidence of the making of the statement appears to be, and that is when I read out the 
statement of truth; (g) is whether oral evidence can be given; (h) is the amount of difficulty 
involved in challenging, and (i) is the extent to which that difficulty is likely to pose to the 
party facing it. 
THE LEGAL ASSESSOR:  Does Section 114 really take the matter any further than 116? 
G
MR TYSON:  No, it is not as strong as 116 and that is why I say it is a subsidiary ground.
That is why I say it is the back door when I really want to go through the front door with 116.
That is where my prime submission lies.  Again, this is a subsidiary matter but I can and do 
refer you to the powers under Rule 50 with the proviso to 115, but again I make the point the 
learned Legal Assessor has made, that Rule 50 says – this is an old rules case – 
H
T.A.  REED 
Day 8 -  36
 & CO. 

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A
“You may receive oral documentary or other evidence on any fact or matter which 
appears to them relevant to the inquiry provided that the only factual matters tendered 
as evidence would not be admissible”. 
So you have a power to admit it if you are satisfied that your duty of making due inquiry into 
the case makes it desirable.  The important words here are that you can receive it even if it is 
not admissible, and say in fact it is admissible and should be admitted.  Those are my 
B
submissions. 
THE LEGAL ASSESSOR:  As regards Section 116, the burden of proving that this evidence 
comes within 116 rests upon you, does it not, Mr Tyson? 
MR TYSON:  I accept that. 
C
THE LEGAL ASSESSOR:  And it is the criminal standard. 
MR TYSON:  I accept that also. 
MR COONAN:  Madam, so far as the legal framework is concerned, my learned friend was 
troubling himself unnecessary.  This has nothing to do with Section 123.  What we are 
concerned about is Section 116, which is really the focus of what you need to consider.  Also 
D
I entirely agree and commend to you that what we have to look at is precisely the sections to 
which your attention was drawn, and in particular 116(2)(b).  May I just repeat it?  This is 
one of the conditions and it is really the prime condition for your consideration, 
“That the relevant person [in this case Mr H] is unfit to be a witness because of his 
bodily or mental condition”. 
E
As has already been conceded by my learned friend in answer to a question put to him by the 
learned Legal Assessor, it is for the complainants at this stage to prove, because the burden is 
on the complainants, to a criminal standard, so that you are sure that that condition has been 
satisfied.  It is not for us to prove anything. 
The guidance – and I draw the learned Legal Assessor’s attention to the commentary in 
Archbold to the relevant paragraphs – is that coupled with the principle that it is the criminal 
F
standard of proof that applies, is guidance to a court supplying it that lip service to this should 
not be paid; there are dangers in paying mere lip service to this.  It therefore requires an 
examination of the evidence that is available to you upon which you need to make that 
decision.
May I give you two preliminary background factors?  First of all, the events with which you 
are concerned here occurred in 1990, and the statement, which is now sought to be adduced 
G
in evidence, is dated 29 October 2006 – 16 years later.  What therefore is the evidence? 
You have a letter from Dr Upton, and I stress that it is a letter and a very short letter.  You 
will not have any opportunity of asking Dr Upton any questions at all about this man’s 
condition other than that which is stated.  As against that, you have the evidence which was 
given to you by Mrs H, and I refer again to Day 6, page 34 of the transcript, picking it up at 
letter H.  She confirmed that Mr H has a job at the Morriston Hospital in Swansea; he is a 
H
dental technician; he works a five-day week.  She told you at letter E on page 35 that 
T.A.  REED 
Day 8 -  37
 & CO. 

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A
travelling to London is not a problem.  She appears to focus on the fact that giving evidence 
would be too much. 
As against that you know – page 36 letters D to E – that she agreed that Mr H a very short 
while ago, in 2006, was interviewed by journalists; he took part in a television programme; 
was able to be filmed walking along near the beach in Swansea; was willing to answer 
questions put by a journalist, but she makes a distinction between being asked questions by a 
B
journalist and being asked questions here.  I accept, of course, that there is a qualitative 
difference between being asked questions by a friendly possibly a compliant journalist.  Of 
course there is.  But whether or not the condition described in such few words by Dr Upton 
is, on its face, sufficient to prevent him in his capacity as a potential witness from giving 
evidence, where you have the ability to control how questions are put; how long the evidence 
is to be given by him and so on, you are the masters of that; whether that is sufficient for that 
condition to be satisfied, it seems to us at least to raise questions , and it will be for you to 
C
rule on that. 
I hope that you will see immediately the basis for our concern; that if, in truth, the condition 
is not satisfied on proper examination and proper inquiry, why then evidence would have 
been admitted in written form without any possibility of the defence to cross-examine this 
witness, somebody who you are told is purportedly going to corroborate Mrs H on an 
important issue in this case.  All the more reason, therefore, why the prejudice to the defence 
D
may be considerable.  That is why you should look with very careful scrutiny at whether or 
not the burden of proving that this condition is satisfied is made out. 
It is perhaps interesting too that Mr H not only says that he does not want to come here 
appearing at the hearing, but he does not even want the comfort of a video appearance. 
You have already decided that video evidence is appropriate and we would say that it 
therefore does raise question marks over whether or not this is – and again I do not want to 
E
raise the temperature – a bit of a challenge(?).   
The doctor, Dr Upton, does not deal with the question of video evidence.  He deals with the 
question of appearing at the hearing, and by that I read as appearing here before you in the 
flesh.
I respectfully agree that section 114, correctly described as a residual basis for an application, 
F
really does not take the matter very much further, but insofar as you are moved to look at it, 
I do stress that the relevant condition is in subsection 2(g): 
“whether oral evidence of the matters stated can be given and, if not, why it cannot.” 
Well, it is the same point that I have just been addressing you on.  Subsection (h): 
G
“the amount of difficulty involved in challenging the statement.” 
Well, it is unnecessary even to assess the amount of difficulty.  The difficulty is absolutely 
100 per cent.  There would not be any opportunity to talk, to cross-examine this witness.  At 
subsection (i): 
“the extent to which that difficulty would be likely to prejudice the party facing it.” 
H
T.A.  REED 
Day 8 -  38
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A
Mr Tyson appears to say, “Oh well, since Mrs H gave evidence on the point and dealt with it 
and gave important evidence, there is no prejudice because Mr H is going to say the same.”  
That is what it amounts to.  That is a rather Kafka-esque argument, I must say.  Indeed, we 
would prefer to look at it in a different way.  I have cross-examined Mrs H.  It is a matter for 
you to make an assessment of what the weight is to be attached to that evidence given by her.
If you are now to receive evidence on the same point, purportedly corroborating her, and 
I cannot cross-examine, the prejudice to the defence is immense.  That, we would say, is the 
B
sensible way of looking at it. 
As to section 116, we say look very carefully at whether the evidence before you is indeed 
sufficient to satisfy 11-6(2)(b).  If it is not, we would say it is insufficient even to look at 114, 
but if you did, then for the reasons I have already indicated, with particular reference to (g), 
(h) and (i), in those respects the evidence ought not to be admitted before you.  
C
Madam, those are the submissions that I make. 
THE LEGAL ASSESSOR:  Rule 50? 
MR COONAN:  Thank you very much.  Rule 50.  In a case of such importance and on issues 
of such importance, if you take a view and come to a decision that the evidence is 
inadmissible following a consideration of the application of 116 or 114, this is not a case for 
D
the application of rule 50, which is a long stop.  I entirely accept that in some cases rule 50 
can come to the rescue of the prosecutor, but not here, because by definition if it is found that 
the document is inadmissible for the reasons I have already analysed, it would be wholly 
prejudicial to the defence to admit it under rule 50.  It would be to drive a coach and horses 
through a finding of inadmissibility and render such a degree of unfairness to the defence as 
to raise questions under Article 6, in our submission. 
E
That is the way I put it. 
MR TYSON:  What my learned friend is effectively saying is, “Ignore the letter and the 
advice from this witness’s GP.”  In my submission, it is impermissible for you to ignore the 
solid advice of this potential witness’s clinician when he not only confirms that the witness 
has ischaemic heart disease and angina of effort, but also he says the important words: 
F
“… I feel that the stress of appearing at the hearing would exacerbate his angina.” 
That is a clear medical opinion which you have in relation to this. There is no other medical 
opinion.  My learned friend has not brought another saying, “No, he is perfectly all right.”
The only medical document that you have is that one and, in my respectful submission, it 
easily mounts the hurdle, however high it is – criminal, which I accept, and for me to prove, 
which I accept – that this person is unfit to be a witness because of his bodily condition.
G
You have it in one clear sentence from his general practitioner, who knows his patient.  It was 
directly related to this hearing, and in my respectful submission whether he appears in person 
or appears by video link, there is no qualitative difference in that he will still be having the 
stress of a hearing and the stress of answering questions under oath and the stress of being 
cross-examined and the like.  There is no qualitative difference, as we have rehearsed in 
previous arguments, between giving evidence in person and giving evidence on video link, 
H
because they are virtually the same. 
T.A.  REED 
Day 8 -  39
 & CO. 

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A
If for any reason – and I do not accept this for a moment – you hold that letter that I have not 
proved to the criminal standards that this person is unfit, it is then that section 112 or rule 50 
apply, which does give you a residual right to admit it.  But, as I say, my primary and 
important submission is that this person should be entitled to put his evidence before.  It is 
important, relevant, admissible evidence that he seeks to give.  He is merely prevented from it 
by way of his physical condition and you have abundant, clearly stated opinion as to why he 
B
should not come.  To go round this letter, if there is no evidence to the contrary, in my 
respectful submission is not open to this Panel. 
Those are my submissions. 
THE CHAIRMAN:  Would you just give me one moment?  (The Chairman and the Legal 
Assessor conferred)  It is now for the Legal Assessor to give advice to the Panel.  The Legal 
C
Assessor has indicated to me that he requires some time to consider his reasoned advice and 
given the time we will be taking the lunch break.  I propose that we rise now until 2 o’clock 
to give the Legal Assessor some time to consider his advice.  He indicates we should be ready 
by then. 
(Luncheon Adjournment)
D
THE CHAIRMAN:  The Legal Assessor I believe is now ready to deliver his advice.  I call 
on him.  He has prepared a written copy. 
THE LEGAL ASSESSOR:  Mr Tyson makes application for the admission in evidence of a 
statement by Mr H.  At this stage the Panel is concerned only with the admissibility of the 
statement and not its weight. 
E
His application has three prongs: 
First he relies upon section 116 of the Criminal Justice Act 2003. 
The provision of the statute relevant to this application is that such evidence is admissible if 
the maker of the statement is unfit to be a witness because of his bodily or mental condition.  
It is the Panel’s task to decide whether Mr H is unfit within the meaning of the statute. 
F
The burden of proving this rests upon the complainants; the doctor does not have to prove 
anything, in particular he does not have to prove that Mr H is not unfit. 
Before the Panel can find that he is unfit, it must be satisfied so that it is sure that this is the 
case; nothing less is good enough. 
G
Mr Tyson relies upon two matters.  First, the evidence of Mrs H, transcript day 6, page 34B; 
second, the letter from Dr Upton. 
Mr Coonan draws attention to the evidence of Mrs H in cross-examination at pages 34-36 of 
the transcript. 
It is for the Panel to consider all these matters when reaching their decision. 
H
T.A.  REED 
Day 8 -  40
 & CO. 

---

A
The second prong, which Mr Tyson says is secondary should his first submission fail, is 
made under section 114 of the Act.  This provides that a statement is admissible if it is in the 
interests of justice that it should be.  The factors to which the Panel must have regard are: 
a. how much probative value the statement has in relation to the matters in issue; 
b. what other evidence has been given; 
c. how important the evidence is;  
B
d. the circumstances in which the statement was made; 
e. how reliable the maker appears to be;  
f.
how reliable the evidence of the making of the statement appears to be; 
g. whether oral evidence can be given and, if not, why; 
h. the difficulty involved in challenging the statement;  
i.
prejudice to the party facing it. 
C
Mr Tyson relies on a, b, c, d and g; Mr Coonan points to g, h and i.  Mr Coonan points in 
particular to the fact that this is a corroborative statement of the evidence of Mrs H that is 
firmly in issue and the consequent prejudice to the doctor. 
The third prong is in regard to rule 50 which enables the Panel to receive evidence which 
appears to be relevant.  He (that is, Mr Tyson) describes this as a long stop should the other 
submissions fail. 
D
Mr Coonan contends that it would be wholly prejudicial and unjust to admit the evidence 
under rule 50 if it were held inadmissible under the statute. 
I advise the Panel that it should consider section 116 first and only if not satisfied that the 
witness is unfit should it consider section 114.  They should move to rule 50 only if that 
contention also fails. 
E
The Panel may well feel that the real thrust of this application is under section 116. 
The decision in regard to this application is of course a matter for the Panel and the Panel 
alone, it being the judge of the facts as well as the law. 
THE CHAIRMAN:  Thank you.  Does either counsel have any comment on the legal advice? 
F
MR TYSON:  No, madam. 
MR COONAN:  No, thank you, madam. 
THE CHAIRMAN:  The Panel will now retire into private to consider the application. 
G
STRANGERS THEN, BY DIRECTION FROM THE CHAIR, WITHDREW
AND THE PANEL DELIBERATED IN CAMERA
STRANGERS HAVING BEEN READMITTED
DECISION
H
THE CHAIRMAN:   I am now going to read the Panel’s determination. 
T.A.  REED 
Day 8 -  41
 & CO. 

---

A
Mr Tyson
You have made an application that Mr H’s statement be admitted in evidence. 
B
The first ground of your application is that Mr H’s health is such that he is unfit to give 
evidence and that his statement should be admitted in accordance with section 116 of the 
C
Criminal Justice Act 2003. 
You contend that Mr H is too ill to give evidence to the hearing either in person or through 
video-link.  You have referred the Panel to the letter from Dr N. Upton, dated 24 August 
D
2006.  This states that Mr H is suffering from ischaemic heart disease and angina and that the 
stress of attending the hearing would exacerbate his angina.   
E
You make a secondary submission that it is in the interests of justice to admit this statement 
under section 114 of the Act.  You submit that this witness’s evidence would have probative 
value.
F
Finally, you also referred the Panel to its discretionary power under rule 50 of the GMC 
Procedure Rules, which enables it to receive evidence that appears to be relevant. 
G
Mr Coonan has opposed your application.  He contends that the report of Dr Upton is 
inadequate to satisfy the Panel that Mr H is unfit.  He refers to the evidence of Mrs H that  
Mr H is in full-time work and is able to travel to London.  He also submits that the difficulties 
that would arise and the consequent prejudice to Dr Southall if this statement were admitted 
H
T.A.  REED 
Day 8 -  42
 & CO. 

---

A
under section 114 would give rise to injustice.   Mr Coonan further contends that if the 
statement were held inadmissible under the statute it would be unjust to admit it in evidence 
under rule 50.
B
The Panel considers that the letter from Dr Upton is not of itself sufficient to prove that  
Mr H is too ill to give evidence at this hearing.  It makes no reference to any medical history 
or medication.  Further, the letter does not address whether Mr H would be fit to give 
C
evidence through a video link.  The Panel has considered this letter, together with the oral 
evidence of Mrs H, but it has concluded that it has not been proved to the required standard 
that Mr H is unfit to give evidence.  Your submission under section 116 therefore fails.  
D
The Panel next considered your submission under section 114.  Mr H’s statement has been 
described by you as being corroborative of the evidence of Mrs H.   The Panel has concluded 
that the difficulties facing Dr Southall in challenging the statement, and the consequent 
E
prejudice to him, significantly outweigh the factors on which you rely.  It has therefore 
concluded that it would not be in the interests of justice for this statement to be admitted.  
Finally the Panel has considered its powers under rule 50. It has concluded that, as it has held 
F
this statement to be inadmissible under the statute, it would be wholly unjust to admit it under 
rule 50. 
G
The Panel therefore does not accede to your application. 
MR TYSON:  Madam, before I close my case formally there are a number of matters which 
can be dealt with most expeditiously by admissions rather than by calling any more evidence.  
My learned friend and I are hard at negotiating on those admissions and I think we jointly 
invite the Panel to close its deliberations for the day so that I can, by 9.30 tomorrow, close 
H
my case, without having to call any further evidence.  There are a number of matters on a 
T.A.  REED 
Day 8 -  43
 & CO. 

---

A
travelling draft, if I can put it this way, that look likely to admitted that would be acceptable 
to the complainants.  Dealing with machinery, I think my learned friend may have other 
things to say. 
THE CHAIRMAN:   Thank you.  Are there things that you would wish to say to the Panel at 
this time, Mr Coonan? 
B
MR COONAN:  Yes, just one or two helpful things.  I am grateful to Mr Tyson, and 
I respectfully agree with that.  Can I confirm that the parties are indeed well down the line of 
agreeing certain matters which will have the effect, when agreed, of saving the Panel a great 
deal of time and, dare I say, tedium in listening to a lot of what may be called formal 
evidence about documentation.  It is a common approach in cases such as this and indeed in 
other forums, and you are likely to receive tomorrow morning therefore, reduced into 
digestible form, a series of admissions upon which you can work in the future.  So it is 
C
designed to save you time in that respect. 
The other matter:  after my learned friend has closed his case, which, as he says, he 
anticipates at about half-past nine tomorrow morning, my intention at the moment, and I do 
want just a little time to ponder the matter overnight, my intention at the moment is to address 
you on a number of features of the notice of inquiry under rule 27(1)(e)(i).  Madam, I am 
reluctant to develop any submissions I may have at this stage, obviously (a) because my 
D
learned friend has not closed his case, because that would be the time for making any such 
submissions, and, secondly, because, as I have already indicated to you, I need a little further 
time to ponder the position in order to make whatever submissions I do have much more 
efficient and directed to assist you.  I anticipate those submissions could be made pretty 
shortly after half-past nine tomorrow morning. 
THE CHAIRMAN:   Thank you.  It seems clear that in the interests of good conduct of the 
E
case we should adjourn and allow you the time that you need, and I understand from both of 
you then that you will be ready to begin again at nine-thirty tomorrow. 
MR TYSON:   Madam, that is what we anticipate.  It is always difficult when one is 
responding to submissions of no case to answer if one does not know what the submissions 
are going to be about.  My learned friend has given me some rough indications for which 
I am grateful, but I would be grateful if, before he leaves the building tonight, he felt able to 
F
tell me the particular counts which he seeks to attack so I will have some meaningful 
submissions to make in reply. 
Dealing with housekeeping matters as to where we are now, if my learned friend was to make 
submissions, it would appear to me that they would take up to and possibly over lunchtime 
tomorrow to determine, when my learned friend would doubtless wish to call his client, 
Dr Southall.  He has helpfully indicated to me that he thinks that that may be some time, 
G
which would take us, let us say, into Friday, sometime into Friday, no-one can say, pieces of 
string being as long as they are.  Could I put just a small marker down that the later on Friday 
he stops, the more reluctant I would be to start cross-examining him, and would be looking 
for a break between the end of the doctor’s evidence in-chief and the start of my cross-
examination.  If I again lay a small marker down that I anticipate I may well be making 
application that I would start my cross-examination on the Monday. 
H
T.A.  REED 
Day 8 -  44
 & CO. 

---

A
These are all floating matters, and I am just trying to keep you informed as to the thinking of 
how the advocates are at the moment. 
THE CHAIRMAN:   We appreciate that.  Thank you.  So we will adjourn now until nine-
thirty tomorrow morning. 
(The Panel adjourned until 09.30 hours on Thursday, 23 November 2006)
B
C
D
E
F
G
H
T.A.  REED 
Day 8 -  45
 & CO. 

---

GENERAL MEDICAL COUNCIL
FITNESS TO PRACTISE PANEL (PROFESSIONAL CONDUCT)
Thursday 23 November 2006
44 Hallam Street, London, W1W 6JJ
Chairman:   
  
Dr Jacqueline Mitton 
Panel Members:
Mrs Leora Lloyd 
Mr Alexander McFarlane 
Dr Sameer Sarkar 
Mr Arnold Simanowitz 
Legal Assessor:   
Mr Robin Hay 
CASE OF: 
SOUTHALL, David Patrick 
(DAY NINE)
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 JOLLIFE 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
 
SARAH LOUISE ELLSON 
  Statement 
Read     1 
 
ADMISSIONS (Document D9) 
 
 
MR COONAN 
 
 
 
 
6 
 
 
MR TYSON   
 
 
 
 
6 
 
SUBMISSION (Rule 24(4)) 
 
 
MR TYSON   
 
 
 
 
7 
 
 
MR COONAN 
 
 
 
 
9 
 
 
MR TYSON   
 
 
 
          11 
 
ADVICE FROM THE LEGAL ASSESSOR  
          12 
 
DECISION 
 
 
 
 
 
          13 
 
FURTHER ADMISSION (Head 13(b)) 
 
          14 
 
SUBMISSION (Rule 27(1)(e)(i)) 
 
 
MR COONAN 
 
 
 
         15 
 
 
MR TYSON   
 
 
 
         19 
 
 
MR COONAN 
 
 
 
         30 
 
ADVICE FROM THE LEGAL ASSESSOR  
         32 

---

A
THE CHAIRMAN:  Good morning.  Mr Tyson, we are with you. 
MR TYSON:   Madam, I am grateful for the time both yesterday evening and this morning, 
as a result of which a considerable amount of shortening of my case has taken place.   
The last bit of evidence that I need to deal with is to read to you aspects of the statement of 
B
Sarah Louise Ellson.  You in fact have this as C8, and perhaps I can ask you to get out your 
C8, and I need to, as it were, read into the record some portions of it.  For your benefit, I am 
going to read paragraphs 4-18 and then 31-48. 
STATEMENT OF SARAH LOUISE ELLSON
MR TYSON:  This is a statement of Sarah Louise Ellson, and if we go to paragraph 82 she 
C
says:
 
“I understand that my statement may be used in evidence for the purposes of a hearing 
before the General Medical Council’s Fitness to Practise Panel and for the purposes of 
any Appeal, including any Appeal by the Council for the Regulation of Healthcare 
Professionals.  I confirm that I am willing to attend the hearing to give evidence if 
asked to do so. 
D
 
I believe the contents of this statement are true.” 
It is signed by Sarah Louise Ellson on 15 November 2006.  Paragraph 4 says: 
 
“On 24 January 2006 Hempsons solicitors wrote to the General Medical Council.  On 
page 12 of their letter reference was made to protocols being established by Professor 
E
Southall, including a protocol as to how Professor Southall would deal with 
confidential documents.  As a result of this letter I wrote to Hempsons solicitors on 8 
February 2006 asking that they provide any particular written documentation relating 
to the protocol(s).  As a result, on 16 February 2006, I was provided with a one page 
document entitled ‘Security guidelines for Academic Department of Paediatrics’.” 
Just pausing there, madam, that is at C3, section 7(d)(iv). 
F
 
“As pointed out by Hempsons in their letter of 16 February 2006 ‘information’ was 
defined to include computer disks.  Accordingly, on 1 March 2006 I wrote to 
Hempsons solicitors stating ‘we trust that these [computer disks] have been securely 
stored and therefore now request your client provides all computer disks relating to 
the SC files in this case’. 
G
   
On 21 March 2006 I wrote again asking for any further ‘information’ held by 
Professor Southall on computer to be provided as soon as possible.  I also wrote that 
day to the University Hospital of North Staffordshire, with whom I have previously 
had correspondence in order to obtain access to paper records.  I explained to them 
that I now had reason to believe that there might be material held on computers or 
word processors and I asked them to clarify what information was held on computer 
systems at North Staffordshire Hospital (both on the main system and any separate 
H
word processors). 
T.A.  REED 
Day 9 -  1
 & CO. 

---

A
 
On 23 May 2006, presumably as a result of my request, the North Staffordshire Trust 
wrote to Professor Southall indicating that I had made this request and asking him to 
consider whether he had any ‘structured or unstructured information including 
electronic or manual systems’ and asking him to consider the ‘HISS, PC and email 
files’.  I was provided with a copy of this letter. 
B
 
On 31 May 2006 I wrote again to Hempsons reminding them of my request made on  
1 March 2006 and asking for any documentation including information held on 
computer by Professor Southall.  I also made them aware that I had seen the letter 
from the North Staffordshire Trust to Professor Southall dated 23 May 2006.  I wrote 
again to the Trust that day to set out my concerns about obtaining computer 
information. 
C
 
I wrote again to Hempsons solicitors on 26 June 2006 chasing for this information.  
I received a response from Hempsons dated 27 June 2006 which indicated that the 
computer that ‘they’ (presumably Professor Southall and his team) were using at the 
relevant time was still in existence and that the department were working on accessing 
the computer and obtaining print outs in relation to the families at the centre of this 
case [A, D H and B].  In this correspondence Hempsons confirmed that there were 
also analog tapes and chart record of print outs which they stated would be 
D
uninterpretable without the correct equipment (they informed me that this data related 
to the biometric data recordings and that they assumed this would not be required.) 
 
On 3 July 2006 I wrote to Hempsons indicating that I urgently awaited the print outs 
mentioned in their earlier correspondence and required confirmation as to exactly 
what computer information was held in each of my cases.  Instead of asking them to 
provide the analog tape and chart recorder print outs I asked them to provide a 
E
schedule detailing to whom such documents and recordings related. 
 
I also wrote to the Trust that day to confirm that I understood Professor Southall’s 
department were working on accessing his computer. 
 
In a telephone conversation with Pauline Crossley of the University Hospital of North 
Staffordshire on 11 July 2006 she confirmed her understanding that the work on 
F
computer records was being done by Professor Southall’s team. 
 
I had to write to Hempsons again on 14 July, 24 July, 2 August and 14 August 
chasing for computer information and a schedule of the analog tapes and chart 
recorder print outs.  I was informed on 26 July that Professor Southall was on holiday.
Finally on 18 August 2006, in a letter which crossed with a further chasing letter from 
my firm, I received 11 pages said to be print outs of the ‘computer database’ held in 
G
the cases of [D, H and A]. 
 
We were told that there were no recordings file for [M].  The letter from Hempsons 
was silent on the issue of documentation relating to the [B] case despite earlier 
correspondence on 27 June 2006 indicating that there would be computer records for 
this child. 
H
T.A.  REED 
Day 9 -  2
 & CO. 

---

A
 
I wrote to Hempsons on 25 August 2006 to request further information about the case 
of [B], and asking for further information about the ‘computer database’ and for a 
schedule of the analog tapes and chart recorder print outs.  I also specifically asked to 
see the three ‘data files’ referred to in the [H] case. 
 
I wrote again on 1 September 2006 making reference to my letter of 25 August 2006 
and seeking a prompt response.  On 11 September 2006 we received a letter dated  
B
7 September 2006 indicating that Hempsons were taking instructions regarding our 
letter.
 
Finally on 22 September 2006 I received a letter from Hempsons in which they 
suggested that to resolve matters I should meet with Professor Southall and his legal 
representative at North Staffordshire Hospital.  I immediately telephoned with some 
suggested dates but given that we had to co-ordinate three diaries the first available 
C
date was 31 October 2006. 
 
I met with Professor Southall (with his solicitor from Hempsons) shortly after 11am 
on Tuesday 31 October.  We met at the Academic Department for Paediatrics at North 
Staffordshire Hospital.” 
Madam, can I now take you to paragraph 31. 
D
 
“I was then shown a computer in the Academic Department.  I was informed that this 
computer was stand alone and was not networked to other computers.  It was clarified 
that it was from this computer material had been printed and sent to [Field Fisher 
Waterhouse] (see paragraph 13 [above]). 
 
It was explained that actually the computer I was being shown was a physically 
E
different computer than the one originally used by Professor Southall and his team.   
I was told that his computer was seized when he was suspended and taken away by 
IM&T (Information Management and Technology).  On return from suspension 
Professor Southall was given a new (upgraded) computer onto which his files and 
databases had been transferred.  It was this computer being viewed today. 
 
Professor Southall’s solicitor indicated that she had made some enquiries about what 
F
may have happened to the computer during the period it was taken from Professor 
Southall but that the IM&T department had indicated that the staff involved at the 
time had since left.  She had been told that only recently had proper IM&T records 
been kept and that there was no further information available. 
 
Professor Southall explained that there were two databases on the computer ‘SC File’ 
and ‘Recordings’.  When the computer was returned to him he found that the 
G
passwords had been altered for these databases and he had only recently (this 
summer) found out the new passwords (which in fact were the same as the old ones 
but with two additional digits at the beginning). 
 
I asked who would have access to the computer and these databases.  Professor 
Southall thought that he, together with Dr Samuels and the Clinical Physiological 
Monitoring Technician (a nurse) would have known the password and would have 
H
been responsible for entering the data. 
T.A.  REED 
Day 9 -  3
 & CO. 

---

A
 
In my presence Professor Southall opened the ‘SC File’ database first (it uses 
Filemaker software).  He demonstrated that there were a variety of layouts to display 
the information held on each case but it appeared that ‘layout #1’ was the most 
comprehensive.  This creates documents which are headed ‘Patient’s Data’.  (In fact  
I noted when I reviewed the documents again that we have been provided with screen 
shots of layout #8 for D and A but I am reasonably satisfied that this is the same 
B
information as was on layout #1). 
 
Professor Southall indicated to me that he had searched for all the families relevant to 
the GMC case on the database and had printed out and sent (via his solicitor) the ones 
he had found.  He had not previously been able to find anything for B ….. however, in 
anticipation of my visit he had tried again and on this occasion had located an entry 
for her.  We searched under [the first name] and the computer suggested that there 
C
were 30 or so records, we then searched [B] and located the one entry for [Child B]. 
 
Professor Southall could not explain why he had not been able to find this entry 
previously and suggested that he was concerned that somewhere in the transfer of the 
databases to his new computer there may have been some form of corruption, he felt 
that the system was not now totally reliable. 
D
 
Professor Southall then printed out the page we had found for [Child B].  He 
explained that a further problem created by the transfer of the database and/or the use 
of a new printer was that the layout when printed was not correct (some text prints 
over other text).  For this reason, for some of the print outs he has supplied Professor 
Southall has prepared a screen shot version of the data. 
 
The data printed out for B from this database consisted of one page.  I asked if there 
E
was other information held on this database about this family but Professor Southall 
informed me that the sheet printed out held the entirety of the information on that 
family (that he had been able to find). 
 
On this database there are 4449 records.  This figure can be seen for example in the 
screen shot version of the printout for D. 
F
 
We then repeated the search exercise for the other families.  On this database we 
found one entry for ‘[H]’, one for ‘[D]’ and one for ‘[A]’ – we had earlier been sent 
these printouts by Hempsons on 18 August 2006. 
 
I was then shown the second database ‘Recordings’.  This database contains the 
template letter where the information ‘We performed a x hour overnight recording on 
the {date}’ with recordings and signals and result set out. 
G
 
There are 1856 records on this database (this figure can be seen on the screen shot 
version of the print out for B).  Again Professor Southall demonstrated a search in 
relation to each of the relevant families.  We found entries for B (this was only 
apparently found on the morning of my visit) and H.  There are in fact two entries for 
H both of which have previously been provided (marked record 1 and 2 (the digit near 
the top left hand corner of the printout)). Professor Southall indicated that this was 
H
because of the two recordings undertaken on H. 
T.A.  REED 
Day 9 -  4
 & CO. 

---

A
 
We could not find entries for D (although we searched under [the names there listed]) 
or A (we searched under [the names there listed]).  Again I asked if the database 
contained more information than that shown in the printout.  I was told that it did not. 
 
I was asked whether either or both databases had ever been copied.  Professor 
Southall indicated he did not know exactly what had happened when the computer 
B
was taken away during his suspension.  He told me, in answer to my questions, that he 
did not have a copy of either database either on disc or on his laptop.  He added that 
he viewed the information as confidential which is why he would not have it on his 
laptop.
I asked about the request which I understood the Trust made some time ago, that all 
material relating to children who were not patients at North Staffordshire Hospital 
C
should be removed from Trust property.  Professor Southall said that he had not fully 
complied with the request.  He said that he had removed the physical SC files for the 
relevant families (indeed his solicitor confirms that she now has (from 
Professor Southall) the original SC files for H and A).  He said that he had removed 
such SC files to a secure storage site. 
Professor Southall said that he had refused to remove the tapes, he felt they should 
D
remain at the hospital secured in a secure room.  Following discussion with the Trust 
it was agreed that the tapes could stay.  In relation to the databases, he could not 
easily remove part of them; he agreed that the databases included children who had 
and had not been Trust patients.” 
That is all I need read about that.  I understand that my learned friend is going to make 
various submissions and perhaps he would like to deal with the submissions he is going to 
E
make on behalf of his client. 
MR COONAN:  Madam, could I just introduce this?  As you have probably gathered from 
last evening, there was discussion between the parties in the hope that we could reduce down 
to a digestible form evidence of a formal nature which would otherwise have to be given to 
you.
F
MR SIMANOWITZ:  Chairman, I am sorry to interrupt.  I must apologise.  I have left some 
papers in my briefcase downstairs which I need to have.  Could I have two minutes to go and 
get them? 
THE CHAIRMAN:  You have heard Mr Simanowitz. 
MR COONAN:  Yes, of course.
G
THE CHAIRMAN:  Could you indulge him for a moment? 
MR COONAN:  Of course.  I will start again when you return, if that is all right. 
MR SIMANOWITZ:   Yes. 
H
(Short pause in proceedings)
T.A.  REED 
Day 9 -  5
 & CO. 

---

A
MR COONAN:  Forgive me if I just begin again.  As you heard from counsel last evening, 
we were engaged in discussion to try and reduce down to really digestible parts evidence 
which would otherwise have to be given to you in a rather laborious way.  It concerns 
essentially the nature and location of documents, of which there are, as you appreciate, many 
in this case.  I think my learned friend has referred to it as a travelling draft, and indeed the 
travelling stopped this morning.  We have reached agreement.  What I am going to do is to 
B
hand to you now a signed document, signed by Dr Southall and dated, and I shall draw your 
attention to the content.  My learned friend has, of course, a copy.  (Copies distributed)
THE CHAIRMAN:  It will be D9. 
MR COONAN:  It is strictly a ‘D’ document because I have been invited on behalf of 
Dr Southall to make the admissions, and I do that.  It just means that it is helpfully done at 
C
this stage of the case rather than later on.  You can see on the second page that it is signed 
and dated 22 November.  I do not at the moment propose to read it into the record.  It may be 
that you would care to study it, and the significance of it can become apparent as and when 
Dr Southall gives evidence on the relevant topics.  For my purposes, that encapsulates the 
formal evidence that would otherwise need to be given, and I hope that is helpful. 
MR TYSON:  Madam, perhaps I can assist broadly as to the effect of these admissions.  
D
Essentially, it is an admission in relation to the Appendix One documents, that save for one 
document, all of the documents in Appendix One are original hospital medical records.  The 
one document where that admission is not made is in relation to the manuscript note of  
Dr Samuels which is in item 2 under Child H in Appendix One.  Apart from that document, it 
is admitted that all the documents in Appendix One are original hospital medical records. 
The second important aspect of the admissions is that save in relation to one document, it is 
E
admitted that each and every one of the documents in Appendix One are not contained 
elsewhere in the hospital medical records relating to that child.  The only exception from that 
is that it is not admitted that the MRI report in relation to case A is not contained elsewhere in 
the hospital medical records.  This considerably narrows down the issues in relation to 
Appendix One, bearing in mind, you may recall, the four questions that I said that you had to 
answer in relation to the charges relating to Appendix One, which I set out in my opening.  
Those included the questions:  “Are they original hospital records?” 
F
MRS LLOYD:  Could you speak up please? 
MR TYSON:  “Are they original hospital records?” and, “Are they not contained elsewhere 
in the hospital medical records?”   
I am asked to give an admission, the nature or purpose of which is not clear to me, but I will 
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give it nonetheless.  I admit that on 20 July 2005 the complainants’ solicitors, Messrs Field 
Fisher Waterhouse, served on the doctor’s solicitors, Messrs Hempsons, the statement of  
Mrs D.  I know she served two statements. 
MR COONAN:  The witness statement of 22 November 2004. 
MR TYSON:  The witness statement of 22 November 2004. 
H
T.A.  REED 
Day 9 -  6
 & CO. 

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A
MR COONAN:  Thank you. 
THE CHAIRMAN:  I am sorry, I did not quite follow that end bit.  Could you possibly repeat 
it, so it is clear what you are admitting? 
MR TYSON:  Yes.  I admit that on 20 July 2005 Field Fisher Waterhouse, solicitors for the 
complainants, served on Messrs Hempsons, solicitors for Dr Southall, the statement of  
B
Mrs D, dated 22 November 2004. 
THE CHAIRMAN:  2004? 
MR TYSON:  Correct. 
Madam, I now have an application to make to you under the old Rules, rule 24(4), relating to 
C
an application to amend certain parts of the heads of charge.  Rule 24(4) says: 
“Where at any stage of an inquiry it appears to the Committee that a charge should be 
amended, the Committee may, after hearing the parties and consulting the legal 
assessor, if they are satisfied that no injustice would be caused, make such 
amendments to the charge as appear necessary or desirable.” 
D
I have had a number of conversations with my learned friend, and some of these are at his 
request and suggestion and some of these are at mine.  In relation to head of charge 10(a) my 
application is to add some words at the end of (a) and the words are “by you or on your 
behalf”, so head of charge 10(a) would now read, if you grant my application: 
“You created, or caused to be created, an ‘S/C’ File wherein certain original medical 
hospital records relating to the child were then placed by you or on your behalf.” 
E
The second application follows, in a sense, from the first, and it is in relation to the stem of 
head of charge 11.  The application is to insert, after the word “placed”, the words “by you or 
on your behalf.”  The second application relating to this charge is that in between the words 
“such” and “original” you insert the word “cited”, so that the stem would read: 
“The placing, or causing to be placed, by you or on your behalf, of such cited original 
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medical records in a ‘S/C’ File.” 
The reference to “cited” is a reference back, madam, to head of charge 10(b) where I say, 
“The cited medical record is not elsewhere …”, and where I have cited the medical record is 
of course in Appendix One itself.  The purpose of putting “by you or on your behalf” is to 
clarify the nature of the allegation against the doctor in this case, so the allegation in head of 
charge 10(a) is that he created or caused to be created the SC file and documents were then 
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placed either by himself or on his behalf.  Bear in mind that “on his behalf” I put in, as his 
function was that he was head of department and he was responsible for the management and 
control of the medical records of that department.  Similarly, for the same reason there is the 
amendment to the stem of head of charge 11.
Madam, also, and finally, I ask for an amendment which is beneficial, in my submission, to 
the doctor.  I ask that in head of charge 11(a) you delete the first four words and insert the 
H
four words “damaged the integrity of”, so that head 11 as amended would read: 
T.A.  REED 
Day 9 -  7
 & CO. 

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A
“The placing, or causing to be placed, by you or on your behalf, of such cited original 
medical records in a ‘S/C’ File, 
a.
Damaged the integrity of the child’s hospital medical records.” 
Madam, in relation to that last application you may recall when Professor David was asked 
B
questions by you, madam, in relation to that matter, you indicated that you and your 
colleagues had consulted a dictionary and the reference to this exchange between you and 
Professor David is on Day 5, page 40 and 41.  The exchange goes: 
“[THE CHAIRMAN]:  One final question is, you were asked about the use of the 
word, “tampering”, and we took the opportunity in the break, we had to consider the 
meaning of tampering.  I just wanted to be clear that we were understanding this the 
C
same way, because obviously we want to see a word that is in a head of charge as 
having the same meaning.  As I had understood, it seems to be reflected in various 
definitions that we have to mean to interfere in a harmful manner;  to engage in 
improper or secret dealings as in to “tamper” with a jury;  to play around with, alter or 
falsify, usually secretively or dishonestly, to interfere without authority so as to cause 
damage.  All those definitions seem to imply a level of perhaps either intent or 
dishonesty or whatever which I think you said you did not intend in your use of the 
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word.
[A] 
That is absolutely correct. 
[Q] 
But we have in the heads of charge something that says it amounts to 
tampering with, so I wanted to be quite clear whether the Panel’s view of the word 
“tampering” was the same as your view when we were perhaps looking at the 
evidence in your report in connection with this head of charge? 
E
[A] 
I accept that there are obviously many different definitions of the word, and 
some of them imply intent and quite clearly that is not what I am saying.  I suppose 
my summary of it is just two words, and that is damaged integrity – the integrity of 
the medical records has been damaged – and I use the word tampering simply because 
it is a word that appears in the context of medical records when that has happened.  
I accept that many examples are where somebody has intended something quite 
dishonest, and that is not the case, but it is damaged integrity of the medical records is 
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my use, if you like, of that record. 
[Q] 
I think that perhaps the distinction is that tampering in its most usual word 
would be to do something to something that exists, to alter it, whereas I think that you 
are saying, as I read what you said in your report again, that to fail to put something in 
that in your view ought to be there amounted to tampering because, as in the words 
you are now using, it damaged the integrity.  Would that be a correct way of 
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interpreting how you have used the word? 
[A] Yes 
…”. 
I cannot put the case any higher than Professor David, my expert, puts it.  He used the word 
damaged integrity on the records and that is why I apply to amend head of charge 11(a) in 
those ways. 
H
THE CHAIRMAN:  I see Dr Sarkar is indicating he may have an immediate question. 
T.A.  REED 
Day 9 -  8
 & CO. 

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A
DR SARKAR:  It is not a question, it is just a comment, because it goes in the record.  You 
started off your submission by saying the exchange between Madam Chairman and Professor 
Southall, when it should have been exchange between Madam Chairman and Professor 
David.
MR TYSON:  I apologise.  Thank you very much for the correction, of course it was with 
B
Professor Tim David.  I am grateful for that.   
So those are my applications to amend in three ways: one in relation to 10(a), one in relation 
to the stem of 11, and one in relation to 11(b).  In my submission, these are, if I can put it this 
way, helpful ---
THE CHAIRMAN:  11(a) rather than 11(b) I think, is that right?  
C
MR TYSON:  I seem to be saying all the wrong words.  11(a):  In my submission they are 
helpful amendments because they focus on the task that this Panel actually has, they set out 
the responsibility as to the claims alleged, and they do not put the case relating to the medical 
records any higher than the expert, Professor David, put it himself.  So that is my application 
under rule 24(4). 
D
THE CHAIRMAN:  Mr Coonan? 
MR COONAN:  Madam, could I deal with the last matter first, so we are looking at 11(a).
My learned friend is quite right to draw your attention to the questions and indeed answers 
given that he has just rehearsed at Day 5/40 and 41.   
Just for completeness, so that you have a full picture of the exchanges, of course they began 
E
with my questions to Professor David.  You can find those at Day 5/12C-F.  Since my learned 
friend has actually in effect read out the exchanges, I hope you will forgive me if I do the 
same.  It is quite short.  Picking up at C: 
“I suggest to you that what we have here is not a case of tampering at all; what one 
has here is filing in a different place – and we have been through that – but they are 
all securely kept; none of them, it would appear, have been lost; none of them, it 
F
would appear, have been damaged; none of them spirited away; and, depending on the 
evidence, all are available for access.  I am not following, therefore, the basis for you 
saying that the medical records have been tampered with. 
[A] 
Would you like me to comment? 
[Q] Please. 
[A] 
I think it is a very fair question [says Professor David].  I have not brought a 
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dictionary with me to explore the meaning of the word ‘tampering’, but it may be 
helpful for me to clarify as to what I do not intend it to mean? 
[Q] Right. 
[A] 
I do not think there is any evidence of any deliberate intent to mislead or 
damage or cause harm.  I use the word ‘tampering’ simply because it is a word that is 
used quite frequently when reference is made in circulars that we get about the 
H
integrity of medical records being lost, and I accept that some of those cases will 
T.A.  REED 
Day 9 -  9
 & CO. 

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A
concern deliberate interference with a medical record, a doctor deliberately taking out 
a set of notes because he or she does not want someone to see what he has written.  
Clearly nothing like that is involved here.  Or it might be used where a doctor – I 
suppose Dr Shipman is the most famous example – created his own false medical 
records.  There is no evidence of anything like that.  So I think the question is very 
fair.  Tampering is not a word that I normally use, [just pause there, of course, as you 
know, it is referred by him in his report] but I meant it as a word that is used to 
B
describe a process that adversely affects the integrity of medical records, and I guess 
the justification for a fairly strong word is ultimately what I think everybody agrees, 
which is the sacrosanct nature of medical records.  I hope that helps clarify where 
I am coming from? [says Professor David]”.   
Of course that was followed, madam, by your question to Professor David. 
C
I thought it might be helpful so that you had as it were the answers from two quarters that you 
can put together when you make your decision in relation to this application.  Having said 
that, I do not oppose the application.  That is not to say I agree with the allegation made, of 
course, that is a totally different matter, but it now in effect, and I hope I am forgiven for 
using this expression, has the effect of diluting the strength of an allegation that would 
otherwise have been made and that is, therefore, an important matter and I agree with 
Mr Tyson that in that sense, as an allegation, it is beneficial to Dr Southall.  As I say, whether 
D
the evidence actually supports the allegation remains to be seen, but I do not object to the 
amendment in the terms proposed by Mr Tyson.  I hope that you understand therefore the 
reasons for my stance on that.  
That is the first matter.  The second matter concerns head 11, the stem.  There are two matters 
here but I am going to deal with the first freestanding matter, which is the proposal, by way 
of application, that the word “cited” should appear between the word “such” and the word 
E
“original” in the stem.  Again I do not object that, indeed, again, if my learned friend will 
permit me, it was at my suggestion that that word appears precisely there.  The reason for it is 
that it focuses the Panel’s attention on precisely the particular medical records which is going 
to be the subject of inquiry in head 11.  So it is beneficial to you, it is not prejudicial to the 
doctor, and indeed, as I said, we suggested it and Mr Tyson agrees.  So that is not contentious 
but ultimately of course it is a matter for you.   
F
I do have something to say about the other two matters, and that relates to head 11, where it is 
proposed that after the word “placed”, the phrase “by you or on your behalf” appears as 
a proposal and exactly the same formulation in 10(a) after the word “placed”, the same 
phrase, “by you or on your behalf”.  Now I am concerned at the breadth of that term and so in 
its present form I do object to it.  The proposal that I made originally, and I renew, is that 
there should be an amendment, both to 10(a) and to 11(a), in precisely the same parts, to 
insert the phrase “by you” simpliciter: “by you”.  Or, alternatively, and again, I simply say 
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this, I hope, to be helpful, it is entirely a matter for you whether you allow any of them, or the 
phrase “by you or at your direction”.
You may say to yourselves, “Well, what is the difference between the phrase ‘by you or on 
your behalf’, and, on the other hand, ‘by you or at your direction’?”  There is, in our 
submission, a difference because it caters, my formulation, my proposal, caters for any 
possible instance which may emerge in the course of the evidence to deal with cases of 
H
misfiling.  It may be thought that the phrase “by you or on your behalf” would catch as 
T.A.  REED 
Day 9 -  10
 & CO. 

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A
a proved head cases of misfiling simply because Dr Southall was the head of the department.  
So what I am suggesting here is that the formulation of these allegations must allow for 
a finding by you in due course, one way or the other, to allow for a finding that there may or 
may not have been this finding but in a way which does not actually mean that Dr Southall 
therefore bears responsibility for it per se, because, in those circumstances, it would be 
difficult for me or may be difficult for me to submit that such a misfiling may not have been 
by or on his behalf, in other words misfiling by a junior member of staff, secretary, research 
B
student, so forth.   
Again, I hope you do not think this is dancing on a pinhead, not at all, it is, we suggest, a fair 
way of focussing the Panel’s attention on the proper focus of the allegations in this case.  
Certainly some amendment is required.  That much I entirely agree with Mr Tyson.  It has to 
be focused down in such a way as to place an allegation, right or wrong, at the feet of 
Dr Southall.  We are arguing therefore about precise terminology.  How that is done and how 
C
the principle with which Mr Tyson and I both agree, that some amendment is required, again 
is for you to decide, in a way which gives transparency to your findings, allows Dr Southall 
to know precisely what your findings are in relation to any particular head, and allows third 
parties to know also, and that is the reason for my proposal.
THE CHAIRMAN:  The Legal Assessor has a question.
D
THE LEGAL ASSESSOR:  Mr Coonan, in regard to your proposal relative to 10(a) and the 
stem of 11, adopting this secondary one, “by you or at your direction”, I suppose by putting it 
this way, this would mean that if there were a mistake by a member of staff or a member of 
staff acting through ignorance, this would not rebound on Dr Southall. 
MR COONAN:  Precisely so. 
E
THE LEGAL ASSESSOR:  If his system were such that in effect they are acting in 
accordance with the system set up by him, not by a mistake or by ignorance on their part, 
then that would rebound on him. 
MR COONAN:  Well it depends, as I understand it, my learned friend is going to or may,  
I do not know, be submitting that system plays a part.  It was with that in mind that my 
primary position was that there should be an allegation that it was done by him because 
F
systems can produce any set of facts by virtue of the system, but the thrust of this case, as we 
understand the case we have to meet, is that it was Dr Southall’s personal responsibility for 
filing these documents, not a responsibility arising out of, as I said before, a clerk, a junior 
research fellow, or anybody else who may have filed documents wrongly, contrary to 
Dr Southall’s intention.  It would be quite wrong for findings to be made in those 
circumstances.  I hope that meets the query, sir, you put to me directly and squarely. 
G
THE LEGAL ASSESSOR:  Yes, thank you. 
MR TYSON:  Precisely the area that the Legal Assessor has drawn to your attention, which is 
why I seek to have the wording that I asked for, which is “by you or on your behalf”, because 
that covers as it were system failure, bearing in mind it is our case that Dr Southall was 
responsible for setting up, managing and controlling the system.  We will have to hear the 
evidence in answer to any of the particular matters in Appendix One whether the evidence is 
H
going to be, “My secretary got it wrong”, in which case I will then take the view, having 
T.A.  REED 
Day 9 -  11
 & CO. 

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A
heard the evidence, as to whether to pursue any particular item in the Appendix, but does not 
stop me from saying that the allegation that I want to pursue, and this is my application, and 
these are my heads which I have to prove, to include the words “by you or on your behalf”.
I accept that “on your behalf” is wider than the words that my learned friend wants, which is 
“at your direction”.  At present, I wanted to prove this case in the widest sense in order to 
cover his responsibility of head of department, for the management and control of the filing 
within his department.  As I say, within that, of course if the evidence comes out that it is 
B
simple clerical error, then of course I would not wish to say that if you accept that evidence,
I would not say, as I charge in relation to these matters, that that was inappropriate and an 
abuse of his professional position and the like, but the charge should remain, whether the 
evidence fits within the charge is a matter we will have to hear the evidence. 
So I say he either placed it or matters were placed on his behalf there.  That is against that 
test, I suggest, that you should judge the evidence and no narrower test.  I readily accept that 
C
simple clerical error would not come into either my learned friend’s or my charge, but I want 
to prove this case on my heads.  
THE CHAIRMAN:  I will ask the Legal Assessor to advise the Panel on this application. 
THE LEGAL ASSESSOR:  Madam, your powers under rule 24 amount to this, that at this, or 
indeed any stage, you may permit the charge to be amended.  The fundamental to it is that 
D
you must be satisfied that no injustice would be caused, injustice of course applies to both 
parties, both the complainants and to the doctor, and any such amendments may be made as 
appear to you to be necessary or desirable in your task in determining the issues here. 
In regard to 10(a), tampering, and to the stem of 11, cited, there is no opposition to 
Mr Tyson’s application, Mr Coonan has helpfully expanded a little on what the overall 
position is but he takes no opposition to the proposal. 
E
In regard to the rest of the proposal under 11, to the stem, the issue, as you have heard, is 
really a question of how it should be worded because it is not disputed that there should be 
some amendment.  You have heard the two proposals and they really amount, you may think, 
to a question of the width or breadth of how the allegation would be put.  The submissions of 
counsel have made the positions plain.  You will also bear in mind what I might describe as 
Mr Tyson’s qualification, that depending on how the evidence would come out, if it were to 
F
indicate mere mistake by a member of staff, that he may well not pursue this position.  You 
would doubtless wish to take that into account.   
In essence this question, which is entirely for you, is whether or no there would be likely to 
be any injustice to the doctor. It is a question of the breadth of the allegation and of course 
eventually your decision would depend upon the evidence but you must focus now upon the 
specifics of the charge in the light of the proposed amendment.  When I say proposed 
G
amendment, of course you have two contrary proposals before you.  The task before you in 
effect is, first, to consider in regard to the unopposed matters whether you feel it would be 
appropriate to amend the charge but, second, the more substantial matter, is in regard to the 
two proposals as to amendment in regard to the stem of 11 and that is a matter entirely for 
you.
THE CHAIRMAN:  Thank you.  Do either of you have any comment on the legal advice? 
H
T.A.  REED 
Day 9 -  12
 & CO. 

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A
MR COONAN:  No, thank you, madam. 
MR TYSON:  No, madam. 
THE CHAIRMAN:  The Panel will go into private to consider your application. 
STRANGERS THEN, BY DIRECTION FROM THE CHAIR, WITHDREW
B
AND THE PANEL DELIBERATED IN CAMERA
STRANGERS HAVING BEEN READMITTED
DECISION
C
THE CHAIRMAN:   I will now read the Panel’s determination. 
Mr Tyson: 
The Panel has considered your application made under the provisions of Rule 24(4) of the 
D
General Medical Council Preliminary Proceedings Committee and Professional Conduct 
(Procedure) Rules Order of Council 1988.
E
Rule 24(4) states: 
“Where at any stage of an inquiry it appears to the Committee that a charge should be 
amended, the Committee may, after hearing the parties and consulting the legal 
F
assessor, if they are satisfied that no injustice would be caused, make such 
amendments to the charge as appear necessary or desirable”. 
G
You have applied for Head 10(a) and the stem of Head 11 to be amended by inserting the 
words “by you or on your behalf” after the word “placed”.  You have also applied for the 
word “cited” to be inserted between “such” and “original” in the stem of Head 11 and in 
H
T.A.  REED 
Day 9 -  13
 & CO. 

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A
Head 11(a) to substitute the words “Damaged the integrity of” for “Amounted to tampering 
with”.
The Panel has taken into account your submissions and the submissions made in reply by  
B
Mr Coonan on behalf of Dr Southall.  It has noted that Mr Coonan has not opposed your 
proposed amendments to insert the word “cited” in the stem of Head 11 and to change Head 
11(a) to read “Damaged the integrity of the child’s hospital medical records”.  
C
In respect of the insertion of the words “by you or on your behalf” Mr Coonan agrees that 
some amendment is necessary. However he does not accept the phrase proposed by you.  
Mr Coonan’s contention is that the amendment should be limited to the insertion of the words 
D
“by you” or alternatively, that the phrase should read “by you or at your direction”. 
Having considered the submissions made, and in the light of the evidence that has been 
E
presented thus far, the Panel is satisfied that the amendments suggested by you are both 
necessary and desirable in order for these heads of charge to be clear and that they would not 
cause any injustice to either the complainants or Dr Southall. 
F
MR TYSON:  Madam, that is the case for the complainants. 
THE CHAIRMAN:  Mr Coonan? 
MR COONAN:  Madam, the first matter I would like to deal with is to make another 
admission in relation to the heads of charge as they are amended.  Can I take you to 13(b) 
G
please.  This admission which I now make in relation to 13(b) reflects the document which 
was handed in to you earlier. I therefore now make that admission in the terms therein set 
out.
THE CHAIRMAN:  Thank you.  I therefore have to announce that head of charge 13(b) is 
admitted and found proved. 
H
T.A.  REED 
Day 9 -  14
 & CO. 

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A
MR COONAN:  Thank you. 
Madam, there is now a matter that I need to raise at this stage.  I gave you as it were a slight 
indication of the territory by making reference yesterday to rule 27(1)(e)(i) and it is that that
I direct your attention to as forming the backdrop to what I have to say.  The submission that 
I make here is directed towards head 17 and its linked Appendix Three. It concerns Mrs D.
This submission is confined to Mrs D.  For the purposes of considering the evidence, may I 
B
just give you the direct passages that bear on this question.  It is Day 6/67A-69G and Day 
7/9E-22D.  I am not going to take you at length to that evidence.  I am going to invite you, 
please, after having heard my submissions, to read those two precise citations so that you can 
make a judgement in the light of the submissions that I make.  I adopt that approach simply to 
save time. 
The submission that I make is based on well known principles of law which apply to these 
C
proceedings, and may you see, please, an extract from the practitioners’ book Archbold which 
may assist you, subject of course to any advice you may receive from the Legal Assessor, but 
you may find it helpful just to see what the position is in summary form.  My learned friend 
already has a copy.  (Document handed)
THE CHAIRMAN:   This will be D10. 
D
MR COONAN:   The principle that I address is the principle which starts at paragraph 4-293, 
and the principle is encapsulated in the well known case of Galbraith.  Perhaps I could read 
this to familiarise yourself with the concept. 
 
“A submission of no case” – this is the submission I am making – “should be allowed 
when there is no evidence upon which, if the evidence adduced were accepted, a 
reasonable jury” – that is you – “properly directed, could convict.  In such a case, a 
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directed verdict must be taken from the jury.” 
Then the citation from the judgment in Galbraith itself bears examination.  The Court of 
Appeal said this, having reviewed the earlier authorities and guidance was given as to the 
proper approach to be adopted in the Crown Court: 
 
“(1)  If there is no evidence that the crime alleged has been committed by the 
F
defendant there is no difficulty – the judge will stop the case.  (2) The difficulty arises 
where there is some evidence but it is of a tenuous character, for example, because of 
inherent weakness or vagueness or because it is inconsistent with other evidence.
(a) Where the judge concludes that the prosecution evidence, taken at its highest, is 
such that a jury properly directed could not properly convict on it, it is his duty, on a 
submission being made, to stop the case.  (b) Where however the prosecution 
evidence is such that its strength or weakness depends on the view to be taken of a 
G
witness’s reliability, or other matters which are generally speaking within the 
province of the jury and where on one possible view of the facts there is evidence on 
which the jury could properly come to the conclusion that the defendant is guilty, then 
the judge should allow the matter to be tried by the jury.” 
Then there is a comment by the learned editors of Archbold:
H
T.A.  REED 
Day 9 -  15
 & CO. 

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A
“The Lord Chief Justice [in Galbraith] then observed that borderline cases could be 
left to the discretion of the judge.” 
They then cited an example in the case of Lesley.  Over the page there is then cited, and  
I draw particular attention to this authority, the case of Shippey.  Mr Justice Turner in that 
case:
B
 
“…held that the requirement to take the prosecution evidence at its highest did not 
mean [and I draw your attention to the quotation] ‘picking out all the plums and 
leaving the duff behind’.  The judge should assess the evidence and if the evidence of 
the witness upon whom the prosecution case depended was self-contradictory and out 
of reason and all common sense then such evidence was tenuous and suffered from 
inherent weakness.  His Lordship [that is Mr Justice Turner] did not interpret 
Galbraith as meaning that if there are parts of the evidence which go to support the 
C
charge then that is enough to leave the matter to the jury, no matter what the state of 
the rest of the evidence is.  It was, he said, necessary to make an assessment of the 
evidence as a whole and it was not simply a matter of the credibility of individual 
witnesses or of evidential inconsistencies between witnesses, although those matters 
may play a subordinate role.” 
Then there is a passage which relates to committal proceedings which does not apply to you.  
D
Then the last paragraph beginning “As to the evidential value” again is not applicable to these 
proceedings. 
So therefore at this stage the principle in Galbraith has to be interpreted in line with the 
decision of Mr Justice Turner in Shippey and applied to the particular facts of a case.  I do 
stress that the decision reached is very case specific, very fact specific. 
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The principle in Shippey and that of Galbraith is applied up and down the land pretty well 
every day of the week and is now the accepted approach to the consideration of evidence at 
this stage of the proceedings. 
So therefore, with that backdrop of the principles of law that you follow, could I come on 
therefore to what I say about the evidence in relation to Mrs D.  I submit in broad terms that 
if the evidence stopped here, that no reasonable Fitness to Practise Panel, properly directed in 
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accordance with the principles of the standard and burden of proof, could properly convict 
upon it.  Secondly, in order to determine that principle, it is important to look at the whole of 
the relevant evidence.  As I have already drawn attention to, in the case of Shippey, it is 
extremely important that, in exercising that approach, you do not simply pick out the plums 
and leave the duff behind.  You have to look at the evidence as a whole. 
What is the evidence which bears on this question in head 17 and Appendix Three?  Mrs D 
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was the sole witness to these events.  There is no corroborative evidence by her partner.  Her 
evidence is based on memory and impression which emerged, and this is now undisputed, ten 
years later for the first time at the earliest, it could be said on the state of the evidence.  In 
other words, on the evidence the first time that she put pen to paper in terms of any detail of 
this matter was in 2004 when she made a witness statement, in November 2004.  Is there, if 
one could put this rhetorically, cogent, safe evidence that these events of which complaint is 
now made were in fact etched on her memory as is contended?   
H
T.A.  REED 
Day 9 -  16
 & CO. 

---

A
You may care to consider the following forensic pointers:  first of all, there is no evidence 
that any contemporaneous note or record was kept by her or anybody else of these events.
I draw a distinction for these purposes between that and the case of Mrs M.  Mrs M, of 
course, you had, did you not, evidence received of a note by Dr Southall himself, a note 
written by Mrs Salem, an attendance note by the solicitor Mrs Parry, and a note written by
Dr Corfield.  You do not have any of that in this case.  Secondly, there is no evidence of any 
of what lawyers call, but you will understand immediately what I mean, of any recent 
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complaint, that is to say no evidence that she, having experienced what she says now she 
experienced, then complained, as it is so that Mrs M did to the solicitor or to Dr Corfield.  
Indeed, when complaint was made to the GMC in 1997, there was no complaint about what is 
now said, and I encapsulate it in this way, to the corridor incident.  She made a further 
complaint in 1999 to the GMC; not a word about what she now complains of at that stage. 
MR TYSON:  I hesitate to interrupt my learned friend, but there is no evidence before this 
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Panel as to what she did or did not say in 1997 or what she did or did not say in 1999. 
MR COONAN:  Well, I do not accept that. 
MR TYSON:  It was not put to her, documents were not put to her.  We are dealing with 
evidence.  I have no recollection that what she did or did not say in 1997 or what she did or 
did not say in 1999 are matters before the Panel. 
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MR COONAN:  I do not accept that.  One has to look at the transcript.  She accepted that the 
first time that any complaint about the corridor incident was made was in 2002 in the 
statutory declaration.  She accepted that she had made complaints to the GMC in 1997 and 
1999, did not contain any complaint at all about the matters of which she now complains.  
She accepted that there is indeed a reference to that in the statutory declaration.  The main 
point is, as I have said, and I do not move from this position, that there was not a word about 
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it in 1997 and 1999.  Moreover, when she made a complaint to the Trust in 1999/2000, the 
precise date does not matter but the year-end date does, no complaint there about what she 
now complains about.  The first time that there is any complaint about anything that 
happened in the corridor is contained in a statutory declaration made in July 2002, paragraph 
97, which she read out, and it is on your transcripts.
You will remember that she described simply that Dr Southall had been “very abrupt”.  She 
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accepted that what she complained about in that statutory declaration, made eight years after 
these events, was “very different than the complaint which she now makes”.  The first time 
therefore that there could realistically be any evidence that she was making a complaint about 
the matters which she now describes to you must have been sometime after 2002.  You know 
that she made a witness statement in November 2004.   
I think I am permitted to make the observation, and I hope not extravagantly, but the account 
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has grown over time.  She points to the fact that there is or may be an explanation for her 
partner not witnessing these events.  That explanation, and I refer to the nurse aside leading to 
a coffee for the partner, appears for the very first time in evidence before you.  There is no 
reference to this incident, seeking to explain in effect why it may be that the partner did not 
witness this, no reference to that in the statutory declaration, and, she accepted, no reference 
in her witness statement in November 2004, and that fortifies and supports the proposition 
that this is so recent that the first time it appears in any document that has been disclosed to 
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us is in evidence she gives to you. 
T.A.  REED 
Day 9 -  17
 & CO. 

---

A
Now, of course, you know that these events occurred in 1994, whatever may have been those 
events.  That is, on any view of the matter, a long time ago, twelve years ago.  This 
submission that I am making to you is not simply based on the fact of delay, because, and  
I recognise three factors, in a case where you simply have the fact of delay there is obviously 
no statute of limitations in the criminal law (that is trite law), and ultimately in such a case it 
may be for a jury to attach such weight to that set of circumstances as appears proper, and, 
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moreover, to have regard to the question of prejudice to the defendant in a criminal case, or 
the doctor here, that might arise simply because of a later complaint.  All those factors one 
recognises, and could, in many cases, be dealt with as part of the rubric, if you like, of trial 
management by the judge.   
Here the situation is different, because it is not just a question of a late complaint being made, 
and the lateness of the complaint we now know must have been after 2002, but it is the fact, 
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coupled with that, that she made a complaint in 2002 which was in effect false by omission;
in other words, very different both in quality and nature from what it is she is now telling 
you.  She of course advances before you a reason for why she did not set out in her statutory 
declaration the nature of the complaint that she now makes.   
I invite you at this stage, carrying out the Galbraith/Shippey function, to consider this:
although there were complaints about Dr Southall in that statutory declaration, nobody 
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disputes there was not, she was sufficiently focused even then to describe Dr Southall’s 
conduct as being very abrupt, but, as she now concedes, very abrupt, yes, on the one hand, 
but how it has elaborated to the present.  Equally, it cannot be the case that the explanation 
that is now put forward for not mentioning these matters in 2002, or at any time before that, is 
because of fear, or shame.  If I can pause there, obviously in many cases where there is delay 
one can begin to explain why there is such a delay, particularly in sexual assault cases and so 
forth, but that does not apply here.  There are no suggestions that that was in play.  This 
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witness, Mrs D, in effect made a deliberate decision to describe Dr Southall’s conduct in the 
terms she did in 2002. 
Leaving aside her evidence, you have also to consider, do you not, the question of fairness to 
Dr Southall?  There must be, on any view, potential prejudice to him on the basis that 
notification of this allegation could only have come after 2002, but even then if he had had 
notification shortly after 2002 it would have been limited to “very abrupt”, hence you might 
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now understand the relevance of the admission my learned friend made earlier this morning.
The witness statement that she made to the GMC of 20 November 2004 was only served on 
Dr Southall’s solicitors in July 2005.  It therefore follows that he is being placed, and this is 
on the basis of the evidence as it stands at the moment, he is being asked to deal with an 
allegation, of the detail and nature wherein she has described to you, about eleven years after 
it occurred. 
G
You are entitled to ask yourselves this question, on the one hand to say to yourselves, “Well, 
of course, he can come and deny it”, and of course he can, but the question is what is the state 
of the evidence as it stands at the moment?  Where might that leave Dr Southall in attempting 
to defend himself?  Putting it again very starkly, how is he able to go to the group of doctors 
that he was with in 1994 in a corridor, assuming he was there, which I do for the purposes of 
this argument, and say to any one or other of them, or one of the nurses, “Do you remember 
how I spoke to that patient on 15 December 1994?”  They would look at him blankly, would 
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they not? 
T.A.  REED 
Day 9 -  18
 & CO. 

---

A
The further matter for your consideration, and I simply raise it as a possibility, there is a risk 
of contamination.  Mrs M had signed up, if I can use that expression, Mrs Mellor as her 
advocate by 10 January 2000, and we know that, it is in Mrs M’s own writing at D1.  You 
also know from Mrs D’s evidence that Mrs Mellor was, as it were, on board I think was the 
expression I used when I cross-examined her before she made her statement to the GMC in 
November 2004.  That is a fact and it is a factor for you to take into account when 
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considering whether it may be safe, whether it may be tenuous within the principles set out in 
Galbraith and Shippey.
You are also entitled, in our submission, to take into account the fact that on the evidence 
Mrs D’s view of Dr Southall may well have been – and this is my expression, but I hope it is, 
again, not an exaggeration – somewhat baleful.   
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MR SIMANOWITZ:  I am sorry, somewhat ---? 
MR COONAN:  Baleful.  She referred in the course of her evidence in the transcript to, on a 
later occasion, coming across Dr Southall and another doctor laughing and she was clearly 
upset by that – not on this occasion, but much later.  She has brought a legal action against 
the Trust; she was certainly contemplating legal action against Dr Southall in respect of other 
matters.  The real issue for you is you have to make a judgement, putting all these factors 
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together under the umbrella of the lapse of time before this complaint ever emerges, and 
determine whether or not – not taking the plums and leaving the duff, but looking at it 
altogether, looking at the complainant’s case at its highest – this is evidence that is fit or 
would be fit to go before a jury.  In other words, fit for you to decide that it should go any 
more before you.  In considering that question you have, even at this stage, to apply the 
burden and standard of proof, the criminal burden and standard of proof. 
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Madam, those are the submissions I want to make. You will be conscious of the fact, as I said 
right at the beginning of these short submissions, that I was not going to take you to specific 
passages in the transcript.  I reiterate that I invite you to do that, each of you, at your leisure.  
If I do that I may be guilty of taking plums from the duff and I do not want to be considered 
to be guilty of doing that. 
Thank you very much. 
F
MR TYSON:  May I ask my learned friend for some elucidation?  When we had informal 
discussions about this matter he indicated, amongst other things, that he was going to submit 
on heads 17(b) and (c).  Am I to understand that in fact he has expanded what he has told me 
informally and that it is now the whole of head 17 in relation to this witness? 
MR COONAN:  I am sorry, there appears to be some misunderstanding.  I said head 17 and  
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I intended that to cover the whole of head 17. 
MR TYSON:  I do not want to intrude on private discussions.  I now realise, which I did not 
realise before, that I am faced with the whole of head 17 in relation to this witness. 
Madam, as far as the law goes what my learned friend says about Galbraith and Shippey
I cannot dispute, because it is there in Archbold at paragraphs 4-293 to 4-295 to which you 
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have been referred, but I need to make some observations on that aspect of the law because 
T.A.  REED 
Day 9 -  19
 & CO. 

---

A
there is a slight difference, you may think, between the way it is put in the Rules and in the 
principles set out in Archbold at paragraph 4-293.    Can I take you to paragraph 21(e) of the 
Rules, and it is of course the 1988 Rules. 
THE LEGAL ASSESSOR:   Paragraph 27(1)(e), not 21. 
MR TYSON:  Paragraph 27.  I have a problem with numbers today.  Paragraph 27(1)(e)(i): 
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“At the close of the case against him the practitioner may make either or both of the 
following submissions, namely:- 
(i)
in respect of all or any of the facts alleged and not admitted in the charge or 
charges, that no sufficient evidence has been adduced …”. 
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I rely on the words “no sufficient evidence has been adduced.”  Bearing those words in mind, 
can you go to the principle set out in Archbold at 429-3, where it is said: 
“A submission of no case should be allowed when there is no evidence”, 
and note the difference between “no evidence” and “no sufficient evidence”, 
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“upon which, if the evidence adduced were accepted, a reasonable jury, properly 
directed, could convict.” 
My submission to you, my global submission to you on the point, is that the rule 27(1)(e)(i) 
test presents a higher hurdle for the doctor to surmount in these submissions than the “no 
evidence” hurdle set out in the principle at 429-3.  That is a simple submission on law on 
which your learned Legal Assessor will doubtless advise you. 
E
The other thing I need to say is about Shippey.  We are familiar with Shippey because every 
doctor who makes submissions makes great play on Shippey, just like every defendant who 
makes submissions in the Crown Court.  The important thing about Shippey is that you 
should only go down the Shippey line if you consider that the evidence upon which the 
prosecution case depended (and this is about the fourth line down) was self-contradictory, out 
of reason and all common sense.  You may have a number of views about Mrs D, none of 
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which, in my respectful submission, are permissible at this stage.  Those three descriptions do 
not describe her evidence.
The other important thing about Galbraith, and indeed the approach to submissions that you 
should make, is that I rely on the second limb of Galbraith, which is (b), which, just to 
remind you, states: 
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“Where however the prosecution evidence is such that its strength or weakness 
depends on the view to be taken of a witness’s reliability, or other matters which are 
generally speaking within the province of the jury and where on one possible view of 
the facts there is evidence on which the jury could properly come to the conclusion 
that the defendant is guilty, then the judge should allow the matter to be tried by the 
jury.”
H
T.A.  REED 
Day 9 -  20
 & CO. 

---

A
That is a very, very important statement, because here the complainants are relying, and in 
fact Mrs D is a complainant herself …  The entirety of the head of charge 17 relating to her 
depends on the view taken of her reliability.  Witness reliability is not, I repeat, not an issue 
to be taken at this stage.  Witness reliability is a matter for you not wearing your judge hat, 
which you are wearing at the moment, but your jury hat when you are considering the matter 
at stage one.   
B
It is very important that you realise you have two functions here.  You are at the moment 
sitting, as it were, as a judge, and deciding in your judge hat: Is there sufficient evidence to 
be left, or not, to you, in your jury hat later when you are making your findings of fact?  At 
the moment, wearing your judge’s hat, you are not permitted under the second limb of 
Galbraith, as I say, to take a view on the witness’s reliability or other matters which are, 
generally speaking, the province of a jury, because that is you in your later hat.  All I have to 
establish is that on one possible view of the facts there is evidence.  If I can get over that 
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minimal hurdle: 
“… where on one possible view of the facts there is evidence upon which the jury 
could properly come to the conclusion that the defendant is guilty, then the judge 
should allow the matter to be tried by the jury.” 
My submission on Galbraith is that all I have to show to you is that there is one possible 
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view of the facts, there is evidence.  Whether or not you accept that evidence now is 
irrelevant.  Whether or not you think the witness is reliable is irrelevant.  What is relevant at 
this stage to see whether the doctor has a case to answer is whether, on one possible view of 
the facts, there is evidence in support of head of charge 17.  The quality of the evidence is a 
matter you consider at a later stage when you are in your fact-finding jury hat.  All you have 
to consider at the moment, wearing your judge hat, is whether there is evidence in support of 
head of charge 17.
E
I cannot emphasise that too strongly because you do have complicated and different 
functions, bearing in mind that you are both the judges of the law and judges of the facts as a 
Fitness to Practise Panel.  There are some times – and this is one of them – where you have to 
separate out your functions.  You are not at this stage in a fact-finding role.  You are at this 
stage in your judicial role and in your judicial role all you have to determine is whether, on 
one possible view of the facts, there is evidence upon which a jury could come to the 
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conclusion that he is guilty.  In those circumstances, provided there is some evidence, then 
you should properly allow the matter to be heard by you at the later stage. 
The other important issue of law is that my learned friend has come up with – by the back 
door, if I can put it this way – an abuse argument.  If he were to allege that no fair trial can be 
heard on head of charge 17 because it is prejudicial to the doctor, because it is so old and he 
has only heard about it later and he cannot get witnesses, that is not, I repeat, not a matter for 
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you to consider at this stage. He has not made an application to strike out this matter on the 
grounds of abuse of process.  Wholly different considerations apply to abuse of process 
applications which are made at the beginning of a case, to strike them out.  My learned friend 
has made his application, as he said it clearly, under rule 27(e)(1), which is not the abuse 
ground, and to try and bring in an abuse argument, prejudice, fair trial, Article 6 and the like, 
is impermissible on an application for no case or submission of no case to answer.  
H
T.A.  REED 
Day 9 -  21
 & CO. 

---

A
You are not under the principles of Galbraith, Shippey or any other, to consider prejudice.
You are not, under Galbraith or the other, to consider prejudice.  All you are to consider 
under Galbraith is:  Is there, on one possible view of the facts, evidence upon which you can 
find head of charge 17 proved?  Dismiss entirely from your considerations any of the abuse 
of process arguments which my learned friend has sought to get in through the back door.
His application is under rule 27 and under rule 27 matters of consequences of difficulties for 
the doctor to get any rebuttal evidence, or the like, are irrelevant matters not to be taken into 
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account.  All you have to consider under rule 27 is whether sufficient evidence (or 
insufficient evidence) has been adduced upon which the Panel could find these matters 
proved.
I am going to go to the facts, but I do not know whether this might be a convenient time to 
stop, having dealt with the important aspects of law. 
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THE CHAIRMAN:  I think it may be that it would be a good idea to break now.  It is clear 
that you have more to say and I think it would be appropriate to take the lunch break now.  It 
is about five past one on my watch.  Can we be back at about five past two?  Thank you. 
(Luncheon Adjournment)
MR TYSON:  Madam, as I said earlier, and I want to emphasise, I trust that your learned 
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Legal Assessor will give you advice upon this matter, your task is to look at the evidence now 
in support of heads of charge 17 and not – I repeat: not – any difficulties in rebutting that 
evidence, which is a matter either for an Article 6 abuse argument at the beginning or 
a matter which my learned friend could pray in aid in closing but it is not a matter to be dealt 
with at this stage. 
Again going to the pages that my learned friend gave you, he did not go as far as he could 
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have done, and should have gone up to and beyond page 27 on Day 7.  27 contains an 
important exchange between you, madam, and the witness, where you elicited from the 
witness both plums and duff, as far as I am concerned, in that you elicited one matter which  
I will take you to from the witness which makes my case on 17(c) rather difficult but it helps 
me more on 17(b) but I will take you to that.  May I say, in the interests of fairness, you 
should go beyond the reading that my learned friend gave you. 
F
Can we first look at the heads of charge together, that it is said that there is no sufficient 
evidence in support of.  Paragraph 17 says:
“In the cases set out in Appendix 3 you failed to treat [and this is an important word, 
‘you failed to treat’ I ask you to emphasise that] the respective children’s mothers in 
the ways set out below, or any of them, 
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“a. Politely and considerately’ 
“b. In a way they could understand, [and]
“c. Respecting their privacy and dignity”.
Then we go over to Appendix Three in relation to Mrs D and you see that the matters are 
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particularised there.  The matters particularised under there are: a raised voice; dismissive 
T.A.  REED 
Day 9 -  22
 & CO. 

---

A
manner; walking away; not giving mother any opportunity to ask questions.  Those are the 
allegations, the specific allegations, in support of the global submission that is made at head 
of charge 17.
At the risk of being accused of taking you plums and duff, I am going to ask you to focus on 
some matters because the evidence that you have got to look and constantly remind 
yourselves is: is there evidence upon which a jury properly come to the conclusion the 
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defendant was guilty?  Or, to put it another way: is there evidence upon which a Panel could 
properly come to the finding that this head of charge is found proved?  I take you please, first, 
to Day 6 when asked questions in-chief by me.  Could I take you to page 68?  We pick it up 
at B:
“[Q] 
Can you take it slowly because a note will have to be taken of this. 
[A] 
I believe that Professor Southall stated that everything was normal.  
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I questioned this, especially with my son having the reaction that he had had the night 
before, and I questioned Professor Southall that how could it be normal with alarms 
going off, and what was happening to my son.  Professor Southall became quite angry 
and said that there is no such thing as delayed reactions”. 
Again, looking at the allegation here, the allegation at 17, is politeness and consideration, 
amongst other things, and, in my respectful submission, it is impolite for a consultant to 
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become angry with a mother of a child patient. 
“[Q] He 
said? 
[A] 
‘There is no such thing as delayed reactions’. 
[Q] Yes. 
[A] 
The way he spoke to me, I just felt very, very sick in my stomach, and I just 
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felt that he was stopping me from asking any more questions by the tone and the 
anger in his voice [again that, you may think, goes to 17(a)].  At the time I did not 
understand why he was so angry with me, [that, you may think, goes to 17(b)] but in 
hindsight I believe it was because I was asking questions, and Professor Southall later 
went on to accuse me of exaggerating my son’s [symptoms], and I believe that he did 
not want me to raise questions that things were not okay the night before, or indeed 
the three nights of the recordings. 
F
Again, in my submission, it is impolite to accuse you of exaggerating your son’s problems.   
If I can take it on to F: 
“[Q] 
You told the Panel that he became angry and you felt sick because of the tone 
and anger in his voice.  At what part of this conversation did he become angry, and 
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what were the words that you thought were particularly anger making words? 
[A] 
When he said everything was normal, that was a calm voice, and I believe, 
and, as I said, I may have got things not in the correct order, but I believe now that, 
looking back and getting my head round that day, that I believe it was when 
I questioned Professor Southall that he became very angry and said there was no such 
thing as delayed reaction.  It was the anger that I just could not understand at the time. 
H
T.A.  REED 
Day 9 -  23
 & CO. 

---

A
[Q] 
When he said, “There is no such thing as delayed reaction”, how was his voice 
in terms of volume? 
[A] 
It was quite loud, louder than he had been speaking, but it was more the anger 
I think. 
[Q] 
Were you given the opportunity to ask questions? 
[A] 
I felt so sick, and also with Professor Southall sort of like raising and turning 
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away, I was too frightened to ask any more questions, or to raise the issue of how my 
son had been those three nights. 
[Q] 
You say he turned away.  Did he turn away in the course of this conversation? 
[A] 
Yes, I believe he did, because I think that was a sign, that, no, you know, 
I cannot ask him any more questions. 
C
[Q] 
Did he make any gestures at all that you can recall? 
[A] 
I believe that he just put his hand up and he said that there is no such thing as 
delayed reaction, it was as if, like, dismissive of me”. 
Again, pausing there, you may think, and I would say, that that is evidence of being impolite 
and inconsiderate when he is being dismissive. 
D
“[Q] 
You are showing, for the sake of the transcript, a raising of the right hand. 
[A] 
That is what I remember.  As this all happened so long ago there are some 
things that you do forget, but there are also things that are imprinted in my memory”. 
You will recall that she uses the word “imprinted” a number of times.  Again matters that you 
think were imprinted, you may well think at this stage, that that is evidence upon which you 
can properly come to the conclusion at this stage that there is evidence on this head of charge 
E
so much to leave it to you at a later stage. 
“As this all happened so long ago there are some things that you do forget, but there 
are also things that are imprinted in my memory and you do not forget.  If I can give 
another example, at the case conference in the room, prior to discussions ---  
and I took her away from the case conference. 
F
“[Q] 
We are talking about an incident now nearly twelve years ago.  What are the 
aspects of this conversation that are really imprinted in your memory? 
[A] 
Because of the sickness that I felt at the time. 
[Q] 
What are the aspects about what he said or did that is imprinted in your 
memory? 
G
[A] 
Because he had said that everything was normal and it clearly was not, and 
that made me feel, well, how can my son be helped if the doctor was denying what 
was seen in his own hospital and that other doctors had seen as well.  I was worried 
for the safety of my son, because I had gone there thinking that Professor Southall 
would be able to help, which is the impression that he gave. 
[Q] 
Is the phrase you told the Panel of ‘There is no such thing as delayed reaction’, 
H
is that imprinted in your memory? 
T.A.  REED 
Day 9 -  24
 & CO. 

---

A
[A] 
That is, because of the way it was said and the anger at the time. 
[Q] 
Is his raised voice imprinted in your memory? 
[A] 
Yes, it is. 
[Q] 
Is his raised hand and walking away imprinted in your memory? 
[A] 
The raised hand, it could be that he just turned away, I could not be certain 
B
that he walked or he just moved one step, but it was a turning as he waved his hand, 
and that is in my memory. 
[Q] 
You say that you had gone to Professor Southall to see about whether your 
child could have a monitor.  Was there any discussion, or did you have any 
opportunity to discuss whether your child could have a monitor? 
[A] 
I just got the impression, because he had said everything was normal – I was 
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not given the opportunity to ask him questions”. 
Again, you may think, that is evidence of the impolite and inconsiderate in not giving a 
person who had arrived there on their own volition, you remember this was a complainant, 
who, as it were, got her GP to refer her to Professor Southall, as he then was.  It is not one of 
these cases where this patient had been or the mother had been referred on because there were 
any suspicions of abuse on the night.  She had used the monitor and she got her GP to send 
D
her off to see if the monitor was appropriate.   
Just at the bottom of page 69: 
“I just got the impression, because he had said everything was normal – I was not 
given the opportunity to ask him questions, but I just accepted that he obviously was 
not going to suggest a monitor, but because he had suggested Professor Warner I felt 
E
that there was some hope and some light because maybe Professor Warner could 
help.”
Madam, those, in my submission, are the relevant questions dealing with this issue in-chief.
In cross-examination, can I take to you the next day please, at Day 7, and take you to 
passages on pages 12, 13 and 16.  On page 12, at B, this goes to 17(b), she was asked by 
F
Mr Coonan:
“[Q] 
But you must have been disappointed that you were not getting a monitor and 
that Dr Southall had not, at that stage, provided a solution to the problem. 
[A] 
I believe that I accepted that he was not going to give a monitor, and I felt that 
he did not understand my son’s problems, because he was not an allergist and I felt 
that at least he was referring me to somebody who may be able to help. 
G
[Q] 
So you felt that he did not understand your son’s problems. 
[A] 
Because he said that everything was normal.” 
Then at the bottom, between F and G: 
H
T.A.  REED 
Day 9 -  25
 & CO. 

---

A
“[Q] 
But I do want to come to the area about which there is dispute.  You told the 
Panel yesterday that Dr Southall said these things, and in particular when he said there 
was no such thing as a delayed reaction, with an angry voice. 
[A] 
He did raise his voice. 
[Q] 
Let us look at that.  He raised his voice.  Yesterday you described it as 
representing anger. 
B
[A] 
A raised voice with an angry tone. 
[Q] 
How often had you had to experience how Dr Southall talks? 
[A] 
I had only seen him on the one occasion prior to that and he had not raised his 
voice [at that time]”. 
Picking it up again at D:
C
“Were other parents or members of the public present? 
[A] 
I did not see anybody.  It seemed quite quiet in the corridor. 
[Q] 
I just want to examine this.  You are saying that because of a raised voice, 
which you had not experienced when you met him the first time, and the tone of that 
voice, you concluded, and concluded at that time that he was angry.  Is that right? 
D
[A] 
I felt sick at the way Professor Southall spoke to me and I can only remember 
that as being when somebody speaks angrily at you. 
[Q] 
Not sick because you had received disappointing news? 
[A] 
No, because at that time I was not aware that we were not going home with the 
monitor.  As I explained before, I was actually happier that Professor Southall was 
referring my son to somebody that could sort out the problem rather than the need for 
E
the monitor. 
[Q] 
Let me come straight to the point.  I am going to suggest to you that 
Dr Southall was not angry, he did not raise his voice and he was not dismissive. 
[A] That 
is 
incorrect.” 
Then we pick it up at page 16, under “Mr Coonan”:
F
“Maybe, but I am suggesting to you that this is the first time that this appeared in any 
document that I have seen. 
[A] 
It may have done, but I still feel that because of the time lapse there are things 
that I cannot remember about that day, but I do remember how Professor Southall 
spoke to me because it left a lasting memory.” 
G
Pausing there, madam, you will see, and you will have the opportunity to read the whole 
transcript, and I am not stopping you doing that, in fact I even encourage you, as my learned 
friend did, but throughout it she is clear about what she can remember and what she cannot 
remember.  You may think that that is an essentially reliable witness saying that, albeit, as  
I have to say, as the second limb in Galbraith keeps reminding one, if the prosecution 
evidence is such that its strength or weakness depends on the view taken of a witness’s 
reliability, that is a jury question rather than a judge question. 
H
T.A.  REED 
Day 9 -  26
 & CO. 

---

A
 
“[A] 
It may have done, but I still feel that because of the time lapse there are things 
that I cannot remember about that day, but I do remember how Professor Southall 
spoke to me because it left a lasting memory. 
[Q] 
A lasting memory? 
[A] Yes. 
B
[Q] Okay. 
[A] 
One that I would hope to forget, but I cannot.” 
In re-examination, we go to page 23 and we pick it up at 23G: 
 
“[Q] 
It was suggested to you that your account is one of exaggeration.  Have you 
exaggerated to the Panel that Professor Southall raised his voice? 
C
[A] 
I have not exaggerated, because to exaggerate I feel is very similar to lying 
and I have sworn on oath not to lie, or to tell the whole truth as far as I can recall. 
[Q] 
Did you exaggerate to the Panel that he turned round to go with his hand being 
raised? 
[A] 
That is my recollection and I do not believe that I have exaggerated. 
D
[Q] 
Did you exaggerate when you told the Panel that you had no time to ask 
questions about the monitor? 
[A] 
That is correct, I felt that I was not able to ask any more questions, other than 
asking what was happening to my son the night before when the doctor was called.   
I believe that that is the only question that I was able to ask. 
[Q] 
Did you exaggerate to the Panel when you described the tone of the way that 
E
you were being addressed in the middle of that conversation by Professor Southall? 
[A] 
I do not believe I did, because I felt that it was such a tone that that is why it 
has stayed in my memory.” 
Then we come to important questions on pages 27 and 28 by you, Madam Chairman.  It is 
quite clear from the focus of your questions, madam, that you had head of charge 17(a), (b) 
and (c) firmly in your mind.  We pick it up at 27B: 
F
 
“[THE CHAIRMAN]:  I have a couple of questions that relate to the corridor 
incident, if I can put it that way.  You told us about the nature of the conversation.
Did you have any difficulty in understanding what Professor Southall was telling you 
in that intervention? 
[A] 
I was quite surprised that Professor Southall said everything was normal, and 
I was obviously confused because to me things were not normal.  The alarms were 
G
going off and my son was obviously unwell.  That is why I could not understand why 
he said everything was normal. 
[Q] 
So you understood what he was saying, but you did not understand the 
implications.  Is that a fair way of putting it? 
[A] 
I could not understand how he could say everything was normal. 
H
[Q] 
You did not understand how he could say that? 
T.A.  REED 
Day 9 -  27
 & CO. 

---

A
[A] 
That is right, because to my belief that is why I was there with my son in the 
first place, because everything was not normal. 
[Q] 
If you understand the difference then, you understood his words and what he 
appeared to be saying from his side, but it was the implications that flowed from that 
that raised more questions in your mind. 
[A] 
The questions flowed from when he said everything was normal, because he 
B
then did not clarify what was happening to my son to say this was normal because of 
this.  He gave no clarification whatsoever for just saying everything was normal.  
When I spoke to him for clarification, that was when I believe he became angry and 
I was not able to ask any more questions. 
[Q] 
To the best of your recollection did you ask a question saying what he meant 
by “normal”? 
C
[A] 
No, I do not believe I did use that phrase.  I believe I said what was happening 
to my son last night if everything was normal. 
[Q] 
Did you get an answer to that question? 
[A] No. 
[Q] 
What happened at that point? 
D
[A] 
I believe that is when Professor Southall became angry. 
[Q] 
What did he do then from your recollection? 
[A] 
From my recollection I may have said, “What was happening to my son?  Was 
it a delayed reaction?”  I do not know.  I may have done but I do not recall that, but 
then Professor Southall said that there is no such thing as delayed reactions in an 
angry tone and I felt he was dismissing me from asking any more questions.” 
E
Then there is the important evidence that my client gave at page 28 between C and D which
I have to deal with: 
 
“[Q] 
It has not formed part of your evidence or complaint but it is in fact mentioned 
in a head of charge about respecting privacy.  Was the fact that whatever was said in 
the corridor, was this an issue that you felt was to do with privacy, or was it simply 
F
the tone of his voice? 
[A] 
I think it was simply the tone and how he spoke to me. 
[Q] 
So you were not concerned that confidential matters were being spoken about 
in the corridor. 
[A] 
No, because from my recollection I do not remember seeing anybody else 
other than the people on the ward round. 
G
[Q] 
So that was not an issue? 
[A] 
No, and from my recollection the playroom was very quiet as well.  From my 
recollection we were the only people in there at that time.” 
So, madam, you may think, and I would encourage you to think, that not only is there some 
evidence upon which you could find the facts proved, but there is an enormous amount of 
H
evidence in which you can find the individual items set out in Appendix Three – raised voice, 
T.A.  REED 
Day 9 -  28
 & CO. 

---

A
dismissive manner, walking away, not giving the mother any opportunity to ask questions – 
there is ample evidence in the matters that I have read out in support of each and every one of 
those particularised allegations. 
As to the description of those set out in head of charge 17, dealing with the question of 
“politely and considerately”, in my submission there is ample evidence that by raising his 
hand, walking away and speaking in a raised voice he was not behaving either politely or 
B
considerately.
The question about “in a way that they could not understand”, there are two aspects, two 
ways, that you can look at that.  First is the way that I would ask you to look at it, in the way 
approached by you, Madam Chairman, and that is this, that it is not that she could not 
understand the words that he was saying, what she could not understand, the two things, first 
of all the tone in which he was saying them, the manner in which he was saying them, the 
C
manner being such that made her feel seek in the stomach, or whatever, and, secondly, what 
she could not understand was how was he saying and why was he saying that her child was 
normal when there had been an incident the night before, when the child went down to 
extremely low levels on the monitor, which we have seen when we looked at the nursing 
notes, which called a registrar to have to see the child, and, as she says, alarm bells were 
going off all the time.  She could not understand why it was that Professor Southall was 
saying to her that everything was normal.  So I put that in two ways:  it is not the physical 
D
understanding of the words (she is intelligent and she can understand the words and so on), 
she could not understand the tone nor could she understand the premise.  She could not 
understand the tone that he was using, which was angry and dismissive;  she could not 
understand the premise that everything was normal when to her it clearly was not normal. 
As far as respecting privacy and dignity is concerned, madam, in view of the answers that this 
witness gave specifically to you when asked about that aspect, I would have difficulty, and  
E
I realistically face up to that, in keeping head of charge (c) in respect of Patient D.  So in 
respect of Patient D I would say that all the items in Appendix Three should remain and the 
descriptions of those should be, perhaps fairly, characterised under 17(a) and 17(b), but I 
have difficulty, in view of the comments, attaching 17(c) to the particularised matters in 
Appendix Three. 
Can I deal with one or two matters that my learned friend raised.  He made a point about this 
F
being, as it were, a recent invention, and what I say about this is exactly what the witness said 
about it.  In particular, she spoke about this at length in Day 7, between pages 19 and 20, that 
her prime concern and the prime focus of her complaint was matters relating to Dr Southall’s 
care of her child and the consequences of that care.  I think those are matters which this Panel 
is not being asked to look at, but that was the main focus of her complaint.  When asked to 
particularise on one aspect that she mentioned in her statutory declaration, she did 
particularise it and go into more detail in her witness statement some two years later.  It is not 
G
that this is a matter of recent investigation and greater exaggeration, it is a matter that to her, 
in the global scheme of things, when she was worried about her son and she was being dealt 
with, did not appear to her in that context to be of enormous importance, but when asked 
about it she was able to give the appropriate details. 
It is not, we would submit, a recent account, it is just a recently particularised account, and, as 
I say, she had good reason to only recently have to particularise it because she was asked to 
H
do so in the context of this particular case. 
T.A.  REED 
Day 9 -  29
 & CO. 

---

A
Again, her motivation, in view of the fact that she had at one time I think taken a legal action 
against the Trust, I remind you about that, but I do know that she did not take action against 
Dr Southall personally in that, and her motivation, as you can see, is that she is a concerned 
mother wanting to do the best for her son, and the suing would be in relation to the treatment 
of the son, not of the treatment of her in the corridor that night. 
B
As far as the “polluted by Mrs Mellor” argument, there is absolutely nothing in that, you may 
think.  There is no evidence that these two women have ever met or communicated in any 
way.  My learned friend sort of touched on that in a way trying to muddy the waters, but you 
have to deal with this case on the evidence, and is there evidence (a) that either of these 
women in question got in any serious contact with each other, or, more seriously, is there any 
evidence that the witnesses in question ever talked to each other about these matters at all?  
Forget all that. 
C
Evidence as to whether her account is supported or otherwise by her ex-partner, again that is 
not a matter which you have to consider here provided you are satisfied that there is evidence 
upon which you could find these facts proved.  That is all the test is at this stage.  You do not 
have to go into the question, provided, and I accept, as it were, the Shippey take on the 
matter, you can look at evidence and say “This is not good enough”, and if you think the 
evidence of Mrs D is so contradictory, out of reason and/or common sense, to that extent you 
D
can take it into account, but on-one, in my respectful submission, who has heard that this 
woman could characterise her evidence with any of those descriptions. 
My learned friend said rightly that his client has rights in these matters, but so of course does 
the complainant.  The complainant has brought a serious allegation by the doctor, and she has 
a right, providing the evidence is not so tenuous that it is self-contradictory, out or reason 
and/or common sense, she has a right to have that complaint heard and determined, and it is 
E
in the public interest, and that is a big matter in your function, that serious complaints made 
by doctors are heard and determined on the evidence.  So the public will know, in your public 
duties, whether this is a nonsensical allegation or a serious allegation.
Provided there is sufficient evidence that we have shown a prima facie case, to use old-
fashioned language, that there is a case to answer, in my respectful submission the evidence 
shows there is a case to answer;  how you in fact determine it on the evidence, those are 
F
matters for you at the end of the day but not at this stage.  For all those reasons I would urge 
you to reject my learned friend’s submission. 
THE CHAIRMAN:  Mr Coonan. 
MR COONAN:  Madam, I think I can keep my reply short.  There is one matter of fact which 
I need to correct my learned friend on, where he asserted not a moment or two ago that there 
G
was no evidence that Mrs Mellor and Mrs D had ever met.  Could I direct you, please, to  
Day 7/21 and you will see the evidence to the contrary.  You should read the whole of those 
exchanges because, of course, all I am dealing with is the fact of contact.  What you make of 
that is entirely a matter for you, but it is a matter which I simply seek to correct my learned 
friend on. 
Can I go to perhaps more substantial matters.  The public interest point alluded to by my 
H
learned friend of course is an important factor, but it also applies whenever the case of 
T.A.  REED 
Day 9 -  30
 & CO. 

---

A
Galbraith is applied in a criminal case.  The public interest argument does no damage, nor 
should it, to the operation and the proper operation of Galbraith.  Nobody has suggested, save 
in one respect, that Galbraith with the gloss provided by Shippey should not apply in these 
proceedings.  The exception, however, concerns the first point my learned friend made in his 
submissions to you.  He sought to argue that there was a higher hurdle for the defence to 
overcome than Galbraith, which is represented by rule 27(1)(e)(i).  May I say straightaway 
that we do not accept that proposition of law.  What is set out in 27(1)(e)(i) in effect is an 
B
expression of the principle of law articulated in Galbraith and does not move it. 
The second matter I want to draw your attention to is this, that when you look at the second 
limb of Galbraith, which is important, we are both agreed on that, when you look at the 
second limb it is very important not to construe it as if it were a statute, because if that were 
right, there would have been no need for the gloss on it supplied by Shippey.  That is why it is 
important to read the principles in Galbraith and apply them in the context, in a fact specific 
C
way, to the operation which you see outlined in Shippey.  So it is somewhat artificial simply 
to say at this stage, “Apply a judicial hat without any regard to aspects of the evidence”.  Of 
course, you must look at the evidence, and, as judges at this stage, you take a view, but a 
permissible view.  The permissible view is the one which is bounded by the principles in 
Galbraith and Shippey together. 
So much for the law, and your learned Legal Assessor will of course give you proper 
D
guidance on that.  I make two comments about the facts because having invited you to look at 
the evidence given by Mrs D – she is the only witness on this issue – I repeat that invitation.
I just make two observations.  The first is that her statutory declaration in 2002 was indeed to 
set out her complaint to the General Medical Council about this doctor and the high point of 
that complaint was that he had been very abrupt, full stop.  That does not support the 
particulars of this allegation set out in Appendix Three.
E
The second observation I make – and it is really a query which I invite you to consider – is 
whether 17(b), even if you accept the evidence for the purposes of this stage, really adds 
anything to head 17(a).  I do not develop these submissions in any strong way.  I invite you to 
think about that, or whether in fact 17(a) is the real gravamen of the allegation. 
Madam, those are the submissions I make. 
F
(The Chairman and the Legal Assessor conferred)
THE CHAIRMAN:  It has been suggested that perhaps the right order of things would be for 
the Panel to do the reading first and receive the legal advice after that.  Do you have any 
view?  I think the Legal Assessor would in any case like a few minutes to prepare his advice. 
MR TYSON:  Madam, I have got no observations on that, save that of course whilst you are 
G
reading the Legal Assessor is not able to give you any advice.  Secondly, I make a specific 
request to the Legal Assessor that he covers in his legal advice whether and to what extent it 
is permissible to bring in abuse arguments at this stage.  Other than that I have no objection, 
whichever way round it is. 
THE CHAIRMAN:  Mr Coonan? 
H
T.A.  REED 
Day 9 -  31
 & CO. 

---

A
MR COONAN:  I think it is a sensible suggestion for you to read it before the learned Legal 
Assessor gives his advice. 
THE CHAIRMAN:  It seems to be fairly agreed that that is the way round we should do it, so 
we will adjourn from public session for the time being while the Panel reads the sections of 
the transcript which have been pointed out to us.  Just to be quite clear on this, my 
understanding is it is Day 6 from 67A to 69G and Day 7/9E through to page 27? 
B
MR TYSON:  Page 28. 
THE CHAIRMAN:  Page 28. 
MR TYSON:  My learned friend invited you to stop at page 24, but I say 28, because there is 
stuff useful for him on page 28. 
C
THE CHAIRMAN:  That then covers what both of you have suggested we should read and 
we will call you back then when we have completed the reading and the Legal Assessor is 
ready to give his advice. 
MR COONAN:  Thank you. 
D
MR TYSON:  Perhaps I should point out that you should not be deliberating until you have 
been given the legal advice.  You can be reading, but not deliberating. 
THE CHAIRMAN:  We will not deliberate.  We will undertake not to speak to each other 
about this matter at all. 
(The Panel adjourned to read documents)
E
THE CHAIRMAN:  The Panel has now completed the reading, but just a tiny point.  When 
reading it we noticed that there was an error in the transcript where what should obviously be 
Child D is actually written as Child H.  I spotted that.  Whether that should be corrected, 
whether that is a matter for the shorthand writer --- 
MR TYSON:  Perhaps for the benefit of tonight’s transcript it ought to be identified. 
F
THE CHAIRMAN:  It is on Day 7/18D, the paragraph that begins, “Chris and I saw 
Professor Southall…”.  There are two mentions there of Child H and it should be Child D. 
MR TYSON:  Was it my fault?   
THE CHAIRMAN:  I have no idea how it arose.  Other than that, the Panel have no questions 
G
arising from the reading, so we will call on the Legal Assessor to give his legal advice.  
(Copies handed to the Panel and counsel)
THE LEGAL ASSESSOR:  Mr Coonan makes this submission under Rule 27(1)(e).  He 
contends that in relation to the facts alleged in head of charge 17 insufficient evidence has 
been adduced upon which the Panel could find those facts proved.  Mr Tyson concedes that 
in the light of the evidence, allegation 17(c) cannot be sustained.  The Panel is therefore 
H
concerned only with head of charge 17(a) and (b). 
T.A.  REED 
Day 9 -  32
 & CO. 

---

A
It is for the Panel members, who are the judges of the facts and also of the law, to decide this 
issue.
It is customary for the Panel to consider such a submission in the light of the well-known 
authorities of Galbraith and Shippey, to which it has been referred.  Mr Tyson submits that 
the use of the phrase in Rule 27(1)(e) “no sufficient evidence” presents the doctor with a 
B
higher hurdle to clear than would be the case under the criminal law.  It is of course for the 
Panel to decide what is the correct approach, but I advise that as is the practice at a Fitness to 
Practice hearing, the Panel should approach this matter on the basis of the Galbraith test. 
In reaching their decision, the Panel members must take the evidence currently before them at 
its highest, remembering that in respect of each allegation they must be satisfied so that they 
feel sure that on the evidence thus far the facts could be proved.  The burden of proof rests 
C
upon the complainants.  The Panel should look at the evidence thus far adduced as a whole, 
not merely that which supports the complainants’ case.  In short, when taking the evidence at 
its highest, the Panel must not, to adopt a well-known judicial comment, just take the plums 
and leave the duff behind. 
It follows that if in regard to an allegation there is no evidence capable of so satisfying the 
Panel, then the submission succeeds.  If, however, there is evidence upon which an allegation 
D
could be made out, for example where it is such that it depends upon the view to be taken of a 
witness’s reliability, then the submission does not succeed.  Of course, if the Panel members, 
as judges of fact, were to conclude at this stage that the evidence is so inconsistent or so 
unreliable that they could not be sure that the allegations could be made out, then the 
submission succeeds. 
I remind the Panel that it must consider each of the allegations the subject of this submission 
E
separately.  The evidence is not the same and it may reach different conclusions as between 
the allegations. 
When considering the evidence the Panel is entitled to draw inferences from what it has heard 
but not to speculate on what other evidence might have been called.   
Mr Coonan has referred to the prejudice which the doctor may suffer by reason of the passage 
F
of time since the alleged incident.  I remind the Panel that when considering the submission 
under Rule 27 its concern is solely with the sufficiency of the evidence; the question of 
prejudice is not germane to that issue. 
THE CHAIRMAN:  Does either counsel have any comment on the legal advice? 
MR TYSON:  I have a comment and it is merely in relation to my concession regarding 
G
paragraph 17.  I am not in a position to withdraw that.  This is a complainant case; I have no 
instructions to withdraw it. I just point it out because I am a member of the bar – the good 
side and the bad side, as it were – and point out that you may feel that the evidence is there 
not to prove it.  But, I am not withdrawing it from the Panel because I cannot, because I have 
got no instructions.  If I was instructed by the GMC I could have taken a robust view and said 
do not consider it.  So, it is formally before you, if I can put it that way, for you to treat it as 
you wish. 
H
T.A.  REED 
Day 9 -  33
 & CO. 

---

A
THE LEGAL ASSESSOR:  Could it be put then on the basis that Mr Tyson neither agrees 
nor disagrees? 
THE CHAIRMAN:  Mr Coonan? 
MR COONAN:  Madam, thank you.  I have nothing to add. 
B
THE CHAIRMAN:  I do just have one point for clarification and that is as written it says “the 
facts alleged in head of charge 17” but in fact there are two parts to head of charge 17, are 
there not, in that it refers to both family D and one of the other families too, family M?  We 
are concerned only at this time with family D. 
MR COONAN:  That is right, madam. 
C
MR TYSON:  And the Appendix to which head of charge 17 relates. 
THE CHAIRMAN:  Yes. 
THE LEGAL ASSESSOR:  I am sure the Panel have those matters well in mind.  I had hoped 
it was clear by inference. 
D
MR TYSON:  Madam, there is a matter of machinery.  I do not know whether the Panel feels 
that it can reach a decision on these matters tonight before 5 o’clock, or whether they are 
prepared to tell the advocates that they would not call the advocates back before 9.30 a.m. 
tomorrow morning, or before ten or something tomorrow morning, or whatever; or do you 
want us to wait?  It is a solely a matter for the convenience of the parties, not the convenience 
of the Panel, that I am making this minor plea. 
E
THE CHAIRMAN:  Yes, I would have turned to that next if you had not mentioned it, 
Mr Tyson.  I think even if the Panel reaches a decision in principle it is very unlikely we will 
have a determination ready for you tonight, so we are certainly looking at tomorrow morning.  
The suggestion here is probably not before ten.  I look around to the Panel, if anybody wants 
to disagree.  (After a pause)  I do not see any disagreement.  Would that be a reasonable 
suggestion?
F
MR TYSON:  That would be fine. 
THE CHAIRMAN:  Thank you.  We will presumably still be in camera in the morning but 
we will call you as soon as we are ready. 
MR TYSON:  Not before ten. 
G
THE CHAIRMAN:  And in any case not before ten. 
MR TYSON:  I am very grateful. 
STRANGERS THEN, BY DIRECTION FROM THE CHAIR, WITHDREW
AND THE PANEL DELIBERATED IN CAMERA
H
(The Panel adjourned until 10 a.m. on Friday, 24 November 2006)
T.A.  REED 
Day 9 -  34
 & CO. 

---

A
B
C
D
E
F
G
H
T.A.  REED 
Day 9 -  35
 & CO. 

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GENERAL MEDICAL COUNCIL
FITNESS TO PRACTISE PANEL (PROFESSIONAL CONDUCT)
Friday 24 November 2006
44 Hallam Street, London, W1W 6JJ
Chairman:   
  
Dr Jacqueline Mitton 
Panel Members:
Mrs Leora Lloyd 
Mr Alexander McFarlane 
Dr Sameer Sarkar 
Mr Arnold Simanowitz 
Legal Assessor:   
Mr Robin Hay 
CASE OF: 
SOUTHALL, David Patrick 
(DAY TEN)
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 JOLLIFE 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) 

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I N D E X 
          
 
 
 
 
Page 
No
DECISION ON SUBMISSION (Rule 27(1)(e)(i))   
1 
DAVID PATRICK SOUTHALL, Sworn 
 Examined 
by 
MR 
COONAN 
    4 

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A
STRANGERS HAVING BEEN READMITTED
THE CHAIRMAN:   Good morning.  I am now going to read the Panel’s determination on 
the submission made by Mr Coonan. 
B
DECISION
THE CHAIRMAN:  Mr Coonan:  The Panel has considered your submission made under the 
provisions of rule 27(1)(e)(i) of the General Medical Council Preliminary Proceedings 
Committee and Professional Conduct (Procedure) Rules Order of Council 1988 in relation to 
C
Head 17, in so far as it concerns Mrs D.
Rule 27 (1)(e)(i) allows the practitioner to submit: 
 
“in respect of any or all of the facts alleged and not admitted in the charge ….. that no 
D
sufficient evidence has been adduced upon which the [Panel] could find those facts 
proved”.
Mr Tyson does not oppose your submission in regard to head 17(c), although he does not 
concede that the allegation cannot be sustained 
E
The Panel has taken into account the submissions made by you as well as those made by Mr 
Tyson.
The Panel has noted and accepted the advice given by the Legal Assessor in its entirety.  In 
particular, the Panel notes that it should approach this rule 27 submission on the basis of the 
F
test set out in the Court of Appeal case of R v Galbraith 73 Criminal Appeal Reports 124 and 
that its concern is solely with the sufficiency of the evidence.  Further, it accepts that the 
question of prejudice that the doctor may suffer by reason of the passage of time since the 
alleged incident is not germane to that issue. 
G
In its deliberations, the Panel had recourse to the guidance in Galbraith.  In particular, it has 
noted the passage:
 
“Where however the prosecution evidence is such that its strength or weakness 
depends on the view to be taken of a witness’s reliability, or other matters which are 
H
generally speaking within the province of the jury and where on one possible view of 
T.A.  REED 
Day 10 -  1
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A
the facts there is evidence on which the jury could properly come to the conclusion 
that the defendant is guilty, then the judge should allow the matter to be tried by the 
jury”.
It has also had regard to the judgement in the case of R v Shippey 1998, Criminal Law 
B
Review 767. 
The test to be applied at this stage of the proceedings is whether the evidence, taken at its 
highest, is such that the Panel is satisfied so that it is sure that the allegations could be proved. 
C
The Panel has considered each sub-head of the charge separately.  It has given consideration 
to all the evidence but has been careful to address only issues of the legal sufficiency of that 
evidence.
The Panel is aware that it has heard only the Complainants’ case. The Panel has not 
D
speculated about the nature of any evidence that might be adduced on behalf of Dr Southall.  
Instead, it has kept in mind throughout that it must reach its conclusions only on the basis of 
the evidence before it so far.
In respect of sub-heads 17(a) and 17(b), the Panel is satisfied that there is sufficient evidence 
E
upon which the allegations could be found proved.  It therefore rejects your submission under 
rule 27(1)(e)(i).
In respect of 17(c), the Panel has concluded that insufficient evidence has been adduced.  It 
therefore accedes to your submission and accordingly it records a finding that Dr Southall is 
F
not guilty of serious professional misconduct in respect of head 17(c) as regards Mrs D.
MR TYSON:   Madam, I wonder whether it would be possible to ask the Panel to rise for five 
minutes whilst we bring all our books back in and we are ready for the next stage of this case. 
THE CHAIRMAN:   Yes, of course.  Is five minutes the length of time you need? 
G
MR COONAN:   Well, madam, about five minutes. 
THE CHAIRMAN:   Yes.  Will you please advise us when you are ready. 
(The Panel adjourned for a short while)
THE CHAIRMAN:   We are all ready, Mr Coonan. 
H
T.A.  REED 
Day 10 -  2
 & CO. 

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A
MR COONAN:   Thank you, madam.  Before I call Dr Southall, could I ask you, please, to 
receive the file for the defence documents that you have received already so they can be 
accommodated, because during the course of the evidence you are going to receive some 
more documents, and it is possibly a neat way of keeping them together.  They will be 
supplied with dividers all ready. 
THE CHAIRMAN:  This will be D11. 
B
MR COONAN:   Well, it is just a file. 
THE CHAIRMAN:   I see.  I am sorry, I did not appreciate there was nothing in it yet. 
MR COONAN:   You will appreciate that we have left you individually to file the documents 
that you have already. 
C
THE CHAIRMAN:   Just so I understand this, are the tabs intended to take the documents we 
have had already? 
MR COONAN:   Yes, they are. 
THE CHAIRMAN:   Then there will be subsequent documents? 
D
MR COONAN:   There will be subsequent documents, yes 
THE CHAIRMAN:   So each individual document will have a D number, but this is merely a 
convenient way of keeping it. 
MR COONAN:   That is right.  You insert your D numbers according to the tab. 
E
THE CHAIRMAN:   Thank you.  Sorry, I did not appreciate that. 
MR COONAN:   So, as I said, there will be more documents to come and more dividers will 
follow.  I am told they run from 1-20 at the moment already. 
(Pause while Panel members assembled their defence documents files)
F
THE CHAIRMAN:   Could I just take this opportunity to say, thinking ahead this morning,  
I understand you are calling Dr Southall, we were thinking of taking another short comfort 
break before lunch, so perhaps towards twelve o'clock. 
MR COONAN:   Certainly, madam.  Thank you very much.  Well, that task having been 
completed, I will call Dr Southall. 
G
H
T.A.  REED 
Day 10 -  3
 & CO. 

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A
DAVID PATRICK SOUTHALL, Sworn
Examined by MR COONAN
Q 
Dr Southall, I think you know the personnel already and there is no need to introduce 
you.
A Yes. 
B
Q 
Can you, for formalities sake, please, just confirm your full name and your 
professional address. 
A 
David Patrick Southall, the Academic Department of Paediatrics, University Hospital 
of North Staffordshire, Stoke on Trent. 
Q 
Could I ask you now formally, please, to produce your curriculum vitae.   
C
THE CHAIRMAN:   (Document handed)  So this will be D11. 
MR COONAN:   Do you have a copy there? 
A 
Yes, I do. 
Q 
Can I just take you then to the current position.  We see, at the top of the second page 
the position at present, you are a locum consultant paediatrician at the University of North 
D
Staffordshire Hospital. 
A Yes. 
Q 
We will come on to this in a moment, the Honorary Medical Director of Childhealth 
Advocacy International. 
A Yes. 
E
Q 
Could I just deal with that now.  What is Childhealth Advocacy International? 
A 
It is a humanitarian aid agency that addresses the needs of mostly mothers and 
children in very poor countries. 
Q 
We look at the formal qualifications, they are self-evident, the Panel can see.  I just 
take you to the non-formal qualifications.  I think you were awarded the OBE in December 
1998.
F
A 
Yes, I was. 
Q 
For work you did in Bosnia and Herzegovina, is that correct? 
A 
Yes, I worked for UNICEF.  
Q 
Can I take you to page 3, because part of your previous career is relevant to the 
Panel’s consideration.  Can we pick it up, please, at the period 1978-1982.  Were you then an 
G
Honorary Senior Registrar in Paediatrics at the Brompton? 
A 
Yes, I was. 
Q 
Having had some experience of general practice. 
A 
Yes, I did. 
Q 
Then between 1982 and 1989 Senior Lecturer in Paediatrics at the Cardiothoracic 
H
Institute? 
T.A.  REED 
Day 10 -  4
 & CO. 

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A
A Yes. 
Q 
Then between 1986 to 1988 an Honorary Consultant in Paediatric Clinical Physiology 
at the Brompton Hospital, is that right? 
A Yes. 
Q         Then from 1988 to 1992 a consultant paediatrician at the Royal Brompton Hospital 
B
and a consultant paediatrician within the Mid-Downs Health Authority and in particular 
centred on Crawley Hospital? 
A         Yes, I was. 
Q         Between 1992 and 2004, were you the Foundation Professor of Paediatricians at the 
University of Keele and, at the same time, running in parallel with that, a full-time consultant 
paediatrician at the University Hospital in Stoke-on-Trent?  
C
A         Yes, I was. 
Q         Did you retire from that full-time post in late 2004? 
A         Yes. 
Q         Since 2004, have you been, as you indicated earlier, a locum consultant paediatrician 
at the University Hospital of North Staffordshire to the present? 
D
A         To the present, yes. 
Q         Your Foundation Professorship, did that lapse when you ceased to be a full-time 
consultant paediatrician at the University Hospital? 
A         Yes. 
Q         It is convenient just to pause for a minute in looking through the formal appointments 
E
to focus on the period that you have set out there, 1992 to 2004.  Was there a period within 
that period in Stoke-on-Trent when you were suspended from practise at the hospital by the 
Trust? 
A         Yes, I was. 
Q         Two matters, we will have to look at this in a little more detail, but for what period 
were you suspended? 
F
A         November 1999 through to, approximately, November 2001. 
Q         Did that mean that you had access to the Trust and to the hospital in that time? 
A         No, the opposite, I could not have any access.  I did go there to meet with 
administrators and managers but not without supervision. 
Q         Did the suspension arise because of complaints and allegations being made about 
G
aspects of your clinical practice? 
A         Yes. 
Q         Were there, and again, in so far as it is necessary, were there any particular aspects of 
clinical practice which the Trust were looking at? 
A         Yes.  Child protection was the clinical practice, and research. 
H
T.A.  REED 
Day 10 -  5
 & CO. 

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A
Q         Were there a series of inquiries during that period, 1999 to 2001, into those aspects of 
your practice? 
A         Yes, there was. 
Q         Carried out by or on behalf of the Trust? 
A         Yes. 
B
Q         What was the result of those inquiries? 
A         I was exonerated. 
Q         Then did you return to work in either the latter part of 2001/beginning of 2002? 
A         Yes.  I had to spend a short period just being realigned clinically and then I went back 
to work. 
C
Q         When you say you went back to work in about 2002, did you go back to work in the 
area of child protection? 
A         No because there were still matters being considered by the General Medical Council, 
so it was agreed that I would wait until they had been looked at. 
Q         Let us just look again at page 3, under the heading of “Special Activities”, we note 
there, just over halfway down, that you were Chairman of the British Paediatric Association 
D
Working Party on the management of pain of sick children between 1994 and 1997.  Can you 
just help the Panel, what was that about, just in a word or two? 
A         Yes.  I had written the paper in a British Medical Journal concerning painful 
procedures in children and the fact that they were not really adequately being addressed.  As 
a consequence, the British Paediatric Association asked me to set up a working party to 
explore this.  We did, and we produced a book, a manual for paediatricians. 
E
Q         Then we see your role in Bosnia and Herzegovina as an advisor on maternal and child 
health, is that right? 
A         That is right, yes. 
Q         Are you still involved in that capacity? 
A         We have a programme in Bosnia but not in the same category as this, not to the same 
extent.
F
Q         Then you were Chairman of the Working Party of UNICEF UK Child Friendly 
Healthcare Initiative between 1999 and 2004.  Again, in a word or two, what was that 
initiative?  
A         This was a programme about the care of children in hospital, looking at the United 
Nations convention on the rights of the child and how it related to hospital care of children all 
over the world and we produced some papers and worked on this with UNICEF UK and are 
G
still working on it at the moment. 
Q         Finally, just to complete the picture, the last reference, I think you were director, since 
2004, of the programme there described.  Again in a word or two, what is the nature of that 
appointment? 
A         Basically we have developed a programme looking at emergencies in mothers, babies 
and children, so far in two countries, Pakistan and the Gambia, looking at ways of improving 
H
emergency care in the hospital sector and in the community sector.  This project involves 
T.A.  REED 
Day 10 -  6
 & CO. 

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A
both training and improvement in resources.  It is in collaboration with the Advanced Life 
Support Group, a charity in the UK, and in collaboration with the World Health Organisation. 
Q         We just move on smartly through this document.  We see, on page 4, a summary of 
research and clinical audit undertaken by you.  I am not going to take you to the detail, the 
Panel are able to absorb that themselves.  We see, on page 6, particularly under heading 7, 
a summary of papers published in peer review journals, either as principal or secondary 
B
author, is that right? 
A         Yes, yes. 
Q         That takes us through to page 13.  Again, the Panel are able to absorb that.  I do not 
think, for my purposes, I need to take you, certainly at the moment, in particular to any 
particular one of these papers.  Do you understand? 
A         Yes. 
C
Q         Then at page 13, you summarise papers published in other journals.  By that, do I take 
that to mean non-peer review journals? 
A         Yes, that is right. 
Q         Finally, we see a summary of chapters you have written in books and invited articles, 
in section 9.
D
A         Yes. 
Q         Again, I am going to adopt the same approach, they are there to be seen, I do not take 
you through them in detail. 
Dr Southall, what I am going to do next please to is ask you some questions about your work, 
firstly at the Brompton Hospital.  Now we have seen from the CV already that you have been 
E
at the Brompton for some time.  For my purposes I am going to concentrate on the period 
from about 1988 to 1992, which mirrors, according to the CV, your appointment as 
a full-time consultant paediatrician at that hospital.  That is not to say that the previous period 
is irrelevant, nor do I wish to shut it out, but I, for my purposes, am going to start in about 
1988.
A         Yes. 
F
Q         When you were appointed as a consultant paediatrician at the Brompton, full-time, 
what were you appointed to do?  It may sound a fairly obvious question but I think it is 
important.  What were you appointed to do?  
A         In respect of the Brompton Hospital, as distinct from Crawley, where I was a district 
general hospital paediatrician, at the Brompton I had a special remit to look after complicated 
respiratory paediatric problems, in particular children – babies and children referred from all 
over the UK who were having difficulties in breathing or suddenly collapsing for no obvious 
G
cause.  Some people have called those collapses apparent life-threatening events.
Q         Shortened to ALTEs? 
A         ALTE, yes. 
What had happened was we developed a lot of equipment, non-invasive monitoring 
equipment and recording equipment, as part of our research work.  This was adapted to be 
H
T.A.  REED 
Day 10 -  7
 & CO. 

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A
used clinically to investigate these children that were referred to us, to try and work out what 
was going on during their events, some of which were clearly life-threatening events. 
Q         When this equipment was used, was it used for the purposes of clinical investigation 
or research? 
A         In the cases that are referred to me as a consultant at the Brompton, it was for clinical 
purposes.
B
Q         You have talked about referral to you at the Brompton, do we understand the 
Brompton in that sense to be therefore a tertiary centre? 
A         Yes.  It was not a district general hospital, it did not have an accident and emergency 
unit, it predominantly treated children referred from other hospitals, and, in my case, for the 
purposes I have just mentioned. 
C
Q         Help the Panel please about the nature of your department.  First of all, what was it 
called?  
A         Department of Paediatric Clinical Physiology and it comprised myself, as the director 
of the department.  We had a registrar, a senior research fellow, Dr Martin Samuels.  We had 
a number of research fellows, doctors coming from abroad usually or from the UK, 
sometimes, to learn about what we were doing.  We had, at various times, one or two clinical 
nurse specialists.  We had monitoring technicians who used to help by applying the 
D
equipment to the children.  Secretary, I think that is – but we worked in parallel with the 
Clinical Department of Paediatrics as well, so that the children, when they first came in, were 
clerked in as per normal, as any child would be by the registrar, senior house officer, senior 
registrar, whatever it happened to be, as normal, and the nurses as well were looking after the 
patients as they would look after normal patients. 
Q         Where was the department situated physically?   
E
A         It changed.  It started off just across the road in the Cardiothoracic Institute and then 
moved to be more close to the wards, when it became, I think, the National Heart and Lung 
Institute; changed name. 
Q         Apart from the clinical investigation work that you described, was there work which 
might be described, and I ask this in general terms, as child protection investigation work? 
A         Not initially.  What happened was that--- 
F
Q         In the period we are talking about, 1988 to---
A         Yes, during that period it was.  That was because in 1985/6 we had been referred 
some children for investigation of ALTE, who had turned out to be suffering from intentional 
suffocation by their parents.  So it was only then that we started to become involved in child 
protection.
G
Q         Again, this is a general question, did some referrals, referred on the basis of clinical 
investigation, as it were translate into child protection cases? 
A         Yes, although usually the paediatrician referring had some idea that might be 
a problem in that direction, before referring, but not always. 
Q         Mention has been made in passing to what has been called covert video surveillance.
This case is not about that, but help the Panel please as to how it fits into the mosaic of your 
H
practice.  Was covert video surveillance performed at the Brompton? 
T.A.  REED 
Day 10 -  8
 & CO. 

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A
A         Yes, it was.  It was performed by the police in collaboration with social services and 
us.
Q         The physiological recordings which were carried out for the purposes of clinical 
investigation, produced what in terms of material?  Help us about that.
A         To start with, we had reel-to-reel tape recorders to collect the data with.  Then we 
developed some computer disks.  Then we produced, from these two sources, printouts, chart 
B
printouts, so you could look at them manually.  Then we developed a screen system that you 
could look at the recordings on and print out only sections that you wanted to look at.  So it 
developed with time. 
Q         In the period 1988 to 1992, and if necessary we can look at some examples, did the 
physiological recordings, quite apart from the tapes, did it produce paper? 
A         Yes. 
C
Q         Did it produce or was it associated with the completion or creation of logs of infant 
activity? 
A         Yes. 
Q         How did that come about? 
A         During the recordings, and in addition to the nursing records, the nurses and the 
D
parents were asked to fill in a form so that if there was any event during the recording, it was 
written on the form, a log of infant activity form.  We would then take that to the department 
after the recording and look at the recording, print it out into chart paper, usually about 
250 pages per recording, and look through that and correlate it with the infant activity chart. 
Q         After the charts had been completed, was there a document called a report which was 
completed? 
E
A         Yes. 
Q         Who completed the report? 
A         Usually it was Martin Samuels or myself. 
Q         What was the purpose of the report? 
A         It was to produce a written copy of the result of the recording, in broad terms, not 
F
each individual bit of it but a summary. 
Q         Can we just look, by way of example, at those two documents.  Again, simply taking 
this at random.  Can you take out C5 and just look at Child A for a minute.  Look at 
page 145, is that an example of the log that you have just been describing? 
A         Yes, it is. 
G
Q 
On the log we see reference to the special case number on the top right-hand corner. 
A Yes. 
Q 
References, on the face of the document, to the tape itself.   
A Yes. 
Q 
If you move to page 147, we see in the top left-hand corner of the document “Report”. 
H
A Yes. 
T.A.  REED 
Day 10 -  9
 & CO. 

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A
Q 
In the middle of the document there is reference to an “SC” number; in this case 
“1209”.
A Yes. 
Q 
Is that a reference to a special cases file number? 
A 
Yes, it is. 
B
Q 
In the bottom left-hand corner, there is an instruction:  “Copies to be taken for:” and 
then there are three boxes:  “Our Departmental patient’s notes”;  “Patient’s Brompton 
Hospital folder”;  and “Accounting file.” 
A 
Yes, that is right. 
Q 
That was the intention. 
C
A 
Yes, it was.  That was the plan.   
Q 
In relation to these documents, at the moment we have about four separate categories 
of material:  the tapes themselves;  the printout (which could be 250 pages);  the log;  and the 
report.
A Yes. 
D
Q 
This case, in part at least, is about storage and transfer of documentation, so I must 
deal with this.  First of all, where were the tapes themselves stored? 
A 
In our department in boxes.  
Q 
Was it feasible to have the tapes themselves within – and it is an expression used by 
Mr Chapman – “the main library notes”? 
A 
No, because these tapes were heavy and sometimes multiple.  It would be impractical. 
E
Q 
Technology moves on, but between 1988 and 1992 what sort of tapes were they? 
A Reel-to-reel. 
Q 
They are probably obsolete now, are they not? 
A 
We have them and we have the recorder. 
F
Q 
But in terms of everyday uses now--- 
A 
Yes, it is mostly computer now. 
Q 
Where were the printouts kept? 
A 
In the box as well.  I think they were in a separate box, because they were even bigger 
than the tapes. 
G
Q 
But they were all stored. 
A Yes. 
 
Q 
We have just looked at a log by way of example.  Where was the log kept? 
A 
In the special case file. 
Q 
Was it ever intended that a copy of the log be put into the main library hospital notes? 
H
A No. 
T.A.  REED 
Day 10 -  10
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A
Q 
Why was that? 
A 
Because it required us to interpret it. 
Q 
When you say, “required us to interpret it” what do you mean by “it”? 
A 
The log of infant activity, the data on it, was relevant to what we were looking at on 
the tapes.  You could not interpret this without the tapes and the printouts.  But we did not 
B
stop the nurses keeping records of any events – in fact, the nurses were encouraged to keep a 
record of any events that were occurring.
Q 
That would go in the Kardex. 
A 
In the nursing Kardex in the main hospital record file. 
Q 
Fourthly, the question of the report.  Looking at page 144 as an example, where was it 
C
intended that document should be found? 
A 
It was intended to go in the departmental patient notes (that is, the SC file), the 
patient’s Brompton Hospital notes (that is, the main record)--- 
Q 
The main library file. 
A 
---and because at some point – and I cannot remember when – these patients were 
being charged for by the hospital, the managers received a copy of this for accounting 
D
purposes.
Q 
You have talked about the placing of at least the log and certainly a copy of the report 
in the departmental files – and you described them as special cases files.  That all brings us to 
this question: what was the underlying purpose of the creation of a special cases file? 
A 
Basically, the patients we were looking after were quite unwell, some of them – 
I mean, dangerously unwell – and at any time could develop difficulties, even in their local 
E
hospital or at home.   We needed a system that the nurse specialist, Martin Samuels or myself 
could find out quickly what was going on with the child.  Our experience at that time with the 
hospital records, although they did their best, was that it was not a particularly fast or reliable 
way of finding out details on a patient.  Having our own filing system like this meant we 
could rapidly, at any time, find out the details of the child.  That was one of the main reasons, 
but there are other reasons as well. 
F
Q 
Let us deal with those other reasons.  What were they?  I am dealing with 1988 to 
1992, but it may be that the reasons underlying it were in the period before that.   Deal with it 
in whichever way you wish. 
A 
Basically, because of the nature of our work, which was at the leading edge, if you 
like, of trying to understand these problems in children, we were writing up our results all the 
time.  We were presenting data at meetings, we were telling people what we were finding, so 
that it would help district hospital paediatricians better manage this kind of problem.  In our 
G
terms, that is “clinical audit” work;  that is, experiencing development work in children’s 
health which we felt we had a responsibility to publish. 
Q 
Did you use the SC files after they have been created to scrutinise and peruse for the 
purposes of the literature in which you were engaged? 
A 
Yes, we did.  It was the best way, because it was all together in one place, that we 
could get our hands on, to look at the data and analyse it.
H
T.A.  REED 
Day 10 -  11
 & CO. 

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A
Q 
Some children, I think we have heard in the case, had home monitoring facilities. 
A Yes. 
Q 
How necessary was it that you would have to have access to the notes on any given 
24-hour basis for such children? 
A 
There were two kinds of home monitoring devices.  One monitored a baby or child 
and set off an alarm.  The other recorded information during an event on to a computer disk.  
B
If that happened, say on a Saturday, the mother/family would be encouraged to contact the 
on-call doctor or nurse from our department and tell them what was going on.  Usually, if it 
was the recording type, the disk would come up and we would analyse it, or, if the event was 
particularly worrying, we would say, “Go to the local hospital now and we will talk to the 
hospital about transfer to come back to the Brompton.”  It is an emergency system.  To get 
hold of hospital records at the weekends and so on was really difficult; yet having this 
material was much easier.   
C
Q 
When the SC files were created and continued in respect of a particular patient, who 
had access to the SC file in a given case?  Would you just run through the people who had 
access.
A 
Predominantly it was the people in our department who had access.   
Q 
And you have referred to them. 
D
A 
Yes, but, if anybody wanted access from the hospital side (that is, either nursing staff, 
doctors, other consultants or administrators), they were there for them and they knew they 
were there.
Q 
When you say, “they knew they were there” can you be a little more specific.  How 
do you know that they knew they were there? 
A 
It was a constant dialogue between the children’s ward and us with each of the 
E
patients.  It was not as if these were coming in rarely.  These were coming in two or three a 
week – maybe more.  Sometimes we were occupying half the beds on the children’s ward 
because of the rate of referral.  Constantly we were doing recordings and collecting data.  The 
nursing staff and doctors on the ward knew what we were doing.  They knew about the filing 
system and how it worked.   
Q 
Again, this is a general question.  Within documents which were filed in what I am 
F
calling the “main library file” would you expect to find references to the existence of the SC 
files? 
A 
There would be the same number; that is the hospital number and the special case file 
number should be on all documents.  I recognise it is not in every case.  It should be.  That 
was the plan.  Being as it is, sometimes I did not fill them in, but usually there would be 
cross-references available in each patient’s main medical file.   
G
Q 
Thus far, when you have been dealing with the reasoning for the creation and 
continuation of the special cases files at the Brompton, you have not touched on the potential 
relevance of child protection issues as a rationale for the special cases file.  Is that, first of all, 
a reason for the creation or continuation of SC files or not? 
A 
When we started to get the child protection cases coming to us and we became aware 
of this problem, we discussed:  “How are we going to store this information?”  As each child 
with a child protection problem presented, you would have social services confidential 
H
documents coming to us on a regular basis, and we were aware that there were some major 
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A
reasons why these documents needed to be kept in a highly confidential way, not the least 
because of the covert video surveillance.  In other words, if we had a strategy planning 
meeting about a child--- 
Q 
When you say “we”, who is the “we”? 
A 
Led by social services, but including the children’s unit staff, our department staff, the 
police.  The minutes of that meeting went into the main hospital file and in it would be a 
B
recommendation that we were going to do, say, covert video surveillance.  If that linked to 
the parent involved, it could be dangerous.  There was all manner of reasons why we felt this 
material should be in the special case file in our department, away from the ward area but 
known about. 
Q 
Did members of your department and ward staff know, as far as you are concerned 
about the repository of – using this in a broad sense – child protection material within the 
C
special cases files? 
A 
Yes, they did. 
Q 
How many special cases files do you think, looking back, were in existence by 1992. 
A 
I do not want to guess.  There is an answer, probably, by looking at the computer.  It 
is over 1,000, I would think. 
D
Q 
I was hesitant to go to the computer because the evidence about the computer – at 
which we will look – relates to a current figure. 
A Yes. 
Q 
I wanted to know if you could estimate. 
A 
I think about 1,000 but it is not accurate.  (Pause)  Actually, it is more than 1,000, 
because for [Child A], what we were just looking at, it is ‘SC1209” which suggests more than 
E
1,000.
Q 
I see.  It ran in numerical order. 
A 
Yes, it did.  Because this was 1987, it could be a lot more. 
Q 
If the precise figure becomes relevant, we can look at it, chairman.  At the moment, a 
significant number:  over 1,000 by 1992. 
F
A Yes. 
Q 
Can I look with you, please, at the question of computers at the Brompton. 
A Yes. 
Q 
Did the department have a computer in the period 1988 to 1992? 
A 
I think this is where my memory is not going to be very good.  I think so but I am not 
G
one hundred per cent sure how much data was going into it compared with later.  I think we 
did, yes. 
Q 
Did the hospital have its own computer system? 
A Yes. 
Q 
Insofar as you have a computer system in the department, was that linked to the 
H
hospital computer? 
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A
A No. 
Q 
What data do you think would have been stored on the stand-alone computer in the 
department? 
A 
I think it would be the basic information about the patient:  name, date of birth, 
referral details, GP, referring consultant – that kind of data – plus the result of the recording 
data.
B
Q 
Who would have had access to that stand-alone computer in the department? 
A 
Department staff only.  My department team. 
Q 
You have described the members of that team. 
A Yes. 
C
Q 
What was the purpose of storing that data on the computer in the department at the 
Brompton when you had hardcopy material or, indeed, hard original material – and we will 
look at that in a minute – in the SC file itself? 
A 
I think we were in the process of developing the database, so that, for instance, if you 
had a diagnosis of Down’s syndrome you could go to the computer and call up all the  
numbers in the special case files that were children with Down’s syndrome and then you 
could pool those special case files and do your clinical audit.  That is what we were 
D
developing but I cannot remember when we developed the database. 
Q 
Would the hospital computer system at that time do that task for you? 
A 
Possibly, but not as well.  The hospital was dealing with paediatric cardiology as well 
as paediatric respiratory disorders and therefore what was entered into the fields, if you like, 
in a database would be different from what we would want to enter into the fields on a 
database.  The answer is that it could possibly have helped you, but not as precisely as what 
E
we were trying to develop over time.  
Q 
Could you take C3, tab 7(d)(i), page 75.  It is the Jawad letter, written or at least 
signed by Dr Jawad on 14 December 1990 under the heading of the National Heart & Lung 
Institute.  I have not asked you about that.  How did that have a relationship with the 
department that you have been discussing? 
A 
That was the research wing; the hospital was the clinical wing.   
F
Q 
The institute was physically situated within the Brompton Hospital site, was it? 
A 
More or less: across the road a bit and early on. 
Q 
It was copied to you and to the ward clerk of the Rose Ward.  Is that the children’s 
ward? 
A 
Yes, it is. 
G
Q It 
reads: 
“…following discussion with Dr Southall, it was agreed that all the cases admitted for 
overnight monitoring…” 
Pausing there, is that the sort of physiological report you have discussed? 
H
A 
Yes, because most of them needed only one night recorded. 
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A
Q It 
continues: 
“…will not require any discharge summaries except for the complicated cases which 
require further procedures and management.  Dr Southall is quite happy with a copy 
of the computer sheet which usually sufficiently states the aim of the admission and 
the possible diagnosis and the recommendations.  The computer sheets are usually 
B
typed and provided by Dr Southall’s department which should be filed in the notes by 
the Ward Clerk.” 
There are three matters I would like to ask you about.  First of all, the reference to “the 
computer sheet” rather suggests that there was a computer in 1990 at the Brompton.  Does 
that suggest a departmental computer? 
A 
Yes, that is our one.   
C
Q 
What are the computer sheets to which Dr Jawad has referred? 
A 
One of them is what we have already seen, the result of the recording sheet. 
Q 
That is the report. 
A 
The report.  The other is a summary of the child’s information – a bit similar to what 
is in the main hospital file already. 
D
Q 
Then it says that these documents “should be filed in the notes by the Ward Clerk”.  
Which notes do you think Dr Jawad was talking about? 
A 
The main hospital file. 
Q 
Would you help us about the concept of a ward clerk.  What does a ward clerk do? 
A 
They sit on the ward near the nurses’ station and are responsible for keeping he main 
E
hospital medical records file up to date with all the results in . 
Q 
Would you expect the ward clerk from time to time to know of the existence of the 
special cases files? 
A 
Yes.  All the time. 
Q 
Did you approve of the content of this letter by  Dr Jawad? 
F
A 
Yes, that is my handwriting.   
Q Whereabouts? 
A 
All of the handwritten parts are mine. 
Q 
During the period we have been looking at, 1988 to 1992, did you or, to your 
knowledge, any of your clinical colleagues in the department have experience of a problem in 
G
access to material in the special cases files which might not have been in the main hospital 
library file? 
A 
I cannot remember, no.  No, I cannot remember anything. 
Q 
Did any problem ever arise in relation to consultants/clinicians from other hospitals 
having a problem getting to know about the full picture of a child’s clinical treatment and 
investigations up to any particular date? 
H
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A
A 
I cannot remember any, but, of course, there are hundreds of patients going through 
and it is possible that, for instance, a referring consultant might not have received a report.  
That happens all the time.  They would have rung up and we would have sent them one.  
I cannot say it did not happen.  I cannot remember it but it probably did happen occasionally 
that there were problems with data. 
Q 
Was any specific problem referable to the existence of a special cases file? 
B
A 
No.  This was over the whole, both the hospital medical files and the special case 
files.  You would of course occasionally get problems in the post or if something went astray 
and a doctor wanted to know about it. 
Q 
We come to 1992.   We have heard the department closed. 
A Yes. 
C
MR COONON: There is a reference in the document. 
MR TYSON:  It is not important, but we have not heard.
MR COONON:  The documents are before the Panel.   
(To the witness):  The department closed, is that right? 
D
A 
Yes.  That is very important.  It did close.  When I moved, the department closed.  
There was no further activity in the Brompton Hospital at that time in that sphere of clinical 
activity. 
Q 
When you say the department closed, what do we understand by that?  Closure can 
possibly mean many things, you understand. 
E
A 
We had, by the time I left the Brompton, a large number of patients being referred on 
a regular basis to us as a tertiary centre. We had a lot of equipment, monitoring, recording 
equipment, data files, everything, that when I got the job at Stoke it was agreed with the 
managers at the hospital that I could take this equipment with me.  You are talking about, you 
know, many hundreds of thousands of pounds worth of equipment which belonged to the 
Brompton Hospital.  So there were lots of discussions around that time, which I cannot 
remember in detail but I know happened, about us being allowed to take all of this with us, 
F
because nobody was going to be left at the Brompton Hospital who could use any of it. 
Q 
Let us just pause there, and I am going to break this down.  Did all or some of your 
staff at the department in Brompton relocate to Stoke? 
A 
All of them, including the nurse and the secretary. 
Q 
The work of the department, was it then, as it were, transferred or absorbed into 
G
another department, or another part of the hospital of the Brompton, as far as you know? 
A It 
stopped. 
Q 
Now, in terms of the equipment, let us break that down.  What sort of equipment went 
from the Brompton to Stoke? 
A 
All the home monitors and event recording equipment, the tape recorders that were 
used to collect the physiological data, the printers that printed it out, the computer with the 
H
data in it, the special case files that were part of the – and I should point out that some of the 
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A
patients moved with us, quite a lot actually moved to Stoke, because this was a tertiary 
hospital in the Brompton, and when we moved to Stoke it became a tertiary hospital for the 
purposes of this kind of patient. 
Q 
It may be obvious, but patients of course remained at their home addresses, the 
referral base shifted? 
A 
That is right, because they still have the district general hospital in, say, I do not 
B
know, Winchester, or something, and we continued to look after them as if we were still at 
the Brompton but now we are at Stoke. 
Q 
When this move was taking place, did you personally have regard to any protocol or 
any policy governing the removal of notes or equipment at that time? 
A 
No, I did not, I did not know of any. 
C
Q 
If you can be a little bit more precise, when did that physical removal take place? 
A 
I think it was June 1992.  Over the period of a week a big lorry, you know, like a 
house move, came and moved all our stuff from the Brompton to Stoke. 
Q 
In the special cases files at that time, and this is a general question now, would there 
have been therefore the logs completed by the nurse and/or parent? 
A Yes. 
D
Q 
Would there have been other material which was not in the main library file? 
A Yes. 
Q 
Did you perceive there to be any problem in relation to the fact that there was material 
in the special cases file which was not in the main library file? 
A 
I did not at the time.  I can see now that there are some issues about this, but at the 
E
time I did not consider that was a problem back then, and once we separated from the 
Brompton to go to Stoke there would be no further contact, if you like, between the 
Brompton Hospital and those patients in terms of the disorders I was dealing with. 
Q 
Again, can you estimate how many of the patients who had been referred to you at the 
Brompton, as a tertiary centre, then, as it were, using your phrase, went with you to Keele, to 
Stoke? 
F
A 
There were two types of patient:  one is those where we are continuing to provide 
clinical input, clinical input, such as say a child with very severe episodes needing drug 
treatment or home monitoring, and then there was the child protection group, where we 
would continue to need to be in touch with the courts, or social services, about them at that 
time. 
Q 
Did Dr Samuels know of these matters, as far as you were aware;  did it extend to the 
G
same as your knowledge? 
A 
No, I do not think it did, because when he came to North Staffordshire he became a 
consultant, but prior to that he was senior registrar in my department, and therefore the 
responsibility at that time was mine rather than his, because he was not a consultant, he was 
still a doctor relatively junior – he is a senior doctor but relatively junior;  he is called a junior 
doctor.
H
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A
Q 
Your appointment at Stoke, first of all, was that straightaway as a consultant 
paediatrician at the University Hospital? 
A 
Yes, it was. 
Q 
Was that associated with you being appointed as Foundation Professor at the 
University? 
A 
Yes, it was. 
B
Q 
Just help the Panel insofar as it is necessary, was there a medical school at the 
University of Keele at that time? 
A 
A postgraduate medical school only, not undergraduate. 
Q 
The foundation professorship was in respect of what academic discipline? 
A 
Paediatrics, research more than education. 
C
Q 
There is one further document I would like you to look at whilst we are still in the 
Brompton arena.  Go back to C3, please, to the same tab we were looking at before, C3 
7(d)(i), just to look, please, at page 3.  Again, it is a document we have looked at before.  Is 
that a Brompton document or a Staffordshire document? 
A 
I suspect it is Staffordshire--- 
D
Q 
Right, we will come back to that. 
A 
---but I cannot be certain.  The reason I suspect is because Dr Samuels is listed there 
not as a research fellow or registrar but in the same category as me, so I think he was a 
consultant, so I suspect it is Stoke, but I cannot be sure. 
Q 
If you just turn over the page to page 4, that clearly is a Stoke document and we may 
look at that later on. 
E
A Yes. 
THE CHAIRMAN:   Mr Coonan, could we look for a convenient point for a short break in 
the near future. 
MR COONAN:   Madam, that is a perfect time, if I may say so. 
F
THE CHAIRMAN:   Thank you.  Can we take fifteen minutes.  Dr Southall, you have heard 
me say many times to witnesses that while you are on oath you may not discuss the case, and 
I give you that reminder. 
(The Panel adjourned for a short while)
THE CHAIRMAN:   Mr McFarlane wants to make a short personal statement arising from 
G
what was heard before the adjournment. 
MR McFARLANE:  Thank you, Madam Chairman.  From perusal of Dr Southall’s 
curriculum vitae, I looked down the list of dates and I wish to announce that in January 1987, 
and I finished at the end of January 1987, I was working as an orthopaedic registrar in that 
part of the world, and my duties included an out-patient clinic on Monday mornings and an 
operating theatre session on Friday mornings at Crawley Hospital.  Outwith those times I was 
H
working at the hospital up the road, the new East Surrey Hospital.  I had no duties within the 
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A
actual main body of the hospital, including the children’s wards, and at no time did I ever 
come across or meet or in fact hear of Dr Southall.  Thank you. 
THE CHAIRMAN:   I trust that statement does not in any way affect you, but we felt it was 
appropriate for it to be made. 
MR COONAN:   I am very grateful.  Thank you very much. 
B
MR TYSON:   I am equally grateful to Mr McFarlane, and in no way would the complainants 
seek to have him having to recuse himself from the Panel in the light of that. 
MR COONAN:   Dr Southall, we were dealing with matters of a general nature at the 
Brompton as to the provenance of special cases files generally.  Can we see, please, how you 
dealt with this in your solicitor’s letter of observation.  If you turn to C2, tab 6(c).  This is an 
C
extract from the letter of 24 January 2006, although the date does not appear on the document 
in front of us but it is in fact 24 January 2006, and if you go over the page to the top of page 9 
you will see the first paragraph beginning: 
 
“Professor Southall first started using Special Case ….. files in about October 1980.” 
A Yes. 
D
Q 
Then there is a series of passages culminating on page 11 at the end of the penultimate 
paragraph, do you see that? 
A Yes. 
Q 
Ending with the move to Stoke. 
A Yes. 
E
Q 
Now, I am not going to take you through this in detail, but does the summary at pages 
9, 10 and 11 encapsulate the evidence that you gave this morning as to the provenance and 
reasoning for special cases files? 
A 
Yes, it does. 
Q 
I should add, if you go to the bottom of page 12 of the same document, right at the 
F
bottom the writer says: 
 
“Thus, Professor Southall used Special Cases files in two situations: 
1.
To keep documentation relating to the specialised monitoring of 
children that he was undertaking.” 
G
Was that true? 
A Yes. 
Q
“In our submission these documents were not part of the usual medical 
records of the patient and it was entirely proper for them to be kept 
separately.”   
H
Can you comment about the formulation there set out by your solicitor? 
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A
A 
Yes.  The main hospital records, say at the Brompton Hospital as we were talking 
about, consists of the clerking of the patient by the doctors, the nursing Kardex, the basic 
structure of a hospital admission - I would say you could use the term “usual”, or “main” 
medical file I think was used this morning earlier.  Our documents, we regarded them as 
different and totally related to what we were doing, and to help us with clinical audit and 
clinical management, particularly in emergencies. 
B
Q 
When the solicitor says “In our submission these”, the word “these”, what was 
intended for that word to refer to? 
A 
The log of infant activity charts, special documents that were completed to help with 
our clinical audit, for example patient data forms, which are asking specific questions, not 
general questions that a clerking doctor would ask, but specific question, for example if you a 
had a child with suspected upper airway obstruction there would be some specific questions 
we would want answers to that would help us write papers on the subject.  The child 
C
protection, in those cases where we were involved in child protection, it would include all 
documentation with regard to child protection, and if for instance a patient became a child 
protection patient, that would be a sea change, if you like, in the way we looked after them.  
This would then become very different to all the other much larger number of clinical 
patients. 
Q 
If you look at the second point you say, or your solicitor says: 
D
 
“To store confidential documents relating to child protection issues.” 
What was intended to be conveyed by that sentence? 
A 
That we had a policy that all documents that related to child protection went in the 
special case files, because they were highly confidential and we could not afford them to be 
looked at by anybody who did not have a direct reason to look at them. 
E
Q 
Over the page, top of page 13, you say, the first three lines: 
 
“…staff working on the unit knew of the existence of the Special Case files and could 
have obtained access to them 24 hours a day via the on-call member of Professor 
Southall’s team.” 
F
Then just to help the Panel the next paragraph deals with Stoke, and I will leave that for the 
moment.  Dr Southall, as I say, I am not going to take you through the body of pages 9, 10 
and 11.  The Panel of course can read it and you can be asked further questions about them if 
necessary, but you have told the Panel that that in effect summarises the background to the 
creation of these files. 
A Yes. 
G
Q 
I want to come on, please, to two specific cases that the Panel are concerned with, 
Child A first, and it is in the context of documentation and special cases files.  This is a 
Brompton patient only. 
A Yes. 
Q 
Now, to set the scene, can we just refresh our memories, please, by taking C2, tab 3, 
and just to refresh our memories and also for you to comment where appropriate as to your 
H
involvement and your team’s involvement with Child A. 
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A
A Yes. 
Q 
Can we start, please, at C2 3(d).  This is a letter from Great Ormond Street to Dr 
Warner at the Brompton, and we heard evidence that, because at that sage you were not, as it 
were, a full-time paediatrician, the patient was admitted nominally under the care of Dr 
Warner, is that accurate? 
A 
Yes.  We were both involved, but he was nominally the consultant clinical 
B
paediatrician. 
Q 
Do you remember Child A? 
A 
Yes, I do. 
Q 
I am just going to take you through briefly the relevant notes for you to comment 
where appropriate.  The Panel of course are able to read these for themselves.  There is a 
C
letter of referral.  Is there anything you want to say about that? 
A 
Only the timing I suppose.  This was shortly after we had been involved in child 
protection work, and I think the word was out that we had some facilities which could help 
sort out these difficult type child protection problems, so I think that part of the referral 
related to our clinical physiology work but also our child protection work. 
Q 
If you go to the third page, you will see under “Opinions”, these are opinions 
D
expressed by Great Ormond Street, first Dr Brett and then Dr Wilson, and then this: 
 
“All consultants wondered about Munchauson-by-proxy.” 
A Yes. 
Q 
Did you become aware that a question mark had arisen about Munchausen by proxy? 
E
A 
Yes, I did. 
Q 
The child was in due course admitted.  If we go to the next tab, which is (e), there are 
clerking notes at the top of page 4:
“Transferred from [Great Ormond Street].   
Admitted for monitoring 
F
 
[complaining of] attacks of apnoea, deep unrousable state;  pallor, hypotonia 
and small pupils.” 
Then over the page, and these matters have been drawn to the Panel’s attention I think by Mr 
Tyson earlier, towards the bottom of page 5, again the history is summarised in relation to 
this child’s attacks.  Then on page 7, on 11 January, “minor episode observed”.  Then on 
page 10 a note, apparently by Dr Samuels, during this admission.  Then on page 11, on 29 
G
January, there is a reference to yourself, halfway down the page: 
“David Southall saw moderately severe episode from onset to completion.  No 
obvious neurological/respiratory problem.  ? significance of pupillary reaction – may 
be response to light/movement/noise, etc. 
 
Feels no need to perform further cardiorespiratory monitoring or video.” 
H
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Day 10 -  21
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A
Then the plan, again Dr Samuels’ note: 
 
“To [discuss with] Dr Leonard’s team” – that Great Ormond Street – “re:  probability 
of going home – support (medical/social) needed locally (?)” and then the locality is 
referred to. 
If you just keep your finger on that document and go to C5, please, and go to page 144, 
B
beginning at 144, are there a series of documents relating to this admission? 
A Yes. 
Q 
144 and 145.  The first one is a report and the second one the log.  Were these all 
produced during this admission? 
A Yes. 
C
Q 
Again, if you can just keep that to one side of you, please, and go back to the main 
notes in C2, I just note this in passing, on page 13, February, is there a note there in relation 
to the carrying out of an MRI scan, halfway down the page? 
A Yes. 
Q         I think finally to complete the summary picture of this admission, just please look 
briefly at C5 again, page 116.  This is a document which appears to be a medical report by 
D
you, signed by you, is that right? 
A         Yes, it is. 
Q         Dated 17 February 1987.  Does it reflect the results of the admission? 
A         Yes, it does. 
Q         I would like please just to take you to the last paragraph on page 117.  I do not think it 
E
is necessary to read it all out but I draw, through you, the Panel’s attention to the body of that 
last paragraph.  I do take to you the summary on page 118.  Can you just read out the 
summary into the record please. 
A         “[Child A] has episodes of--- 
Q         Do not use the first name, please.  
A         I am sorry. 
F
Q         Child A.
A         “[Child A] has episodes of sleep which are associated with pallor, difficulties in 
arousal and small pupils.  They do not affect vital functions and have not in any way 
influenced his development and are therefore harmless.  They are probably a normal 
variant of infantile sleep behaviour.” 
G
Q         Mr and Mrs A.
A         “... must now accept that their child is healthy and not seek further investigations or 
abnormal care procedures.  It is our opinion that this can best be achieved by family 
therapy.”  
Q         Thank you. 
H
T.A.  REED 
Day 10 -  22
 & CO. 

---

A
Having dealt with the summary of that admission, can I then come to the questions which 
will no doubt exercise the Panel.  First of all, when you moved to Stoke, did the main library 
record for Child A remain at the Brompton? 
A         Yes. 
Q         Did you take the tapes for Child A to Stoke? 
A         Yes. 
B
Q         When you told us earlier that the computer at the Brompton went with you to Stoke, 
so I am clear about this, would there have been, do you think, data in respect of Child A on 
that computer? 
A         Yes. 
Q         Did that go to Stoke? 
C
A         Yes. 
MR COONAN:  I want to concentrate, please, on the special cases file.  For these purposes, 
can you have in front of you Appendix One of the notice of hearing, but in its unamended 
state.  Do you have that next to you? 
A         No.  I have the amended version. 
D
THE CHAIRMAN:  Mr Coonan, I have to confess, I myself have disposed of my copy of the 
unamended version.  We considered it was no longer relevant. 
MR COONAN:  It may still be relevant in terms of background history and it may be useful. 
THE CHAIRMAN:  I see I can view a copy anyway. 
E
MR TYSON:  Before this witness is asked to answer these questions, can I just have a word 
with my learned friend because Appendix One has been a living document and I just wonder 
which version of Appendix One he wishes to have.
MR COONAN:  Yes. (Pause)
My learned friend has cleared up the position.  I did not know what document you had had at 
F
the beginning of the inquiry.  It looks as if the Panel had at the outset a document which was 
rather lengthier than the current one.  It was the lengthy document I was going to ask you to 
look at now.  It was at that point that I think Mr Tyson said, “Hang on, wait a minute, which 
document does the Panel have?”  It is now clear you did have a rather more extensive 
document and I can see – if Mrs Lloyd will forgive my rudeness – the document is apparent 
that you have and that is perfect for my purposes. 
G
THE CHAIRMAN:  Unfortunately a number of us did assume that the heads of charge, 
having been amended, that that document was not required.  I know Mr Simanowitz also does 
not have a copy. 
MR COONAN:  It does not cause me a problem personally. 
THE CHAIRMAN:  If the old agenda could perhaps be put there to correct this. 
H
T.A.  REED 
Day 10 -  23
 & CO. 

---

A
MR COONAN:  It may help the witness.  It is Appendix One that I am concerned about.   
Dr Southall, you will see, I am just using this just---  
A         It has gone.  Sorry. 
Q         Sorry, the Appendix One of the old--- 
A         The old one has just on gone. (Pause)  I am sorry, my fault, it is at the back.  Sorry.  
B
Q         Dr Southall, I just want to address with you the material which was in the old version.  
I am going to call it the old version of Appendix One.  We will see in that there were five 
documents.  
A         Yes. 
Q         The assertion, and in fact you have admitted this in the formal admissions, D9, that 
C
there were certain original documents in the special cases file which were not in the main 
library file.  All right? 
A         Yes. 
Q         It is therefore helpful to look at those documents which in fact are not in the main file.
A         Yes. 
D
Q         There are four that I want to look at for the minute.  There are four infant activity 
logs.  The page numbers in the SC file, which is C5, are set out.  All right? 
A         Yes. 
Q         Can we just deal with them compendiously.  In a word or two, what was the reason 
why those physiological recordings on Child A were put in this special cases file but were not 
put into the main library file? 
E
A         Well in order to interpret the physiological recordings, you need the infant activity 
logs.
Q         Did that apply to each of those four infant activity logs? 
A         Yes. 
Q         I am not going to trouble to take you to the documents in C5, we have looked at two 
F
examples this morning already.  I do take you to one other document.  Can you have a look 
please at D9.  It is the admissions.  I will need to look together at some of these items.  Under 
case A, you will see the first four refer to log of infant activity.  Yes? 
A         Yes. 
Q         It is a fax.  I can lead on this, I am sure.  Those four documents are identical to the 
four which appear in the old Appendix One.  All right?  
G
A         Yes. 
Q         So we have dealt with those. I want now to look please at the correspondence which 
is in D9.  That consists of items 5 through to 9. 
A         Yes. 
Q         You have admitted that they are not contained elsewhere in the hospital medical 
H
records at the Brompton. 
T.A.  REED 
Day 10 -  24
 & CO. 

---

A
A         Yes. 
Q         In other words they were in the special cases file which you took to Stoke.
A         Yes. 
Q         Is there a global reason why those items of correspondence were put in the special 
cases file or are there individual reasons per document? 
B
A         There is a global reason. 
Q         Look at them in a minute.  What was the global reason for those documents being in 
the special cases file only? 
A         When a decision had been made that a patient was child protection patient, thereafter, 
clinical activity ceased and child protection activity began.  Any correspondence coming in 
after that date was put into the special case file. 
C
Q         I am going to ask you now therefore to look, in the light of your evidence, to the 
special cases file and look at the correspondence.  This is C5, for Child A.  It starts at 
page 92.  Since it is a letter from Dr Reading to you, obviously it is the original letter. 
A         Yes. 
Q         Again, in your opinion, was that justified in going into the special cases file? 
D
A         Yes.  It fitted with the global policy and it contains information about social services, 
wardship, and is from a consultant child psychiatrist. 
Q         The next document, page 115. I am following the sequence in D9.  Do you follow? 
A         Yes. 
MR COONAN:  This is a file copy letter from you to Dr Reading.  
E
THE CHAIRMAN:  I am sorry, which page is this? 
MR COONAN:  115.  You have accepted in the admissions that there is no copy of this file 
copy in the main notes.  Again, the reason for it being in the SC files? 
A         It is after the date of decision that it is a child protection case, no more clinical 
involvement, and contains information on child protection. 
F
Q         The next document please is at page 37.  This is a letter from Dr Leonard to you and 
therefore is an original letter. 
A         Yes. 
Q         This is not in the main library file.  You have accepted that in the admissions?  
A         Yes, I have. 
G
Q         What is the reason why it was in the special cases file? 
A         Because it was after the decision had been made.  In this case, it does not really 
contain anything about child protection as such but it was because of the policy that we – we 
did.
Q         On page 36, again can I have your comment please on that document? 
H
A         After the policy, does contain information related to child protection. 
T.A.  REED 
Day 10 -  25
 & CO. 

---

A
Q         Finally on page 35, again, in the CS files but not in the main file.  
A         After the policy, but this time I do not think there is anything in there really that 
relates to child protection. 
Q         On its face but, just help the Panel therefore, what is the rationale for it being in the 
special cases file? 
B
A         Because the decision had been taken, this was no longer a clinical case, it was a child 
protection case.  It could have gone into the main file as well, I have absolutely no problems 
with that.  It would not have done any harm or really would not have made any difference.  
The child would no longer be involved in care at the Brompton Hospital after that point 
anyway, so it did not contribute either way. 
Q         We just note in passing, on page 35, there are other examples, but I would use this to 
C
illustrate the point, we see some writing on the top right-hand corner, with initials.  
A         Yes. 
Q         Whose writing is that? 
A         That is my writing. 
Q         What does that writing in that form signify? 
D
A         It means that Dr Samuels, MS, should have a copy or have seen a copy and it should 
go into the SC file.  Is it 1209?  I cannot remember for certain. 
Q         Yes. 
A         Okay, so that is the number, although that is not my writing. 
Q         The number is not your writing? 
E
A         No.  No. 
Q         The number 1209 appears, and I think we have seen it already, on the physiological 
recording document.  
A         Yes, that is right. 
Q         So you are right.  The Panel will be obviously keen to know whether this 
F
correspondence went into the special cases file, placed there either directly by you, at your 
direction, or on your behalf. 
A         Well it would not be by me, so it would have to be either on my direction or on my 
behalf but it was not by me. 
Q         Do you accept that it was placed on your behalf? 
A         Oh yes, yes.
G
Q 
The next aspect to this which I am going to ask you to deal with concerns the MRI 
report, which is the last item in the admissions D9 and also appears in the notice of hearing in 
bundle versions.  Perhaps we could start this sequence, please, by looking, first of all, at C5, 
page 131.  Do you have that? 
A 
I do.  
H
Q 
If you turn the page, you will see in our bundle an exact photocopy. 
T.A.  REED 
Day 10 -  26
 & CO. 

---

A
A Yes. 
Q 
The position about this can perhaps best be illustrated if you now produce the original 
SC file and turn up what we see in our bundle.  (Original SC file handed to the witness)  For 
the record, the SC file in its original form is in a pinkish folder.   
A 
Yes, it is. 
B
Q 
On the face of the folder is there anything written? 
A 
Yes.  It says “Child A.  Original papers from special case file 1209.” 
Q 
Would you turn in your bundle C5 to the very first page.  Is that a photocopy of the 
face of the folder of the file? 
A 
Yes, it is. 
C
Q 
Is that your writing? 
A No. 
Q 
Would you open the file, please, and take out any documents which bear on the 
physical MRI report. 
A 
Which bear on it? 
D
Q 
Any document which appears to be an MRI report.  (Pause)
A 
Yes, I have those two pages. 
Q 
From your standpoint, does one appear to be a copy of the other? 
A 
Yes, the second one appears to be a copy. 
Q 
As to the first one which you have, does that appear to be an original? 
E
A 
Yes, I think it is original. 
Q 
Why do you think it is original? 
A 
It looks like the original ink for the signature. 
Q 
So far as those two documents are concerned, either the original or the copy, did you 
intend that either or both of those two documents should be filed along in the special cases 
F
file? 
A 
No, I did not. 
Q 
Where did you intend or anticipate that the MRI report should be filed? 
A 
The one that is the original signature should be in the main hospital medical file.  The 
copy could have been in the special case file 
G
Q 
Do you accept the proposition that the original report should have been in the main 
library file? 
A Yes. 
Q 
As a matter of pure fact, does it appear that these two documents went within the 
special cases file – in the folder, perhaps, or the special cases file – to Stoke? 
A Yes. 
H
T.A.  REED 
Day 10 -  27
 & CO. 

---

A
Q 
Did you know at that time, when it was removed to Stoke, that it contained the MRI 
report in the special cases file alone and that it was not in the main library file? 
A 
No, I did not. 
Q 
So far as the Brompton computer is concerned, would you help the Panel about this.  
As far as you understand it, would there have been a copy or a representation of the MRI 
report on either the hospital computer or the academic department computer or both? 
B
A 
There certainly would not have been a copy in the department’s computer.  There 
would be no reason for that at all. I cannot recall the systems in place at the Brompton with 
regard to it being on their computer system.  The first I heard about it was with Mr Chapman.  
I always thought, though, that X-ray reports go inside the X-ray folder as well as in the notes.
In any hospital I have worked in, you have both the X-rays themselves, the images, and a 
report in the folder as well as a report in the notes. 
C
Q 
Speaking generally, would any report that goes in the folder be an original or a copy? 
A 
I think it would be original.  There would be one original in the notes and one original 
in the X-ray folder with the images. 
Q 
There can be more than one original? 
A 
Yes – in my experience. 
D
MR COONON:  Madam, I do not know whether you would like to see those two documents.  
You have not seen them before in their present form. 
MR TYSON:  Madam, I am perfectly content that you should look at the two.  Taking into 
account the fact that it is admitted one is an original and one is a copy, you are not being 
asked to look at them in the role of handwriting experts or the like.  I do not want you to use 
any expertise that you might have; it is just commonsensical, I think, in virtue of the 
E
admissions.  You are not being asked to do a forensic task, I suspect, but it is admitted that 
one looks more original than the other because of the handwriting. 
MR COONON:  I would simply want the Panel to see the documents.  It is convenient to do 
that now.  I an not asking them to adopt a role of pathologist or handwriting expert at all.
You may be interested; you may not. 
F
MR TYSON:  I am encouraging you look at them. 
THE CHAIRMAN:  We would like to look at the documents.  We accept Mr Tyson’s caveat.  
(Same shown to the Panel and returned to the witness)
MR COONON: Given the fact that it was never intended by you that this should ever appear 
alone in the special cases file, do you have a comment to make as to how it got there? 
G
A 
I have no idea. 
Q 
The next matter in relation to case A that I would like to move to is for you to produce 
a small clip of entries from the original main library file at the Brompton for the purposes of a 
brief exercise.  (Bundle of documents distributed)  These documents have been photocopied 
by your solicitors and are taken from the main library file which is available in the chamber.
They are there simply, as it were, to demonstrate or not, as the case may be – and I would like 
H
you to talk us through them – references to the existence of a special cases file number within 
T.A.  REED 
Day 10 -  28
 & CO. 

---

A
the main records.   The numbers on the bottom of the pages in dark ink are the number within 
the main library file.  
A Yes. 
Q 
Have you looked at these documents yourself? 
A Yes. 
B
Q 
Just looking at the first one, page 36, we see a reference at the top to special case 
number.  
A Yes. 
Q 
On page 40 we see some writing.  Whose writing is that? 
A 
That is my writing.  
C
Q 
There is a reference, with the arrow:  “Hosp + S/C notes”.  What does that signify? 
A 
They are to go in both hospital and special case notes.   
Q 
When we see that sort of apparent instruction, to whom is the instruction being given? 
A Usually 
my 
secretary. 
Q 
Page 47, again whose writing is that? 
D
A 
That is mine. 
Q 
There is reference to filing in the hospital and special cases’ notes. 
A Yes. 
Q 
It is apparently twice in the notes, so I am told.  On page 61, if you look at the top 
right hand corner, it is somewhat cut off on the photocopy, and you will need to look at the 
E
original if necessary, do you see the top right hand corner? 
A 
I do not think that is my writing. 
Q 
No, but do you see a reference there? 
A Yes. 
Q 
Again, can you help us;  you may have to look at the original. 
F
A 
“S/C [Child A]”.  I suspect it is that. 
Q 
Do you recognise the writing? 
A No. 
Q 
Page 78, there is some writing in the top right hand corner, whose writing is that? 
A 
That is mine. 
G
Q 
It says “File” and then “[Child A]”, does it? 
A Yes. 
Q 
“[and] in hospital notes”;  what does that signify to anybody who was receiving that 
instruction? 
A 
Well, that particular instruction means put it in the hospital notes, the main hospital 
H
file. 
T.A.  REED 
Day 10 -  29
 & CO. 

---

A
Q 
It says “File ‘[Child A]’ [and]” – is that an “[and]”? 
A 
Yes.  I do not know whether it means and it is for that Child A, or and it is in addition 
to going in the other special case file, I do not know. 
Q 
Page 102, in the middle of this document, which is in the main library, with a special 
case number. 
B
A Yes. 
Q 
Similarly on 104, 105, 106, 107, 108, 109 right through to the end to page 112? 
A Yes. 
Q 
Now, when the SC file was taken to Stoke for Child A in 1992, would any specific 
person at Brompton know that this file was now to be found at Stoke? 
C
A 
I just cannot remember who would know.  There were lots of discussions about the 
move.  I cannot remember the details and I do not have any correspondence left about it.  So 
somebody would have known, but I cannot say who it is and I cannot prove it because I do 
not have any correspondence that links it to anybody at the Brompton. 
Q 
Now, when this file, Child A, together with all the other special cases files arrived at 
Stoke, who at Stoke at that time in 1992 knew that there were all these special cases files 
D
coming from Brompton? 
A 
The managers in the child health department would know. 
Q 
Is that the university or the hospital? 
A 
Oh no, not the university at all, only the hospital.  So the managers at Stoke, and 
obviously I brought the whole team with me so they knew already, but as far as the Brompton 
Hospital special case files are concerned, I think I got a new secretary as well as my old 
E
secretary when I came, I think I had my old secretary with me and another one already there 
so she would have known, and of course there were a number of patients who were 
continuing to be looked after, after our transfer, so if they came into hospital for treatment, 
then obviously the nursing staff would know. 
Q 
When the special cases file, and in particular this file for Child A, arrived at Stoke, 
where was it put for storage purposes? 
F
A 
Well, when we moved to Stoke we were given this Portakabin called the Academic 
Department of Paediatrics, which we are still in now, we are still in it, although--- 
Q 
When you say “given”, given by whom? 
A 
The hospital.  We are still in it now, although we are only in it for about two more 
weeks and it is going to be demolished, but we were given the whole of this, and at sometime 
after our arrival, and I cannot remember when, we had a special area set aside with special 
G
locks on it, codes, so you could only get into it if you had the codes;  it was a special room for 
sensitive material, and that is where the special case files were kept. 
Q 
Would that have included Child A’s file? 
A 
Yes, it would. 
Q 
Who knew about this secure area at Stoke? 
H
T.A.  REED 
Day 10 -  30
 & CO. 

---

A
A 
The managers, because they had to set it up, and remember, we were doing covert 
video surveillance, so there was lots of reasons for this at the time, so they knew all about it, 
that we had the special case files in this room.  All the staff in the department knew.  The 
nursing staff on the wards, senior nursing staff, who were involved in looking after our 
patients clinically knew, the ward managers and senior sisters. 
Q 
Knowing about the existence of the room on the one hand, what about actually being 
B
able to gain access to the room if necessary on the other? 
A 
The nursing staff on the ward would not be able to.  The only people who could,
I think, at that time, would be Martin Samuels, myself, the clinical nurse specialist, two 
research fellows, two secretaries. 
Q 
Did the Child A file, as far as you know, remain in that secure area throughout the 
period we will come to look at later, in other words 1992 to 2006? 
C
A 
I can say that with one exception;  I do not know what happened during the period
I was suspended.  In fact, I am pretty sure the child protection special cases files were taken 
out of there for a while. 
Q 
For what purpose? 
A 
Well, there were enquiries going on into the child protection work--- 
D
Q 
You referred to that at the beginning of your evidence. 
A 
Yes.  So I think these files on child protection were probably taken.  I think they were, 
but I cannot be sure, although there is evidence in one of them that there is some complaint 
material which I had not put in it, obviously. 
MR COONAN:   Madam, I note the time.  Would that be a convenient moment? 
E
THE CHAIRMAN:   If that is convenient for you it is convenient for us.  So we will take an 
hour, which, by that clock, is five past two. The usual warning applies about speaking about 
the case. 
(Luncheon adjournment)
MR COONAN:   Dr Southall, before the adjournment I was asking you about the location of 
F
the Child A special cases file, which is a Brompton file. 
A Yes. 
Q 
I asked you about the intervention of the inquiry, and what might or might not have 
happened to this file during that period, during the suspension.  When you returned to work, 
did this file, Child A’s file, remain on the premises in the department in Stoke, or was it 
removed? 
G
A 
I cannot remember where it was, when I first found it again, so to speak, I cannot 
remember where. 
Q 
No, but did it remain there from 1992 until 2006 in the Academic Department, or was 
it elsewhere? 
A 
I think some of the time it went somewhere else, I think. 
H
Q 
This being a Brompton case, what happened to all the Brompton SC files? 
T.A.  REED 
Day 10 -  31
 & CO. 

---

A
A Oh 
right. 
Q 
Did they remain in the Academic Department, or what? 
A 
I cannot remember the date, but the Medical Director at the Trust at some point, and
I think it was mid-2000’s, so 2003, that sort of time, asked me to remove all material from the 
Brompton Hospital, including special cases files, tapes, any printouts that we had, from the 
Trust’s premises. 
B
Q 
Was there a reason given for that? 
A No. 
Q 
Did you, as it were, accede to the request? 
A 
I did object.  I said that I thought these were important records that should be in the 
hospital, and I cannot remember the discussions but eventually I “gave in” and moved all the 
C
special case files to another place, secure place, but I absolutely refused to remove the tapes.  
I cannot think that there any paper records left by then, because I think they had been 
destroyed, but the tapes I was pretty resistant about that, because they deteriorate;  if you 
leave them, say, in a warehouse or somewhere cold and damp, they could go off;  paper, less 
so.
Q 
So where did the tapes remain following that request? 
D
A 
In the Academic Department, but they are not in the secure room, the tapes, I think 
they are in the room next to it. 
Q 
Were those tapes seen when Ms Ellson went to the hospital at the end of October this 
year?
A 
Yes, yes, she saw them.  No, wait a minute, not on that case she did not, because we 
could not find the--- 
E
Q 
I am talking about the tapes generally. 
A 
Oh, the tapes generally, yes, but in regard to Child A we could not find the tapes. 
Q 
You mentioned that the SC files had been removed following a request in about 2003.  
Where did you remove them to? 
A 
I am not totally keen on answering that question exactly and precisely, because it will 
F
reveal where they are.  It is difficult to explain why.  I did put them in a secure place, but I 
worry about the security of them, so if I tell you where they are, then everybody is going to 
know and I am not keen on that. 
Q 
Are they still there? 
A 
No, they are not;  they are not in the hospital, no. 
G
Q 
No.  Are they still in the secure place that you are now describing? 
A 
Yes, they are in the secure place, yes, but I am anxious, unless you really must  
know---
Q 
Just pause for a moment.  We are talking about the Brompton files, the special cases 
files. 
A Yes. 
H
T.A.  REED 
Day 10 -  32
 & CO. 

---

A
Q 
As you speak, they are in a secure place. 
A 
Yes, they are, yes. 
Q 
How many SC files are there? 
A 
Well, over a thousand, as I said earlier.  I do not know exactly. 
Q 
In respect of Child A’s SC file, was that removed by you at one stage following the 
B
request by the Trust? 
A 
No, that never went into the secure place.  I think it was still with either the 
complaints department or somewhere in the Trust other than in with all the rest of them. 
Q 
I want to go back specifically to Child A’s special cases file, and we know that there 
were requests for disclosure of that file by Mrs A. 
A Yes. 
C
Q 
Could you turn up, please, C2, tab 3(b), and start at page 6.  Dr Southall, I am not 
going to take you through the whole of this clip of correspondence, I am just going to ask you 
to look at the letters passing between you and Mr Chapman. 
A Yes. 
Q 
So therefore we start at page 6.  Did you become aware, when you received the letter 
D
of 26 March 1995, of a request for disclosure? 
A Yes. 
Q 
I direct your attention to the first paragraph, where Mr Chapman, in rehearsing the 
history, and I take you to the third line, says: 
 
“You gave consent to disclose the medical records to his solicitors in April 1991 and 
E
Norton Rose [the Trust’s solicitors] were instructed to represent the Hospital.  You 
also wrote a medical report, a copy of which I enclose.” 
Do you remember giving consent to disclosure in 1991? 
A 
I have seen a document, I think, about it, but I do not remember it. 
Q 
You were still at Brompton at the time. 
F
A Yes. 
Q 
Then over the page: 
 
“I have been informed that you may have some records in your possession at the 
University of Keele relating to the treatment and care of certain children in Royal 
Brompton Hospital.  If you have the recordings requested by the solicitors ….. in your 
G
possession, would you please send them to me.” 
Now, pausing there, when you received that document, that letter, did you have a problem in 
acceding to a request for disclosure of those tapes, or the recordings? 
A 
Well, only in the sense that it would be very difficult for anybody to interpret what is 
on them. 
H
Q 
But in principle did you have any problem? 
T.A.  REED 
Day 10 -  33
 & CO. 

---

A
A No, 
no. 
Q 
Turning to page 9, please, you now responding to that letter, you say that you: 
 
“…looked through the records and identified 6 multichannel physiological recordings 
that we performed on [Child A].  These recordings involve physiological signals and 
because of storage, we destroy the paper version and retain only the taped version.” 
B
Was that true? 
A 
Yes, as best as I can recall, yes. 
Q 
Then page 17, this is you to Mr Jacques at Norton Rose: 
 
“I am sending by separate cover, as requested by John Chapman ….. the multi-
C
channel tape recordings on [Child A].  I have been assured by John Chapman that 
Norton Rose will ensure that the recordings are kept in good order and returned to this 
Department in due course.” 
Did you disclose the recordings at that time? 
A 
Yes, I think I did.  Again, I am not sure, I think I did. 
D
Q 
Then if you move to page 18, and if I can compress this to save time, there was a 
request in effect for you to disclose any medical notes that you were in possession of, 
although specifically referable to two specific dates, but leaving that aside did you have a 
problem about disclosing any medical notes or medical records held in the special cases file 
by you at Stoke at this time? 
A 
No, I have no problem with it, but I must say that, to be completely honest, I was 
concerned that the data in there might be not optimal as far as the child is concerned. 
E
Q 
When you say “data” what are you referring to? 
A 
Well, especially the child protection data;  in other words, my understanding of child 
protection data is it relates to the child and therefore providing such data to parents is always 
difficult;  you have got to be sure that, you know, it is appropriate.  So I think, and I cannot 
remember exactly what happened, but I think I sent only the clinically related material, not 
some of the very child protection related material, to Mr Chapman. 
F
Q         Maybe running slightly ahead.
A         I am sorry. 
Q         That is all right.  Let us now look at page 22.  This of course – if I just say for the 
Panel’s assistance – is also photocopied in the Panel’s bundle at C2, 6(a).  You say to 
Mr Chapman, in response to Child A, that you always kept your own medical records for all 
G
the special cases that you dealt with at the Brompton Hospital:   
“I have arranged for these to be photocopied and enclosed with this letter.” 
Then the rest of it, I do not think, matters.  The documents that follow within this tab, in fact 
at pages 24 through to 49.  Yes? 
H
A         Yes, yes. 
T.A.  REED 
Day 10 -  34
 & CO. 

---

A
Q         Were those documents sent to Mr Chapman? 
A         Yes. 
Q         The list that he made is at page 23. 
A         Yes. 
Q         Let us assume for present purposes the list is precisely in accordance with the clip of 
B
the records at pages 24 to 49.  All right? 
A         Yes. 
Q         Let us assume that for working purposes.  This clip of records here, at 24 to 49, is in 
effect, even in physical terms, with somewhat slimmer than the actual SC file that the Panel 
have in C5. 
A         Yes. 
C
Q         I am not going to carry out the quantitative exercise between the two but in so far as 
there is a difference, what is the reason for the difference when you disclose – what I am 
simply going to use this phrase – some of the SC files but not all of them? 
A         I would have to do the analysis but I think it is because the others are not strictly 
speaking my documents, they are social services or Family Court documents that really are 
different to what I have disclosed. 
D
Q         Did you make the decision to as it were photocopy and send some of them and for the 
others to remain behind? 
A         I think so.  I mean I cannot be sure because it is possible it was done at the other end.
In other words I could have sent all of them and Mr Chapman could have done that exercise, 
but I expect it was me that did that, but I cannot be sure at this stage. 
E
Q         Dr Southall, he does use the words, “List of documents sent by Professor Southall”, 
on page 23.
A         Okay, then it was me.  It was me.  
Q         Do you dispute that?  
A         No, no, no.  I think it was me. 
F
Q         When you sent the list, we see on page 23, you included at item 8, which is page 37 of 
the clip of records that was photocopied and sent to him, a copy of the MRI report.  
A         Yes. 
Q         How did you get hold of a copy of the MRI report to send to him? 
A         Well it must have been in the file. 
G
Q         So the Panel follow it, would you have accessed that pink file that you have looked at 
this morning? 
A         Yes.  That is what I probably would have done, yes. 
Q         Dr Southall, you have explained three things: firstly the creation; secondly, the 
transfer to Stoke; and thirdly, maintenance or maintaining the presence at Stoke in the 
circumstances you have described.  Did you think then, and secondly, do you think now, that 
H
there was any risk to Child A by the fact that you had the SC files in Stoke? 
T.A.  REED 
Day 10 -  35
 & CO. 

---

A
A         No risk at all to the child. 
Q         Can you explain to the Panel your reasoning for that. 
A         From the child’s point of view, once he had been discharged from our care at the 
Brompton, with a diagnosis of child protection concerns, he would not return to the 
Brompton Hospital as a patient at any time.  So that clinical risk, if you like, a risk of 
a clinical importance, I do not think there is one.  If you now turn to the child protection 
B
business, the people dealing with that were the Family Court, and the local paediatricians to 
wherever he was living at any specific time, and I know he did move around a bit.  So 
information on the child protection side would have followed him around through local 
hospital care, if he had needed hospital care, and my understanding is he probably did not, 
and so therefore it was family doctor care and the family doctor would be the key person 
involved in any medical aspects of child protection thereafter, not me.  So I do not think there 
was any risk on either clinical or child protection to Child A from us having a special case 
C
file on him. 
Q         You say that you did not think there was a risk.  Is that your view now, that there was 
or was not any risk?  Can you help the Panel.  
A         I do not think there is any risk, now or then.  I think this was a process that I thought 
was reasonably appropriate for this kind of situation:  difficult situation, no rules available;
but I thought this was reasonable.  I still do. 
D
Q         That is all I am going to ask you about Child A.  I am going to adopt the same 
approach and take it slightly more quickly in relation to Child H.  Can you please take C1 and 
begin at tab 2 please.  Dr Southall, I am going to deal with Child H again from the standpoint 
of the documents and I am going to summarise your involvement with Child H up to 1991. 
A         Yes. 
E
Q         Although, the Panel will realise, there was later involvement by you in this case. 
A         Yes. 
Q         Again can we summarise this please.  We open it at C1, tab 2, letter (a), with a letter 
from Dr Dinwiddie referring this child.  Purely to get your bearings in a minute, I refer you to 
the middle paragraph, the end of that middle paragraph in handwriting: 
F
“The question of Munchausen by proxy has also been raised”.  
Did you receive this letter? 
A         Yes, I did. 
Q         Was that writing on the letter when you received it? 
G
A         Yes. 
Q         Again, just if there is any doubt about it, is it your writing? 
A         No.  No. 
Q         The last paragraph:
H
“I would be very interested if you could see him and arrange the necessary further 
T.A.  REED 
Day 10 -  36
 & CO. 

---

A
investigations and advise in any other treatment which you think might be helpful in 
this particular situation.” 
Did you know Dr Dinwiddie at the time? 
A         Yes, I did. 
Q         Was he a friend of yours? 
B
A         We were friendly, we met at meetings.  Yes.  It depends how you define it, not outside 
work but inside work, yes. 
Q         With particular reference to the last paragraph, was that the sort of letter that you 
received either from him or from other referring paediatricians to you at the Brompton at that 
time? 
A         Yes, very similar. 
C
Q         At letter (b), we have the clerking notes.  On the third page a note by, it appears to be, 
Dr Samuels’ signature, following his admission in 1989.  We see about two lines up from his 
signature “rpt”, is that repeat? 
A         Repeat recording, yes. 
Q         With saturated oxygen and carbon dioxide normal.  Just help us briefly with the 
D
significance of that. 
A         The main problem that was being raised by the parents and also, to an extent, the 
hospital at Great Ormond Street was: could Child H have congenital alveolar hypoventilation 
syndrome, or Ondines, as it is sometimes called, which means that when he went to sleep, he 
did not breathe deeply or adequately enough; did he have it?  If he had had it, during sleep 
our recordings would have shown a fall in oxygen saturation, that is SAO2 would have 
dropped, and CO2, carbon dioxide would have gone up.  That did not happen. 
E
Q         If we turn to tab (c), you will see the summary following his discharge.  Do you have 
that?
A         Yes. 
Q         Dr Bush’s note. 
A         Yes, I have that. 
F
Q         “Overnight monitoring was carried out which was normal and the plan is to readmit 
him when he is actually having cyanotic episodes for repeat recordings.” 
Was that your plan? 
A         Yes.  When we first saw him, we heard that he was having frequent episodes where he 
G
needed resuscitation, and yet when we had him in hospital, he did not have any.  I think it 
was thought he might be having a good spell, so we decided to bring him back when he was 
in a bad time to see if we could document what was going on during these events. 
Q         As we know, he was readmitted.  If we turn now to tab (d), 15 March 1990, another 
clerking note.  If you look at page 9 at the bottom of that tab, the SHO has recorded, five 
lines up:  for overnight monitoring.  Again, was that the plan?
H
A         Yes, that was the plan. 
T.A.  REED 
Day 10 -  37
 & CO. 

---

A
Q         So we can complete this snapshot of what was going on, now turn to C2 please and go 
to tab (g).  This is a discharge note, again by Dr Bush, if we turn to the second page, which is 
numbered 22 at the bottom.  I am just summarising this and ask you a question on the basis of 
this.  Dr Bush notes that he was monitored overnight, the results will be sent on to you.  It is 
addressed to the doctors at the bottom.  Follow up will be by Dr Southall’s department.  Do 
you remember any of the treatment details of this patient, independently of what is in the 
B
records? 
A         No.  That is – I cannot, without referring to the records.  I have looked at the records 
so I now remember things but without the records I could not. 
Q         I think we should just flag up – for the Panel’s reference – the special cases file 
reference, which is C7, at page 72.  Is this a medical report that you did in respect of, first of 
all, the care and treatment that you had supplied – you and your team – to this child? 
C
A         Yes, it is a summary. 
Q         It is dated 27 June 1991.  For my purposes is the as it were – about the long stop date 
before the purposes of these questions. 
A         Yes, it is some time after the discharge. 
Q         It is some time after the discharge, quite right.  Does that summarise the care and 
D
treatment and also summarise the concerns, such concerns as you may have had for this 
child? 
A         Yes, it does, yes. 
Q         At that time? 
A         Yes. 
E
Q         Turn to the last page of it, page 76 at the bottom, I am not going to read all this out, 
this being a public hearing, but I just draw your attention to the beginning of the last 
paragraph, indeed the whole of the content of the last paragraph.  Yes? 
A         Yes, that is correct. 
Q         Obviously in due course invite the Panel to read that.  Did you have in relation to this 
child, child protection concerns? 
F
A         I did. 
Q         When did those child protection concerns first arise? 
A         Well, on referral, there was concerns raised in Dr Dinwiddie’s letter, we have just 
seen that.  The first admission, nothing happened in the way of an event, you know, 
a cyanotic event, and he had normal breathing during sleep, so that was a worry, given all the 
circumstances, and then when he came in the second time ---  
G
Q         March 1990.
A         --- there is this history that he is having frequent cyanotic episodes requiring 
resuscitation and yet on the night of the recording, again in the hospital, none were seen.
I think even the SHO put an exclamation mark at the end of his notes.  I have just noticed it, 
about that because it was unusual, given the frequency with which they were supposed to be 
occurring.
H
T.A.  REED 
Day 10 -  38
 & CO. 

---

A
Q 
I would like to come to the question of records against that background.  Did you 
create an SC file for Child H? 
A Yes. 
Q 
Why did you create that file for him? 
A 
Because he was one of the patients referred for sleep studies, or whatever you want to 
call them, to find out why he was having his multiple episodes.  It was like all the other 
B
patients being referred to us from other hospitals.   
Q 
In the SC file there are a number of  cardiorespiratory chart entries, which the Panel 
will see from the old Appendix One.  Could we look at them smartly:  pages 21, 22 and 23 of 
the SC file.  The cardiorespiratory monitoring activity for this child was filled in by whom? 
A 
The top part would probably have been filled in by either our clinical nurse specialist 
or possibly technician.  The bottom bit, where each event is occurring, would probably have 
C
been filled in by the nursing staff or the parents. 
Q 
Did this go into the special cases file deliberately? 
A 
Yes, it did. 
Q 
Again, take it shortly, if you can.  What was the underlying reason for it going in the 
SC file but not in the main file? 
D
A 
If an event had occurred, then we would have seen the time of it and the tape counter, 
and looked at the tape, specifically – you would look at the whole tape, but you would look 
specifically at the tape counter and the time, to see what is going on with the breathing and 
oxygen and heart rate activity.
Q 
Does that apply to pages 21, 22 and 23? 
A 
Yes.   
E
Q 
Is that the same reason? 
A 
Yes, the same reason throughout. 
Q 
Page 24 has been described as an “apparent cardiorespiratory chart” in the old 
Appendix One.  Is it a cardiorespiratory chart? 
A 
It looks as if they have run out of the pages and have used ordinary hospital notepaper 
F
to do it on. 
Q 
Would that have been placed deliberately in the SC file alone? 
A Yes. 
Q 
Then we go to pages 25-31.  This is called, in Appendix One, “A collection of clinical 
data forum” and you have accepted that this document is not in the main library file.  
G
A 
That is correct. 
Q 
In the Brompton notes.  It is only in the SC file.   
A 
Yes, it is . 
Q 
Should it be only in the SC file? 
A 
The policy was that it should only be in there, but it could have been in both.  There is 
H
information that could have gone into the main hospital records.  The purpose for the form is 
T.A.  REED 
Day 10 -  39
 & CO. 

---

A
to help with our clinical audit of such cases and the interpretation of the recordings.  I have 
not a problem with somebody saying to me, “In my opinion, it should be in both.”  I have no 
problem with that, but I think for the purposes in general of what we were doing it would be 
in the special case file.  
Q 
Can we turn, please, to look at page 20.  We will have to look at this in another 
context.  This is the apparent note by Dr Samuels.  I am going to ask you to produce the 
B
original from the original SC file.   (Pause)  Just looking at the front of it, this is the document 
which has at the bottom “Neuro opinion/local paediatrician”? 
A 
Yes, it is.   
Q 
Would you turn the page over.  We may have to get it photocopied, but, for the 
record, does it have a heading on it?  
A 
Yes, it has “Infant problem sheet”.  This is to do with a home monitoring sheet.   
C
Q 
Does Dr Samuels’ note appear to be written on a normal continuation sheet? 
A 
No, this is not hospital paper.  This is not a hospital continuation sheet at all. 
MR COONON:  I wonder if the Panel could be shown that document.  (Same shown to the 
Panel and returned to the witness)
D
(To the witness):  Would you file it back in the file, please, and perhaps you might put 
a yellow post-it note on it so that we can locate it again.  In relation to that document, did you 
personally file it in special cases file? 
A 
I have no idea. 
Q 
Is it the sort of document, looking at it, that you would have filed in the special cases 
file? 
E
A 
It could have been.  As far as I am concerned, it is to help me write a letter.  It is 
drafted by my registrar at the time, Martin Samuels.  It is to help me write the letter.  I could 
have thrown it away or I could have put it in the special case file.  I would not have put it in 
the main file.   
Q 
When you say “write the letter” to which letter are you referring? 
A 
The letter I wrote, just after his second admission, to Dr Dinwiddie to tell him what 
F
we thought about what was going on. 
Q 
We will look at that again in a different context.  That is the letter, for the record – to 
help the Panel – of 22 March 1990 to Dr Dinwiddie. 
A That 
is 
right. 
Q Following 
discharge. 
G
A Yes. 
Q 
In relation to material in the special cases file which is not in the main bundle, that 
leaves about six letters.  To look at these, we need to look at the special cases file, C7, 
beginning at page 48.   This is a letter which is not in the main file.  Is the handwriting on the 
right hand side your writing? 
A 
Yes, it is. 
H
T.A.  REED 
Day 10 -  40
 & CO. 

---

A
Q 
Did you in fact direct that it should go in the special cases file? 
A 
Yes, I did. 
Q 
Looking at the body of the letter against the background of this child’s admission and 
what had been discovered, what was the reason for it going into the special cases file only? 
A 
A decision had been made, on the discharge of that child, that this was a child 
protection case, so all subsequent correspondence and any social services files would go into 
B
the special case file because there was no reason to suspect that the child would come back to 
the Brompton Hospital. 
Q 
Would you turn to page 53, please.  This is Dr Weaver to  you. 
A Yes. 
Q 
Again, this is not in the main library file at the Brompton.  Looking at this letter, is 
C
that your writing in the top right-hand corner? 
A 
No, it is not.  That is Dr Samuels’. 
Q 
The number “2026” is that your writing? 
A 
No, I do not think so.  I am not sure of that, but I do not think it is. 
Q 
The reference to “Good” is that your writing or somebody else’s? 
D
A 
Somebody else’s.  It is actually Dr Samuels’. 
Q 
What was the reason for filing this in the special cases file alone? 
A 
The policy that I have just described is the main reason but if you look at the content 
there are issues here that you would not want people to be reading who did not have to need 
to know. 
E
Q 
To what, in particular, are you referring? 
A 
The phrase “to his mother’s pathological--- 
Q 
Just a moment.  I am trying to be as sensitive as I can. 
A 
Fine.  Okay. 
Q 
Help the Panel to focus on a particular line, please? 
F
A 
It is in the third paragraph, the seventh line down.  This is not the child’s clinical 
problem at all we are talking about now; it is a child protection issue – unproven, I think at 
this stage that there was a child protection problem – and you do not want people looking at 
this unless they have a real reason to do so. 
Q 
On pages 55 and 56, is that your writing or somebody else’s? 
A 
That is my writing. 
G
Q 
What is the justification, in your opinion, for it being in the special cases file alone? 
A 
Exactly the same as the previous letter: the policy, plus some of the content.  
Q 
Could we go, please, to page 114.  This is Dr Mattees to you, senior registrar to 
Dr Weaver.   It appears to be in her handwriting, but on the top right-hand corner there is 
additional writing: the traditional arrow and then “SC file”.  Whose writing is that? 
H
A 
That is mine.   
T.A.  REED 
Day 10 -  41
 & CO. 

---

A
Q 
Were you directing, therefore, that this should go in the special cases file? 
A I 
was. 
Q 
This appears, as you have said, in the special cases file alone. 
A 
It does.   
B
Q 
What do you say now about it being in the special cases file alone? 
A 
That fits with the policy on the child protection side but I think there is a good 
argument that it should have gone in the medical records as well.   
Q 
Can you explain why in relation to this document? 
A 
Because this relates to a subsequent admission of Child H to the University Hospital 
of Wales, where we undertook a long period of overnight monitoring recordings.  Every night 
C
he was there, he was recorded, to see what his breathing pattern was. 
Q 
Did this take place in Cardiff? 
A Yes. 
Q 
When you say “we”, were you or members of your team present? 
A 
Yes.  We provided the recording equipment to do the recordings, which were oxygen, 
D
breathing, carbon dioxide levels and skin.  We analysed the data, and this was undertaken for 
the Family Court, because they wanted to know the results of continuous recordings at night 
to determine what next to do in regard to Child H’s care. 
Q 
In the care proceedings? 
A 
As part of care proceedings in order to decide whether he needed a tracheostomy or 
not, and he did not as a result of this.  So you could argue this is clinical again, because I said 
E
a bit earlier this child was not going to come back to the Brompton Hospital - he did not, that 
is true - but we were involved subsequently in another hospital in doing the recordings, so
I think there is a good argument that this should have gone into the hospital as well as the 
special case file, and I accept that completely.  You could say it is a mistake on my part, and  
I accept it is.  It could be looked at like that. 
Q 
Thank you.  Could you move on, please, to 332.  This is from Dr Weaver to yourself.  
F
There are two sets of handwriting on this document, top right hand corner;  is any of that in 
your writing? 
A 
Yes, the usual ticks, ticks against my initials and Martin’s and Jane, the word “Good”, 
those are my writing. 
Q 
Did you direct that this should go into the special cases file? 
A 
Yes, I think I did. 
G
Q 
Into the special cases file alone. 
A 
It does not say so, but I am sure I did, and I expected it to. 
Q 
Again, same question, please, the justification for it being in the special cases file 
alone? 
A 
Exactly the same as the first set of documents;  child protection policy and it contains 
H
information about child protection. 
T.A.  REED 
Day 10 -  42
 & CO. 

---

A
Q 
Now, for completeness, Dr Southall, I was dealing earlier with the cardiorespiratory 
monitoring charts.  I should just have included the TcPCO2 charts, which is in the old 
Appendix One.  You will find the references at pages 111 and 113.  Are these documents 
different in nature to the cardiorespiratory monitoring charts? 
A 
No, they are not;  they are the same. 
B
Q 
I deal with them because they were described differently in the old Appendix One, but 
they, as a matter of fact, are not in the main library file. 
A No. 
Q 
Again, the justification for that, please? 
A 
These are to interpret the physiological recordings.  They have the tape counter and 
the time for us to look at if there are any events. 
C
Q 
Now, that is the documentation within the SCF that I seek your comment about.  
Therefore can we move on to deal with what happened to it.  Did this SC file go to Stoke? 
A 
Yes, it did. 
Q 
When the department closed? 
A Yes. 
D
Q 
Did the tapes go as well? 
A Yes. 
Q 
Again, take this as shortly as you can, where are the tapes for Child H stored? 
A 
Exactly the same as Child A and the rest of the special case files, in the Academic 
Department at Stoke. 
E
Q 
Is this a set of documentation that was subject to the request at Stoke that it should be 
removed? 
A Yes. 
Q 
Was this SC file in fact removed to your secure storage elsewhere? 
A No. 
F
Q 
Where did it remain? 
A 
I think it was in the complaints or Trust headquarters. 
Q In 
Stoke? 
A In 
Stoke. 
G
Q 
Did you think at the time of transfer, or at any stage after transfer to Stoke, that a risk 
to this child might arise because of the mere fact that the SC file was now in Stoke? 
A 
I could not think of one.  I still cannot. 
Q 
I would ask you now just to produce a very thin clips of extracts from the main library 
notes at the Brompton.  (Documents handed)
H
THE CHAIRMAN:   This will be D13. 
T.A.  REED 
Day 10 -  43
 & CO. 

---

A
MR COONAN:   Do you have a copy there, Dr Southall? 
A 
Yes, I do. 
Q 
These are photocopies from the original library file held at the Brompton in relation to 
H, and do we see within these examples references to the SC number?  If you look at the first 
page, page 12 at the bottom, an SC number reference at the top right? 
B
A 
Yes, I do. 
Q 
On page 13, it appears to be the same document from the main library file, so I jump 
straightaway to 14, again a document in the main library file.  Do you see a reference there to 
the special cases number? 
A Yes. 
C
Q 
On the right hand side towards the top.  Is this document, page 14, a proforma of 
some type? 
A 
Yes.  All the time we were trying to improve our documentation of how we presented 
our results of the recordings, so this is an improvement on previous ones, and you are just 
gradually trying to get better and better with it, so it is a proforma that you fill in, 
handwritten, obviously the filling in is, it has got the doctor to whom you are sending the 
report and copy to all the other consultants at the bottom. 
D
Q 
Page 25 is a letter from a social worker Mrs Moeri to a firm of solicitors.  This comes 
from the hospital main file. 
A 
Well, Mrs Moeri is the hospital’s social worker so you would expect it to be there. 
Q 
The writing on the right hand side, do you recognise that? 
A 
That is my writing. 
E
Q 
Did you make a reference there to “CS/” – help up with the next word. 
A 
It says, “File S/C + [hospital] notes”, is that what you mean? 
Q 
Yes, that is it.  Again, obviously it is self-evident.  Finally, can I deal with the 
question of the request for disclosure of the records held at Stoke.  You need to turn up, 
please, bundle C2, tab (l), at page 11.  This is Mr Chapman writing to you in July 1994. 
F
A 
Yes, it is. 
Q 
I am going to take straightaway to right at the end of the letter: 
 
“I write to ask therefore that if you possess a file within the Academic Department of 
Paediatrics in the North Staffordshire ….. with such correspondence would you please 
send it to me as soon as possible”. 
G
Mr Chapman was referring to the correspondence there in the earlier part of that paragraph, in 
other words correspondence with Mid Glamorgan County Council.  Now, the question is 
simply this:  Mr Chapman has told the Panel that he did not have disclosure from you of any 
material from you while you were in Stoke.  First of all, do you accept that that is the 
position? 
A Yes. 
H
T.A.  REED 
Day 10 -  44
 & CO. 

---

A
Q 
Can you recall now what, if any, circumstances influenced your decision, if any, can 
you recall now the circumstances which prevailed at that time? 
A 
Well, I do not think there is any reason why I would not have disclosed just as I did 
with Child A.  That is the first point.  I cannot remember receiving the letter, but I could have 
done, in which case I would have been expected to reply.  The only thing I would say that
I do recall is that this is 1 July 1994, when I was working in Bosnia a lot of the time, and 
there was supposed to be a locum working at the hospital covering half my work.  So it is 
B
possible at this time that this letter was not adequately dealt with by my department, and, if 
so, then I apologise because it is my responsibility, but I was away half the time.  As I said,  
I would have responded just as I did with
Child A. 
Q 
Did you have any chaser from Mr Chapman that you could discover about this topic? 
A 
I do not think so. 
C
Q 
There is not one before us, but I just ask you formally. 
A 
Well, I cannot recall. 
Q 
Mr Chapman has not produced one.  Do you recall a chaser of any sort? 
A 
I do not recall it. 
D
Q 
So globally, if I can complete this topic in this way, did you have any problem with 
disclosing the SC material first of all to Mr Chapman, or to solicitors acting on behalf of Mrs 
H? 
A 
No, except I have to return to Child A, where I selectively disclosed;  I would not 
disclose social services material. 
Q 
That is all I ask you about Child H in this context, Dr Southall.  Thank you for that.
E
I just want to now move on to a number of general questions about Stoke before we look at 
the two Stoke children.  I am just going to ask you, first of all, a number of general questions 
about the computer.  You have told the Panel that the computer from the Brompton came up 
to Stoke. 
A Yes. 
Q 
Where was it put? 
F
A 
In the Academic Department. 
Q 
When you got to Stoke was there a computer provided for you, or provided by 
anybody else, in addition to the old Brompton computer? 
A 
I think my secretary had a computer from the hospital, but to do with this material, no, 
not that I can recall at the beginning anyway. 
G
Q 
Did there come a time when another computer was supplied in the department? 
A 
Yes.  I cannot tell you when, but I think what happened was we were on Macintosh 
operating system computer at the Brompton, and when we came to Stoke, sometime 
afterwards, we transferred to Windows system provided by the hospital, and the Filemaker 
database was made available as well so we could transfer the data from Macintosh to 
Windows machine. 
H
T.A.  REED 
Day 10 -  45
 & CO. 

---

A
Q 
The Windows machine which was supplied to you by the Trust, whenever that was, 
did that remain the operating computer in the department throughout the whole of the period 
up to 2006? 
A 
Well, in 1999, when I was suspended, all work stopped, because it was not just me, it 
was Dr Samuels as well was suspended, we were both suspended, so all of our department’s 
work came to a halt.  The computer went away to be looked at.  When we were both 
reinstated, the computer came back, but the special case file system that we had, stopped;  we 
B
did not collect any special cases after our suspension.  I know that Dr Samuels is continuing 
to do lots of sleep study work, but he has a separate and different system now. 
Q 
Leaving aside Dr Samuels for the moment, I just want to focus on the computer or 
computers that were supplied by the Trust.  Who had access at least to the first computer 
supplied by the Trust? 
A 
From the Trust?  Well, there was our team in the Academic Department – secretary, 
C
nurse specialist, Martin Samuels and myself – and the computer department as well, they had 
it, they had access. 
Q 
Was there a password for the computer? 
A 
There were two, one for the patient data files and one for the recording result files. 
Q 
Has that password remained the same from 1992 approximately to 2006? 
D
A 
No.  This is what caused quite a bit of difficulty, because when the computer came 
back after the suspension we did not use it, because we were not doing what we were doing 
before.  Then when my solicitor asked for us to obtain records, I tried to access the computer, 
and both Martin Samuels and I could not get into the computer.  We went back to the IM&T 
Department to try and find out what had happened, and after some time they came back with 
different passwords.  Now, they were the same passwords but with two numbers put in front, 
and, as you know, with passwords if you do not get it right, you do not get it right.  Then we 
E
were able to access it. 
Q         Again my global question is this: was there any question of any clinician who needed 
to access any data held on the computer at Stoke having a problem at any stage? 
A         No, because we were on call all the time, one of us, and we had access to the special 
case files through a ledger system.  That is, we had a ledger, A to Z, and we had a ledger,
I think, 1 to 3,000-whatever it was, and we – you could find the special case file that way, or 
F
you could go on to the computer and put in the name and hope it would – it should work and 
produce either the number or whatever, so it was available all the time. 
Q         Dr Southall, I am going to leave computers and I am going to deal with C10 
separately but I just want to ask you this, did you continue to create special cases files at 
Stoke for Stoke patients? 
A         Yes. 
G
Q         Did you adopt the same policy approach to the creation and continuation of special 
cases files that you had done at the Brompton? 
A         Yes. 
MR COONAN:  Were there any meaningful differences in the policy approach?    
A         Not that I can think of, no. 
H
T.A.  REED 
Day 10 -  46
 & CO. 

---

A
THE CHAIRMAN:  Mr Coonan, if you were going to move on to a different topic, would 
that be a good time for a break?  
MR COONAN:  Madam, if I could just highlight one short paragraph, that would bring us to 
the end naturally of this topic. 
THE CHAIRMAN:  Thank you. 
B
MR COONAN:  I am grateful.  (To the witness)  Could you just turn please to C2, tab 6, and 
go to page 13.  C2, section 6(c).  This is Hempson’s letter again, Dr Southall.  
A         Yes.  Yes. 
Q         If you go to page 13 of the clip, you will see the large paragraph there beginning “The 
Special Case papers”.
C
A         Yes. 
Q         If you just cast your eye down it shortly, does that paragraph relate to the position at 
Stoke?  (Pause)
A         Yes. 
Q         Is that accurate? 
D
A         Yes. 
MR COONAN:  Thank you very much. 
Madam, that completes that part. 
THE CHAIRMAN:  Thank you, Mr Coonan.   
E
Perhaps we can take twenty minutes.  Can I indicate that we hoped that we would rise not late 
today, should I say, quarter to five-ish, if possible, or as soon thereafter as you reach 
a suitable break point. 
MR COONAN:  Thank you very much. 
F
THE CHAIRMAN:  Thank you. 
MR COONAN:  Dr Southall has the usual warning, I am sure, ringing in his ears. 
THE CHAIRMAN:  For the record, I am sure he is aware of it and you are aware. 
A         I am aware. 
G
(The Panel adjourned for a short while)
MR COONAN:  Thank you, madam. 
Dr Southall, can we now turn to the two Stoke cases.  First of all, Child B.  Again, adopting 
the same approach, can we just look at the background to your clinical involvement with 
Child B.  If you take C2, at section 5, and just start at tab (a) please.  Again I am just going to 
H
summarise this and for you to make such comment as you think appropriate.  The story starts 
T.A.  REED 
Day 10 -  47
 & CO. 

---

A
with Dr Issler, a consultant paediatrician at Greenwich, to Dr Lewis at Crawley.  The nature 
of the problem is summarised in the third paragraph on page 27, is that right? 
A         Yes. 
Q         Then, over the page, in the middle of the main paragraph, and I draw attention to the 
eighth line down of that main paragraph, to a reference to the experienced nurses sharing 
anxieties and I invite attention to the whole of that sentence. 
B
A         Yes. 
Q         Culminating, in this letter, with the last four or five lines of that paragraph, where 
Dr Issler states that there are severe reservations about the history.  I take it no further.
I invite the Panel’s attention to the rest of those words. 
Do you have any memory of any clinical involvement yourself with this child? 
C
A         Yes, I do. 
Q         If we turn to tab (b)(i), is that a discharge summary from Crawley? 
A         Yes, it is. 
Q         May I take you to the bottom paragraph on page 8.  Then we come to the main entries, 
done, I suspect, in relation to this child, which is the document at (ii).  Can we skip that for 
D
the minute, just noting it in passing, I will come back to it, and move on to the clinical notes, 
at (c)(i).  Are these the admission notes for this child’s admission to Stoke? 
A         Yes, they are. 
Q         Dated 1 September ‘93 and following? 
A         Yes, yes. 
E
Q         In passing, is there any of your writing in this document, in this tab, I should say? 
A         No, there is not. 
Q         You move through to (iii), same tab, tab (c) at (iii), is that your signature on the 
bottom left-hand corner? 
A         Yes, it is. 
F
Q         What is this document? 
A         It looks like a computer generated document, summarising the recording results of 
Child B. 
Q         When you say recordings, just for clarity, do you mean physiological recordings? 
A         Yes I do, yes. 
G
Q         Was that generated by a computer in Stoke? 
A         Yes. 
Q         You noted your clinical impression, Munchausen’s syndrome by proxy? 
A         Yes. 
Q         At tab (v), is there a medical report, is it written by you? 
H
A         Yes, it is. 
T.A.  REED 
Day 10 -  48
 & CO. 

---

A
Q         If you turn to the last of the three pages, there is no signature or date.
A         No. 
Q         My question was based on the first line of the report itself.
A         Yes, on the side. 
B
Q         Is that a summary of your clinical impression of this child during her admission? 
A         Yes, it is. 
Q         Which was in September, as you have told us.  Then, at tab (d), a letter from Dr Lewis 
at Crawley to you.
A         Yes, it is. 
C
Q         In October.  A reply from you to him at (e), which I will come back to in another 
context.  That will do for my purposes.  I have just taken you really on a short sort of Cook’s 
tour of the material.  What was the purpose of creating a special cases file in her case? 
A         Because she was admitted from another hospital for multi-channel physiological 
recordings, to try and determine a cause of her alleged apnoeic episodes. 
Q         Did you find a physiological cause? 
D
A         No, the recordings were all normal. 
Q         So therefore, just in the light of your answer, I just deal please with the three 
documents.  The first is cardiorespiratory charts.  For these purposes, the Panel will able to 
see the reference to them in the old Appendix One, which you should there, Dr Southall.
Cardiorespiratory charts, various dates between 3 September 1993 and 13 September 1993, 
and, in the SC file, pages 13 to 27.  If you have the SC file, which is C5, if you turn to 
E
page 13, in tab (b), do you have that? 
A         I do, yes. 
Q         Tab (b).  Has all the Panel have the correct record?  I am looking at a 
cardiorespiratory monitoring activity chart.  Pages 13 to 27.  I am going to take this 
compendiously, Dr Southall.  These are cardiorespiratory monitoring activity charts.  These 
documents are in the SC file.  
F
A         Yes. 
Q         But not in the main notes.
A         No. 
Q         Held at Stoke this time. 
A         No. 
G
Q         Do you accept that? 
A         Yes, I do. 
Q         Were these documents dated the 27th, were they deliberately placed in the SC file at 
Stoke? 
A         Yes, they were. 
H
T.A.  REED 
Day 10 -  49
 & CO. 

---

A
Q         Just pause a moment.  The reason for that? 
A         The same as before, these are activity charts for any events that might occur in the 
child during the recording, so you could check the date, the time or the tape counter against 
the recording. 
Q         This is 1993.
A         Yes. 
B
Q         Were you still using tapes to do this recording? 
A         Yes.  Around that time we changed from reel-to-reel to VHS tape, same principle, but 
different format. 
Q         There is one letter I would ask you about please, if you would turn to page 31.  The 
letter of 17 September, page 31 please.  This is in fact a letter addressed, you will see this, to 
C
Dr Lewis.
A         Yes. 
Q         Where did that come from? 
A         The computer. 
Q 
This letter is only in the special cases file and not in the main records. 
D
A Yes. 
Q 
What is your view about that location? 
A 
It should be in both. 
Q 
Can you shed any light as to why it is not? 
A No. 
E
Q 
Did you direct it to go solely in the special cases file? 
A No. 
Q 
I turn, again, please, to the third document and the last document that was the subject 
of inquiry: C2, tab 5(b)(ii) – which, for shorthand, I am going to call “the Crawley letter”.   
This is a document, copied in C2 in that form, that is also in the special cases file, copied in 
F
that form, at pages 33 and 34.  I am going to ask you to look at the special cases file version 
rather than the one in C2.  I hope you are not confused by that, but it has been photocopied 
for the purpose of this hearing and it appears in both bundles. 
A 
I have it in both. 
Q 
Would you work off the special cases file, please.  Pages 33 and 34 are two pages of 
text and page 35 appears to be a fax header sheet with fax timings on the top. 
G
A Yes. 
 
Q 
Similarly, on page 36, there are fax timings.  
A Yes. 
 MR COONON:  Perhaps I could ask the Panel, through the Chairman, whether the fax 
header timings have come out on your copies. 
H
T.A.  REED 
Day 10 -  50
 & CO. 

---

A
THE CHAIRMAN: On my copy I can see that there is a header but it is half cut off, so 
I cannot read it. 
MR COONON:  I am going to ask you to produce from the original SC file the original 
documentation as it appears at the present.  (Original special case file handed to the witness)
Dr Southall, may I take this step by step.  In that buff colour folder which you have just been 
handed, is there a series of loose documents? 
B
A Yes. 
Q 
That appears to be the special cases file in its original form. 
A 
Yes, it is. 
Q 
Many of the documents have yellow Post-it stickers on. 
A Yes. 
 
C
Q 
Did you put those on? 
A No. 
Q 
I will invite the Panel in due course to look at those.  Are they yellow stickers with 
“No” or some other comment on them? 
A 
They have “SC” there, then there is “No” on this one and “No” on that one.  
D
Q 
Is any of that writing on the yellow stickers yours? 
A 
I do not think so, no.  I cannot be one hundred per cent sure, but I am pretty sure it is 
not mine.  It is only two letters, so it is difficult, but it does not look like my writing. 
Q 
I want to focus on the Crawley material.  Would you take out the Crawley fax that is 
there and hold it up, please?  (Holding up bundle of documents)  Is there a clip of material 
E
stapled together?   
A Yes. 
Q 
Is there a header sheet? 
A 
Yes. The front sheet is the header sheet. 
Q 
Look now at pages 34, 35 and so forth.  Has the fax front sheet been photocopied by 
F
Field Fisher Waterhouse? 
A No. 
Q 
What does the fax front sheet say? 
A 
It has “Crawley Horsham Health Service” at the top and their address and then “Fax”. 
“To: Academic Department of Paediatrics North Staffordshire Hospital Centre.
G
Fax No:
For the attention of:  Dr Milner, Registrar to Professor Southall.   
Date:  3 September 1993.   
H
From:  Dr N T Khine Associate Specialist.   
T.A.  REED 
Day 10 -  51
 & CO. 

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A
Total No of pages including this page:  2.”
Then there are some handwritten notes by myself, which say, after an arrow, go to:  “hospital 
notes on ward 112 ASAP.”
At the bottom it has:  “Where people matter” and “NHS Trust” on it. 
B
Q 
In so far as that is your handwriting, what does that handwriting signify? 
A 
That I wanted this faxed referral letter to go to ward 112, which is the children’s ward, 
where the patient was, into the hospital notes as soon as possible – because it was late.  The 
fax was arriving late, as you can see from the letter. 
Q 
We will come to that in a minute.  Apart from the facing sheet, the header sheet, is 
C
there a date and fax time at the top? 
A 
Yes, there is.  “September 03 93: 12.54p.” 
Q 
Following that, are there, in fax form, the two sheets that we see at pages 33 to 34? 
A 
No, not immediately.  There is a bit later. 
Q 
Are there other apparently faxed sheets?  The Panel can look at this for themselves, 
D
but I will just seek your assistance.  Is there the same or a different fax time and/or date on 
the other correspondence? 
A 
The first letter that comes immediately following the header is from Atkinson 
Morley’s Hospital.  It is also faxed from Crawley Hospital; it is on this patient; and it is the 
same time and date.  Then there is a transaction report which is the same, although a slightly 
later time:  12.56.  Then there is the letter that is in the special cases file at page 33, which is 
different date and time:  “02.93:  4.29p”.  Over the page:  “02.93:  4.30p”.  Then there is 
E
another letter to Dr Hyatt from Dr Khine:  “02.93:  4.33p”.  The next is:  “02.93:  4.34p”.  A 
letter to Dr Lewis about the same patient, “02.92: 4.32p”. 
Q 
All that has been stapled together. 
A Yes. 
Q 
Did you staple all that together? 
F
A 
I have no idea. 
Q 
Would you have wished what I call “the Crawley letter” of 2 September 1993 to have 
gone solely into the special cases file? 
A 
No.  It is crystal clear: I was expecting this to go in the hospital notes on ward 112, 
where the patient was.  That is what it says in my handwriting. 
G
Q 
Would you now turn to C2, tab 5(e).  It has page 138 at the bottom.  It is a letter from 
you – we see your name on the second page – to Dr Lewis at Crawley, 14 October 1993.
A Yes. 
Q 
I am going to take you to the second line of the first paragraph on page 138. 
“In discussions with her it was clear that there were so many different consultant 
H
paediatricians involved in [B]’s case that she arranged to invite Dr Issler because hers 
T.A.  REED 
Day 10 -  52
 & CO. 

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A
was the only letter that we had available in our hospital records.  [B] was admitted 
under my care without a referral letter.  In fact, a referral letter did not arrive until 
sometime after admission as a fax which did not find its way into the notes until much 
later.  I personally was unaware…” 
and you go on to deal with other matters.  Dr Southall, in so far as you are able, can you shed 
any light as to how it comes about that this fax – which you would have intended and, indeed, 
B
you say in crystal clear terms should have gone on the hospital records – ends up in the 
wrong file? 
A 
I suspect, but I cannot say more than that, that it was in the right file.  With the 
hospital inquiry – which you can see in the same special cases file at the beginning – 
I suspect somebody has just moved it from the hospital file to the special cases file by 
mistake.   That is my suspicion.  I cannot be sure though. 
C
Q 
You have mentioned other material in the special cases file in the context of the 
inquiry.  The first page of tab B of the SC file is rather faint.  Dr Southall, would you read 
into the record what it says, please. 
A 
Yes.   
“COMPLAINT FILE.  HAND DELIVERED TO DIVISION BY ANITA SMITH”  
D
and then Child B’s name. 
Q 
Over the page, at page 1: 
“31/8/04 – re [B]: expert witness file removed by Nicole Dale, Clinical Risk Dept, 
NSRI … to Medico-Legal Department (Pauline Crossley).” 
E
Then there is a series of documents from pages 2 to 9 in our bundle.  Looking at it 
compendiously, what is that material, Dr Southall? 
A 
It is complaint material, requesting access to the various records. 
Q 
Should that be in the special cases? 
A No. 
F
Q 
Did you put it there? 
A 
No, I did not. 
Q 
Do you know who did? 
A 
I can suspect but I do not know. 
Q 
Before we leave the observations on this, perhaps you could offer those pages to 
G
the Panel so they can see that.  (Same handed to the Panel)  Could I also hand out the last 
photocopies of the material which is now coming out of the file for the Panel.  (Documents 
distributed)
THE CHAIRMAN:   The photocopies that have been circulated there will become D14. 
H
(Long pause while the Panel studied the file of original documents)
T.A.  REED 
Day 10 -  53
 & CO. 

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A
MR COONAN:   Madam, as you can see, the photocopying of the original fax has been a 
little poor, but I hope the Panel is satisfied having seen the documents.   
(To the witness)  Dr Southall, could I just bring this Child B in this context to a close, and I 
have a couple of questions, please.  This particular file, SC file, I asked you about the tapes, 
where was the file stored? 
B
A 
In the secure room. 
Q 
In the department? 
A 
In the Academic Department. 
Q 
Has that remained in that location since 1993? 
A 
I can only say up to 99, when the suspension occurred, and then afterwards I think 
C
they were all returned. 
Q 
Returned, what, to you personally, or just returned to the department? 
A 
Well, actually I am not sure, I have to say.  The special case files remained in the 
secure room, but I think selected examples were taken away, the child protection ones for the 
inquiry.  I am not sure whether this one came back or has always remained in the complaints 
department, the Trust headquarters, I am not sure about that.  I just do not know. 
D
Q 
Now, just answer this question:  on the assumption that the Crawley letter was in the 
main medical notes, as you say to the Panel it should have been, on that assumption was there 
any risk to this child at any stage by virtue of the mere fact that a special case file existed?  
A 
No, not in my view, no. 
MR COONAN:   Yes.  Thank you.  Madam, that might be a convenient moment in the light 
E
of the fact that I have completed Child B.  If I were to start on Child E I would definitely run 
over your indication, and I would suggest that I should deal with it all at once. 
THE CHAIRMAN:   That sounds like a good suggestion, I think, given the time.  I see Mr 
Tyson is rising. 
MR TYSON:   Madam, I wholly concur with my learned friend’s course.  Can I just make 
F
two observations at this point.  Firstly, I would like to take away, and I do not know whether 
it is formally within the hands of the witness, the original SC file, and if it is formally within 
the hands of the witness, can I take it away from the witness desk – just a technical matter;   
I do not want to take any document away that is within the Panel’s jurisdiction--- 
MR COONAN:   I have no objection at all.  I think I agree with my learned friend, I think it 
is really for the Panel to say whether that should happen. 
G
MR TYSON:   I have asked to do that.  The second observation I make is that if my learned 
friend is saying that there has been incorrect copying in C5 and documents are missing from 
C5 that ought to be in C5, I merely make the observation that everyone has had C5 since 
January 2005 and we happen to be told in November 2006, late on a Friday afternoon, that 
we have incorrectly failed to put in documents in C5.  My learned friend has produced, as it 
were, a mini Perry Mason moment, which I rather resent, because had we been told that we 
H
T.A.  REED 
Day 10 -  54
 & CO. 

---

A
have not photocopied everything in C5 that is in the SC file, then of course we would have 
put it right. 
MR COONAN:   I am sorry, I do object to that.  The original bundle was handed to us by Ms 
Ellson several days away.  We received it a few days away in the form in which it appears 
now.  All we have done is look at it and found that there is an omission, and I am entitled to 
deal with it in whichever way I feel. 
B
MR TYSON:   I do not want to squabble too much, but they have had our version of the SC 
file sent to them over a year ago. 
MR COONAN:   I do not want just to have the last word, but until we have the original we 
cannot compare what we have been given until we have the original, and we only got the 
originals a few days ago, and then we realised there is an omission.  The fact is there is an 
C
omission.  That is the only point I am making. 
MR TYSON:   I will try and have the last word because the originals were in the custody and 
control of my learned friend’s team rather than mine. 
THE CHAIRMAN:   Mr Tyson, when you saw you want to take, you mean you want to take 
it from--- 
D
MR TYSON:   I want to take it from this room and examine it and take instructions upon it, 
because it is asserted by my learned friend that there are documents in there that have not 
been appropriately photocopied, and I want to examine precisely the fax, the fax headed 
numbers, the fax headed pages, and the like, and take instructions upon it from my instructing 
solicitors.  I will give whatever undertaking is required to take all due care of this original file 
and will give that undertaking to the Panel, and that I will not destroy or take out or remove 
E
any of the original documents in it, but I want to examine it with some care. 
THE CHAIRMAN:   Is there any reason or objection as to why Mr Tyson should not do this? 
THE LEGAL ASSESSOR:   Well, madam, as long as Mr Tyson undertakes to keep them in 
what has been described as a secure place, I am sure there can be no objection at all. 
F
MR TYSON:   If the back of my Audi is described as a secure place, that is where they will 
be for the next three hours. 
MR COONAN:   Just to make it clear, of course I have absolutely no objection to Mr Tyson 
having a look at them, and I would request the same if I were in his position, so I have no 
objection at all. 
G
THE CHAIRMAN:   I take it that the Panel concurs with this view, as long as there is no 
other reason that we are not aware of.  It seems there is not, otherwise I am sure someone 
would have spoken. 
MR TYSON:   I am grateful for the Panel’s indulgence. 
H
T.A.  REED 
Day 10 -  55
 & CO. 

---

A
THE CHAIRMAN:   So if that is the last matter for today we will adjourn now until nine-
thirty on Monday morning.  Dr Southall, I am afraid you remain on oath over the weekend, so 
you may not discuss your evidence or the case with anyone at all. 
(The Panel adjourned until 9.30 on Monday, 27 November 2006)
B
C
D
E
F
G
H
T.A.  REED 
Day 10 -  56
 & CO. 

---

GENERAL MEDICAL COUNCIL
FITNESS TO PRACTISE PANEL (PROFESSIONAL CONDUCT)
Monday 27 November 2006
44 Hallam Street, London, W1W 6JJ
Chairman:   
  
Dr Jacqueline Mitton 
Panel Members:
Mrs Leora Lloyd 
Mr Alexander McFarlane 
Dr Sameer Sarkar 
Mr Arnold Simanowitz 
Legal Assessor:   
Mr Robin Hay 
CASE OF: 
SOUTHALL, David Patrick 
(DAY ELEVEN)
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 JOLLIFE 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
DAVID PATRICK SOUTHALL 
 
Examined by MR COONAN, Continued 
 
 
1 

---

A
THE CHAIRMAN:  Good morning everybody.  Mr Coonan, I understand that there has been 
some minor technical difficulty, if I may put it that way. 
MR COONAN:  Madam, there was.  I am sorry that they have bedevilled matters this 
morning and resulted in a late start, but both teams needed to access photocopiers and I am 
afraid they rather let us down.  There is still some photocopying yet to take place.  As far as 
B
I am concerned, there may come a point at which I will need to check that all that has been 
completed, so I may have to ask your indulgence a little later in the morning to see whether 
that has been done.  I hope that does not cause too much difficulty. 
MR TYSON:  Madam, I share the same technical difficulties which is why I have no 
representative from my instructing solicitors with me, but I am quite content to carry on 
without that representative for present purposes.
C
You may remember last thing on Friday there was an issue between my learned friend and 
I as to the SC file relating to Child B.  You kindly permitted me to take the file away.  Can 
I clear up some misunderstandings because I may have used some overheated words, for 
which I apologise?  Firstly, the original SC file itself was at the trust and not with 
Messrs Hempsons.  Secondly, it was seen by those instructing me some time ago in order to 
see what documents were originals and what were not.  Thirdly, it was seen by those 
D
instructing me on 31 October this year, when both sets of solicitors went over to the trust and 
learnt about computers, and at that time my instructing solicitors took possession of the file 
and brought it down to this hearing.  Thus the only time Messrs Hempsons’ team and my 
learned friend’s team had the opportunity to see the original file was at the beginning of this 
hearing.  Any suggestion that they brought it and had custody and control of it throughout, 
that I might have suggested, is wrong and I apologise for that. 
E
The real problem and where the difficulties have arisen as to why the C5 file, which has the 
photocopy of the SC file, does not have the totality of the facts which you looked at 
separately is, as ever, in that both parties were provided with a photocopy of the SC file by 
the trust.  It was not those instructing me that photocopied the SC file.  They were not given 
access for that purpose, so we were relying on the Trust’s photocopying of the file.  Clearly 
the trust failed to photocopy all the pages and that mistake only became clear over the 
weekend.  I hope that has cleared the matter up.  If and in so far as I made implications or 
F
suggestions against my learned friend or his team about the matter, I unreservedly withdraw 
them. 
MR COONAN:  I thank Mr Tyson for those words.  Indeed it does clear the matter up and 
I am grateful for that.  Madam, with your leave can I turn attention to the next stage of 
Dr Southall’s evidence.  I am going to turn to Child D, which is a Stoke case, and first of all 
deal with the question of documentation. 
G
DAVID PATRICK SOUTHALL
Examined by MR COONAN, Continued
MR COONAN:  Dr Southall, for these purposes can you make sure that you have, first, to 
one side of you, Appendix One of the Notice of Hearing, and also bundle C2.  If you turn in 
C2 to tab 4, I want, with your assistance, just to set the clinical background in context before 
H
coming to a series of questions. 
T.A.  REED 
Day 11 -  1
 & CO. 

---

A
These documents we have looked at at a much earlier stage of the hearing.  At tab (a), 
Dr Rodgers is referring this child, this baby, to the dietician at Wexham Park, back in April 
1989 and one notes the wording of the first sentence that we will see appears in almost 
exactly the same terms in subsequent letters from the GP.  Is that right? 
A Yes. 
B
Q 
At tab (b), again a referral by Dr Rodgers to Dr Connell, a paediatrician at Wexham 
Park.  Then a letter at tab (c) from Dr Connell back to Dr Rodgers, and again I do not take 
you to any of the content of that, simply to note it.  Then at tab (d), again Dr Connell to 
Professor Soothill at Great Ormond Street, and then further correspondence from Dr Strobel 
at tab (e).  Finally, for immediately contingent purposes, we go to tab (f).  Is that the referral 
letter from Dr Rodgers, the GP, to you? 
A 
Yes, it is. 
C
Q 
What did you understand to be the underlying thrust of that letter? 
A 
That child D had severe allergy problems, not in doubt, major issue for the child, but 
also a new problem or a related problem where the mother was worried about him having 
episodes, particularly at night during sleep, where he becomes pale and has a low body 
temperature.  I think she was worried that he might be at risk of something happening to him.  
The referral was for me to investigate those episodes and possibly consider some kind of 
D
home monitor to alert her to their presence. 
Q 
On the last line of the letter there is a reference to “PO meter”.  I think Mrs D was 
asked about this.  What is your understanding of that reference to “PO meter”? 
A 
It is a transcutaneous oxygen monitor that measures oxygen through the skin non-
invasively.
E
Q 
Which part of the body is it affixed to? 
A 
It can be put anywhere, but generally it is on the trunk or the leg. 
Q 
Can that monitor be taken home? 
A Yes. 
Q 
Then Child D was admitted, and the body of those notes you can see in the next tab, 
F
Tab (g).  We see, first of all, on page 601 that the child was admitted on 29 November.  
Again, just for the record, is that your writing? 
A 
I am not sure he was admitted then.  I think that was the out-patient clinic note. 
Q 
It is probably my mistake. 
A 
That is not my writing; that is Dr Kildin. 
G
Q 
We see his signature at the bottom right hand corner on page 605. 
A Yes. 
Q 
On page 605 there is a reference to the child being seen by you. 
A Yes. 
Q 
Do you accept that you saw the child? 
H
T.A.  REED 
Day 11 -  2
 & CO. 

---

A
A 
Yes.  What happened was that the registrar usually saw some of the children and 
I always saw them afterwards, especially new patients. 
Q 
If you drop your eye further down 605, you will see under the typescript, 
“investigations ordered”, the doctor has written, “For admission 12/12/;94”. 
A Yes. 
B
Q 
“Continuous temp recording and O2 recording”.  What therefore – can you flesh this 
out for us – was the plan? 
A 
The plan was for him to come in and have continuous night time, overnight tape 
recordings of non-invasive signals; namely, oxygen levels in the blood and skin, breathing 
movements, electrocardiogram, and in this case in addition he would have continuous 
temperature monitoring from the axilla. 
C
Q 
If we move through the notes – they are slightly out of order – and go to page 604, do 
you have that? 
A Yes. 
Q 
Just over half-way down, Dr Suchak, SHO, appears to have made a note, 
 
“Admit for recordings.  Registrar informed of”, 
D
and then clearly a name which is wrong. 
A 
Yes, it is wrong. 
Q 
Attention was drawn to that by Mrs D herself, do you remember, Dr Southall? 
A 
Yes, I do. 
E
MR COONAN:  “Registrar informed of [name] admission”.  This page is out of order.  It is 
after page 603. 
THE CHAIRMAN:  After page 608, we get 603, 604 and then 609. 
MR COONAN:  Yes, that is right.  Let us go back to that Dr Southall, “Registrar informed of 
[name] admission”.  Is that an arrow? 
F
A 
It may be, “because of”. 
Q 
“Risk of anaphylaxis”, Dr Suchek.  Then the entry at the bottom, I think we have been 
told that that is 13 December 1994.  It is cut off certainly on my photocopy.  “Review”, and 
then, “Discussion with Dr Samuels”.  Can you just deconstruct that note for us, Dr Southall? 
A 
Yes.  Dr Samuels, as you know my colleague consultant, was notified that there had 
been an episode in the recording period the night before.  He therefore suggested a further 
G
night’s overnight recording by the look of it, and the tape to be looked at and saved for 
analysis because of the event that had occurred. 
Q 
If you go over the page, which is in fact paginated at 609, the date in the top left hand 
corner again is 13 December and appears to be Dr Suchak’s note as well, or can you say who 
it is? 
A 
I cannot be sure.  It looks like his writing. 
H
T.A.  REED 
Day 11 -  3
 & CO. 

---

A
Q 
No matter.  Is there a note that there was a discussion with Professor Strobel at Great 
Ormond Street? 
A Yes. 
Q 
You will see on the next page there is a note that you carried out a ward round.  Do 
you have a memory now of being involved in these investigations? 
A 
Yes, I do, but it is vague, but I do have a memory of some of it, yes. 
B
Q 
Taking us through up to, say 14 December – I do that because the last line of the entry 
on 14th, bottom of the page 609, “to discuss with Professor Southall re further plans” – so far, 
on 14 December, what was the analysis?  What was your analysis of what was happening? 
A 
I cannot be sure at this stage, it is 12 years ago, but I think I would have been talking 
to Dr Samuels who had had a bit more contact by then.  I think we would be wondering 
whether this was some kind of allergy even that was relating to something he had eaten 
C
perhaps, or was it that mum was over worried and over anxious about something that was 
perhaps within the normal range of behaviour for such a child’s age. 
Q 
If you go over the page to 610, on 15 December – I will return to deal with this 
occasion later but for the purposes of looking at the background here – do you accept that you 
did a ward round? 
A 
It says I did so I would have done, I think. 
D
Q 
Again it looks as if that is Dr Suchak’s note.  I say that, if you turn over the page. 
A 
Yes, it is. 
Q 
The last entry on page 611 I just want to ask you about.  It is the same day,  
15 December, “D/W [discussed with] Prof Strobel.”  Is that your signature on the bottom 
right-hand corner? 
E
A 
Yes, it is. 
Q 
Did you have a discussion with Professor Strobel about this? 
A Yes. 
Q 
Why did you do that? 
A 
Because Professor Strobel had been much more involved with Child D than we had 
F
and we were getting worried about what was being reported to us and we were concerned 
particularly about the rectal temperatures being taken, the blood sugars that had been 
requested.  As far as we could see, apart from his extreme allergy, which we accepted, he was 
a healthy boy, and I wanted to know what Professor Strobel thought. 
Q 
As a result of, first of all, the discussion with Professor Strobel and the clinical 
impression that you had from his stay in hospital, did you – and I am using that in a personal 
G
sense; you, personally – come to an opinion as to what was happening with this little boy? 
A 
Yes, I did. 
Q Which 
was 
A 
I accepted he has severe allergy but I thought that his mum was exaggerating his 
symptoms. 
H
T.A.  REED 
Day 11 -  4
 & CO. 

---

A
Q 
Then looking at that note, do you see at the third line, “Needs SS strategy meeting.”  
What does that mean? 
A 
If we had concerns that a child might be suffering from exaggerated or fabricated 
illness, the first step was to hold a social services strategy meeting, with social services being 
the lead agency for child protection. 
Q 
The next line: 
B
“To invite Prof Strobel”, 
and the next line, is that: 
“Cons [consultant] Wexham”? 
C
A 
Wexham Park Hospital.  That is Slough.  That is the local consultant paediatrician, 
who would be Dr Connell I think. 
Q 
Dr Connell, and then in the next line what does “DS, MPS etc.” mean? 
A 
DS is me, MPS is Martin. 
Q Martin 
Samuels? 
D
A 
Yes.  “etc.”, well might be the nurses from the ward.  We usually had one of the 
senior nurses would come to give an opinion usually. 
Q 
And the last line, “Martin Banks contacted.”  Who was he? 
A 
Martin Banks was a senior social worker in Newcastle-under-Lyne who was very 
much involved with us in our work, having been involved with a number of covert video 
cases that we had been involved in.  So, he knew about fabricated illness.  I should say, by 
E
the way, that I was not thinking that this was a serious – not serious end of the spectrum.
This is at the least serious end of the spectrum of this condition, which varies from 
exaggeration to fabrication through to induction of illness.  I was not thinking about that at 
all.  We were thinking about exaggeration. 
Q 
Just moving on, I note in passing at tab (h) there are then nursing notes which I just 
identify and move finally, by way of introduction, to your medical report at tab (i).  Is this 
F
your signature on the last page at 269? 
A 
Yes, it is. 
Q 
The report is dated 24 April 1995? 
A Yes. 
Q 
Does this report summarise, as much as stood on 24 April 1995, the events which had 
G
happened to your knowledge since your first contact with this little boy? 
A 
Yes, they do. 
Q 
In particular, if you turn to page 268, is there a series of notes, a series of observations 
in this report in relation to the ward round on 15 December? 
A Yes, 
there 
is. 
H
T.A.  REED 
Day 11 -  5
 & CO. 

---

A
Q 
Finally, at the bottom of page 268, looking at the last sentence, was this really the 
high point of the admission: 
“It was agreed that a Social Services strategy meeting should be established”? 
A 
Yes, it was. 
B
Q 
Dr Southall, against that background could I therefore deal with the question of the 
special cases file and for this you will need C6, please.  (After a pause)  The first question is:  
Do you accept that you created a special cases file for this patient? 
A I 
did. 
Q 
What was the reasoning for the creation of an SC file? 
A 
All patients referred for monitoring and as tertiary referrals had a special case file. 
C
Q 
Was that the reason that applied to this child when the special cases file was opened? 
A 
Yes, it was. 
Q 
There are a number of documents which are cited in Appendix One.  You will see that 
in Appendix One, Dr Southall, the last item in the list is item 4, which is described as 
“Patient’s Data 13 December 1994” at page 313.  Can you open the file at page 313?  It is 
D
right at the back of the file, and page 313 is headed “Patient’s Data” and on the top left-hand 
corner we see a case reference number 3874.  Is that the special cases file number? 
A 
Yes, it is. 
Q 
Was this, in its layout, a proforma document? 
A 
Yes, it is. 
E
Q 
Where is it generated from? 
A The 
computer. 
Q 
That is the computer in the Academic Department or the hospital computer? 
A 
No, the Academic Department computer. 
Q 
We see that the date of it is 13 December 1994, the top right-hand corner? 
F
A Yes. 
Q 
In other words, relating to the time he was admitted to hospital? 
A Yes. 
Q 
It is a fact, because you have admitted it, that this document does not appear in the 
main hospital medical notes. 
G
A That 
is 
right. 
Q 
You accept that? 
A 
I accept that, yes. 
Q 
But it is in the special cases file? 
A 
Yes, it is. 
H
T.A.  REED 
Day 11 -  6
 & CO. 

---

A
Q 
Should this or a copy of it have been in the main file? 
A 
It was my policy that it should have been, but it is not essential, in my view, unlike 
the recording reports which I designated must go in.  This one could have been in, should 
have been in, but all the information on it is the standard information that is collected by the 
nursing staff anyway.  It is generated for the purposes of our clinical audit work and our 
database.
B
Q 
I am going to leave that on one side and deal with the rest of the documents.  The rest 
of the documents which are cited in Appendix One consist wholly of correspondence? 
A 
Yes, that is right. 
Q 
You have admitted that some of them are original documents, original letters – that is, 
letters coming from others to you? 
A Yes. 
C
Q 
Quite clearly originals, others are top copies which have been sent by you to others, 
and others are copies, copied to you, passing between third parties? 
A Yes. 
Q 
We see that in Appendix One.  First of all, if I can take this globally, these documents 
do not appear in the medical records, the main medical records? 
D
A No. 
Q 
What is the overriding reason, if there is one, as to why these documents are in the 
special cases file only? 
A 
Because when Child D was discharged from our hospital he was discharged with a 
label or diagnosis of child protection concerns.  There would be no further involvement of 
our hospital in medical matters and, therefore, as part of our policy all correspondence, 
E
particularly child protection related correspondence, would and must go in the special case 
file, not in the major main hospital medical file.  That is the policy that we had at that time. 
Q 
In Appendix One there are, as I say, I think it is 28 letters, if my maths is right, and  
I am going to take you serially through them, very briefly, and I am going to ask you two 
questions in relation to each one.  First of all, looking at the document, whether in your view 
it properly fell within the policy that you described, and secondly, whether or not you would 
F
do anything different today. 
A Yes. 
Q 
We have been told that this SC file, the way it has been photocopied, runs from front 
to back, so we started at page 313 and so we are going to have to go backwards through the 
bundle.  Do you understand? 
A 
Yes, fine.  Yes. 
G
Q 
The first document, therefore, is at page 305, in March 1995, about three months after 
this child is discharged.  Looking at that document, Dr Southall, was that properly within the 
policy that you have described? 
A 
Yes, it was.  It mentions factitious illness.  It is not the sort of thing that we would 
want in medical records that were available to people, numbers of people that did not have to 
know.  It related to issues with regard to the family rather than the child themselves per se. 
H
T.A.  REED 
Day 11 -  7
 & CO. 

---

A
Q 
The reference I think is five lines from the bottom of that paragraph.  Is that right? 
A 
Yes, it is. 
Q 
Turn, please, to page 304.  What do you say about that? 
A 
Exactly the same argument. The letter on its own does not reveal child protection 
concerns but of course it is attached to the report which you just mentioned, which does 
contain concerns. This was about Child D being admitted for further investigation by 
B
Professor Warner. 
Q 
I should have asked you in relation to the first document, and I ask you it in relation to 
this: Would you file these any differently today? 
A 
No, I would not. 
Q 
Page 281, please.  We are now in May, 14 May 1995.  This is from Professor Warner 
C
to you.  First of all, did that fall within the policy that you have described? 
A 
Yes, it would fall within the policy. 
Q What 
about 
today? 
A 
I accept that it does not contain any information that could link it to child protection 
concerns, so I do not have a problem with it going in the main medical record, but it seems in 
my view preferable to have the policy and have all of the correspondence in one place; but
D
I would not have a problem with somebody saying, “Well, this should be in the main medical 
record” or “could be in the main medical record”, I think is the way I would look at it. 
Q 
When we see the dates on these letters can you help the Panel please as to when it 
would have been that the document would have been filed? 
A 
Shortly after their receipt I think. 
E
Q 
Page 279, please.  On the top part of the page is that your writing? 
A 
Yes, it is. 
Q 
Did you make the SC number reference in your writing? 
A 
I do not think that is my writing. 
Q 
Is this a document which was correctly filed in the SC file in accordance with the 
F
policy, or not? 
A 
Yes, it is. 
Q 
What about your approach today? 
A 
The same.  I think it should be there. 
Q 
Can you turn on to page 277.  This is you to Mr Banks. 
G
A Yes. 
Q 
Again, the same question:  Was that filed in accordance with the policy, or not? 
A Yes. 
Q 
Why is that? 
A 
Because it is all about child protection. 
H
T.A.  REED 
Day 11 -  8
 & CO. 

---

A
Q 
Can I draw your attention for comment, if you wish to make any, to the bottom of 
page 277, the final paragraph. 
A It 
is 
self-explanatory. 
Q What 
about 
today? 
A 
Yes, I think it should be in the special case file only. 
B
Q 
Page 276 please.  This is from Dr Rodgers, the GP, to you, and we are now in June 
1995, six months down the line.  On the top right-hand corner is that your writing? 
A 
Yes, it is. 
Q 
Was that filed, in accordance with the policy, in the SC file only? 
A Yes. 
C
Q 
Do you have any reservations about that? 
A 
Only that I would be happy for it to go in both. 
Q 
Given the fact that it only went in one, what is your view? 
A 
I think it was appropriate, given the blanket policy.  He was not coming back to our 
hospital, there was no clinical involvement.  The only involvement was child protection. 
D
Q 
Page 275, please.  This is Professor Warner to you.  There are two pieces of writing 
on this.  First of all, the word “File”, is that your writing? 
A 
Yes.  I was looking at 275A.  Yes, “File” is mine. 
Q The 
number? 
A 
I do not think that is my writing. 
E
Q 
We have seen a number of instances where you have commented to the same effect, 
that the numbering is not in your writing. Who, as a matter of system, would note the 
numbering on the document? 
A Usually 
my 
secretary. 
Q 
The number that we see on that document, for example, is different from the special 
cases file number. 
F
A 
Yes, it is. 
Q 
Can you help there about what the apparent instruction to file may mean? 
A 
Well, it may be that my secretary was not sure which file to put it in, because it does 
not say “File S/C”, it just says “File”, so she may have looked it up on the hospital computer
system, his name, and got the number.  Then at the top there is this “S/C”, so she may have 
realised that all correspondence was going into the SC, having looked at the hospital file, 
G
possibly.  I mean, I am speculating, I do not know. 
Q 
The “S/C”, is that your writing? 
A 
I do not think it is.  I am not sure though, but I do not think so. 
Q 
Again, same question, looking at the body of this document, was that apparently filed 
in accordance with the policy, or not? 
H
A 
Yes, it was appropriate to go in the SC file. 
T.A.  REED 
Day 11 -  9
 & CO. 

---

A
Q 
Should it have gone into the medical records at that time, or not? 
A 
It could have done, but there is the word “case conference” on it, so I think it should 
not have done in my view. 
Q 
Turn on, please, to 273.  It is a letter from Professor Strobel to Dr Rodgers,  
5 September 1995.  There are two pieces of writing:  the word “File”, is that you? 
B
A 
That is me. 
Q 
The same hospital number? 
A Yes. 
Q 
Is that your writing? 
A No. 
C
Q 
Now, I am deliberately not taking you through the whole of the body of a lot of these 
documents.  The Panel have read them and will be familiar, and can read them again.  What 
do you say about the justification for putting this letter solely in the special cases file and not 
in the medical record? 
A 
The same principle again, the policy was there.  Just reading this, there are some 
concerns about modalities of admission, but, just looking at it, there is no real reason why it 
D
could not have gone in the main hospital medical records, but I think the overriding issue was 
the policy. 
Q 
Next, please, in chronological terms, we move now to page 265, and we are now in 
October 1996, so we have jumped a year. 
A Yes. 
E
Q 
It is yourself writing to Mr Banks.  This is filed, as we know, in the special cases file 
only.  What about the justification or otherwise of filing this in the special cases file alone? 
A 
Well, this is absolutely purely child protection.  It is appropriate in the special cases 
file only then and now. 
Q 
264, please.  There should be a 264a inserted in the bundle where you will see that 
you are one of the persons being copied into this. 
F
A Yes. 
Q 
Again, sorry to go through the same form here, but we see two pieces of writing on 
264.  Is the word “File” your writing? 
A 
Yes, it is. 
Q 
What about the numbering? 
G
A 
That is not mine. 
Q 
This was filed in the SC file alone.  What do you say about that? 
A 
Again, it fits with the policy.  However, there is not anything in it that is about child 
protection.  It is a copy letter to me.  The prime person receiving it is the GP of course, which 
is the most important person.  Professor Warner is important.  I am involved because of the 
child protection issues only.  So I would not be averse to it being in the main medical record, 
H
but there is really not much point, but I do not have a problem with it. 
T.A.  REED 
Day 11 -  10
 & CO. 

---

A
Q 
Can we just pause for a minute.  This is October 1996, which is almost two years now 
after the child is admitted for that short period in 1994.  What hat are you wearing two years 
down the line? 
A 
The child protection hat. 
Q 
What does that mean? 
B
A 
Well, I was still concerned about this child’s well-being.  Professor Strobel and 
Professor Warner and the GP all knew that I was concerned still, although I was getting more 
distant from it at that time, I remember that, and I think it was Dr Whiting’s involvement 
which brought it back, if you like, more into my immediate attention. 
Q Dr 
Whiting 
was? 
A 
She had taken over as a consultant community paediatrician in the local area where 
C
the family lived. 
Q 
As of October 1996, when documents first of all were being copied to you, what did 
you understand the reason why others should be copying you into this correspondence? 
A 
I just think that quite often there is a system that is set up and it just carries on, and 
Professor Strobel was continuing to keep me informed of what was happening to the child.   
I know he was still concerned as well about him.  At some point we did have a strategy 
D
meeting at Great Ormond Street Hospital about him.  I cannot remember exactly when it is 
without going through the records.  He was keeping me informed because of the child 
protection involvement.  I am not an allergist.  None of this information is material which  
I could have much of an input into. 
Q 
Turn now back to 262, and a letter from the social services to yourself. 
A Yes. 
E
Q 
Why was this letter filed only in the special cases file? 
A 
Because it relates to child protection concerns and it was from a social worker, copied 
to Mr Banks, Social Services, Newcastle. 
Q 
On the second page, on 263, on the last line, we see the observation made by  
Mr Haverson, and then there is an asterisk and somebody has written the words there 
F
appearing.  Is that your writing? 
A 
Yes, it is. 
Q 
What do we understand that comment to signify? 
A 
I remained concerned about this child.  I thought there was something going on here 
in this family that had not been addressed, and the reason why the illness was being 
exaggerated related to some problem in this family that was not being addressed properly.  
G
Social services were clearly involved already in the family for care, not protection reasons, 
and I was concerned that there was missing data somewhere in the care of this child that 
needed to be addressed.  So I was not happy with his opinion that there was no need for 
further concern. 
Q 
Now, the next correspondence begins at 261, which appears to be a fax.  This clip 
begins at 261, Dr Southall.  There is a fax cover sheet, and towards the bottom it says, 
H
T.A.  REED 
Day 11 -  11
 & CO. 

---

A
“Attached is chronology re:  [Child D]”, and if you go back now to page 245, if you begin at 
245 and run it on to 260, is that the material referred to in the fax header? 
A 
Yes, it is.  I should say I had already had a phone call at this stage from Dr Whiting 
outlining the concerns that she had had, completely independently of me, about the family, 
and this fax followed that telephone conversation, which is not recorded. 
Q 
We will look at the document in a moment, but just by way of introduction, what was 
B
your first contact with Dr Whiting, the consultant community paediatrician, phone call or 
letter? 
A Phone 
call. 
Q 
Do you understand why she should be telephoning you? 
A 
I presume that she had seen somewhere that I had raised concerns about Child D. 
C
Q In 
correspondence? 
A 
Yes.  She was a community paediatrician so she would be involved in community 
child health issues. 
Q 
So looking at 245, we see the date there, it is exactly two years since he was 
discharged from your care in the hospital. 
A Yes. 
D
Q 
She refers to the chronology, and then over the page, beginning at page 246 to 260 
there is the chronology prepared by Dr Whiting.  Why was this document, together with the 
covering letter from Dr Whiting, why was that filed solely in the special cases file? 
A 
Well, firstly, the fax cover comes from Rosemary Marson, Clinical Specialist Child 
Protection, that is page 261, so this is about child protection issues. 
E
Q 
So just pause and look at 261.  Rosemary Marson, Clinical Specialist Child 
Protection.  What is a Clinical Specialist Child Protection? 
A 
I suspect, I cannot be sure, but I suspect she is a nurse in the community health field 
who specialises in child protection, I suspect, but I am not certain. 
Q 
So again this may be obvious but I need to ask it:  what would you understand to be 
the link or connection between Rosemary Marson and Dr Whiting? 
F
A 
I suspect they worked together when there is a child protection concern particularly. 
Q 
Looking at it now in 2006, ten years down the line, what is your view about this being 
filed in the special cases file only? 
A 
Completely appropriate for the policy reasons. 
Q 
Now, I am going to ask you to move again back to 229.  229 to 244 are, I hope this is 
G
uncontroversial, photocopies of what we have just been looking at. 
A Yes. 
Q 
With extras, and I am going to draw your attention to them, but they are photocopies.  
Can you help us at all as to why it might be that there are two versions of this material in the 
special cases file? 
A 
I think that the first one is the fax and the second is by letter.  That is what I think is 
H
the most likely reason. 
T.A.  REED 
Day 11 -  12
 & CO. 

---

A
Q 
Let us go and look at 229 for a minute, and we see that on the face of that document 
there is some writing “S/C File”, is that your writing?  
A 
Yes, it is. 
Q 
Was that a direction to somebody, secretary or whoever, to file it in the SC file? 
A 
Yes, it is. 
B
Q By 
you? 
A Yes. 
Q 
Then the actual document, the chronology, as we just move through it, on many of 
these pages are matters which are underlined or asterisked in one column or another.  Is that 
your writing, Dr Southall? 
C
A 
Yes, it is. 
Q 
On a few occasions there are comments written in.  Is that written in your writing? 
A 
Yes, it is. 
Q 
In particular, can I take you to 235, please, in the right hand margin; can you read that 
writing? 
D
A 
Yes, I can. 
Q 
What does it say? 
A 
“Frequent symptom in MSBP”. 
Q 
“MSBP” being what? 
A 
Munchausen syndrome by proxy. 
E
Q 
On page 238, just before halfway down there is a reference to a quote from the notes, 
and in the left hand margin there is a series of letters.  Can you help about that, what it may 
mean? 
A 
I can, but I am not sure whether I should.  I am sorry, it is difficult to explain why. 
Q 
Let me just deal with it this way.  Is that because this is in public? 
F
A 
Yes.  I am not very keen. 
Q 
Right.  Can I ask you in this way:  does it relate to the issue of child protection? 
A 
Yes, it does. 
Q 
Then lastly in this clip, 244.  Just under halfway down there is a series of notes, 
handwritten notes.  Is that your writing? 
G
A 
Yes, it is. 
Q 
Again, do the notations on the documents help you in any way to consider whether 
this was properly filed under a policy relating to child protection issues? 
A 
Yes, it was. 
H
T.A.  REED 
Day 11 -  13
 & CO. 

---

A
Q 
227, please.  This is a letter from you to Mr Haverson, and I just pause and draw your 
attention to 228, where there are the various people who are copied into this correspondence.
Was there an approach here by you to copy people in, or not? 
A 
Yes, there was, yes. 
Q 
This letter, as we know, because you have accepted it, was filed only in the special 
cases file. 
B
A Yes. 
Q 
The reason for that? 
A 
It is about child protection. 
Q 
I just ask you, please, to look at the first couple of lines.  First of all, you say, “Thank 
you for letter of the 10th of December”.  I just note in passing, to help the Panel, that is page 
C
262, and then I am not going to read this out, but I just invite your attention, Dr Southall, and 
the Panel’s, to the first few lines. 
A Yes. 
Q 
Again, can I have your blanket comment to that, please. 
A 
It is just further information, particularly at this time, from Dr Whiting’s assessment 
that there are child protection concerns. 
D
Q 
The last sentence on page 228, the last two sentences, there is a reference to
Dr Whiting attempting to sort out a multi agency meeting.  What is a multi agency meeting? 
A 
This is probably a case conference, which, as you know, happened later. 
Q 
We move forward, please, to 215.  This is you to Dr Whiting, and what is the reason 
why this was filed in the special cases file only? 
E
A 
The policy, it is child protection then and now. 
Q 
Turn to page 214, please.  This is a letter in respect of which you were copied in from 
Dr Whiting to Professor Strobel, and you were one of a series of people who had been copied 
into this.  I draw your attention please to 214a.  Looking at the list of people, is that correct? 
A Yes. 
F
Q 
On the main page, 214, there are two sets of writing and the word, “file”.  Is that you? 
A 
Yes, it is. 
Q 
Was this directed to be filed in the special cases file by you? 
A 
It does not say so on there. 
Q 
But that would be your feeling. 
G
A 
It should be. 
Q The 
reason? 
A 
It is child protection.  It is part of the policy then and now. 
Q 
Just looking at 214a, and looking at the list of people who were copied into this,
Mr Haverson is a social worker in the disability team. 
H
A That 
is 
right. 
T.A.  REED 
Day 11 -  14
 & CO. 

---

A
Q 
From your standpoint, what was the relevance of the disability team being involved in 
this? 
A 
Certainly Child D did have a major allergy problem with what could be considered 
special needs as a child.  There is no question about that.  I think that is why Mr Haverson 
was involved.  The word, “disability”, though is not quite in keeping.  It is a little bit 
suggesting that he was disabled and one of the concerns I had was that perhaps he was being 
B
inappropriately disabled by being pushed around in a pushchair and things like that, but he is 
not involved in the child protection side of social services. 
Q 
Turn to page 208, please.  This is Professor Strobel to Dr Whiting.  We see in the 
middle of the page there the word, “file”.  Is that your writing? 
A 
Yes, it is. 
C
Q 
This was found in the special cases file only.  Was that correctly filed or not? 
A Yes. 
Q The 
reason? 
A 
It is part of the policy and it does discuss child protection issues.  It talks about the 
strategy meeting that had been held at Great Ormond Street Hospital. 
D
Q 
Can I just draw your attention, for a comment please, to the second bullet point and to 
the last bullet point on page 208?  Do you have any comment to make about that? 
A 
It was felt that a case conference was going to have to be the next way forward in 
trying to sort out the problem. 
Q 
I think the next document is at page 196.  This is you to Mr Evans at social services.  
Mr Evans is there described as the child protection co-ordinator, and the letter is copied to  
E
Dr Whiting, Professor Warner and Professor Strobel.  There is a reference in that letter to the 
Children’s Act. 
A Yes. 
Q 
And a reference in the last line to a case conference. Again, looking at this globally, 
what was the reason why this was filed in the special cases file alone? 
A 
The policy.  It is now three years down the line from the admission. 
F
Q Not 
quite. 
A 
Not quite, but in the third year.  It is about child protection so I think it should be in 
the special case files both then and now. 
Q 
Two days later, at page 185, you write to Mr Evans again.  In between times,  
Mr Evans had replied to you on page 194. 
G
A 
Yes, that is right. 
Q 
At 194 we see the word, “file”.  Is that your writing? 
A 
Yes, it is. 
Q 
On page 185 there is no writing by you at all. 
A No. 
H
T.A.  REED 
Day 11 -  15
 & CO. 

---

A
Q 
But as a matter of fact this letter has gone into the special cases file alone. 
A 
Yes, that is right. 
Q It 
says, 
“Thank you for your letter.  I am sorry that you feel unable as yet to proceed with a 
child protection conference on the basis of what I referred to in my original letter”. 
B
You then deal with a number of specific matters referred to by Mr Evans in his letter. 
A Yes. 
Q 
Again, I am not going to read this out.  What is the reason why this document was 
filed in the special cases file only? 
A 
Policy.  It is child protection so the same would apply now. 
C
Q 
Can I deal with it this far?  In the first paragraph are there matters touching on child 
protection issues? 
A Yes. 
Q 
In paragraph 2, are there child protection issues or not? 
A Yes. 
D
Q 
In paragraph 3 and over the page are there child protection issues? 
A Yes, 
there 
are. 
Q 
In paragraph 4? 
A Yes, 
there 
are. 
E
Q 
And paragraph 5? 
A Yes. 
Q 
And the final catch-all paragraph? 
A Yes. 
Q 
The next document is way back in the file now at page 76.  Dr Southall, this is a letter 
F
from Professor Warner to Dr Smart, who I think was part of the GP practice. 
A 
I am not sure, but probably. 
Q 
If we look at page 77 we see that it is copied as well to Dr Whiting, Professor Strobel, 
you and Mr Evans of social services. 
A Yes. 
G
Q 
Professor Warner begins the letter by referring to a promise he made at the case 
conference.
A 
That is correct. 
Q 
Looking through that letter, do you divine from the content of it reasons for it being 
filed in the special cases file alone, or not? 
A 
Yes.  There is the policy.  There is the fact that it discusses the case conference and 
H
that it is copied to the child protection co-ordinator of Slough Social Services. 
T.A.  REED 
Day 11 -  16
 & CO. 

---

A
Q 
Just for completeness, I refer you on page 76 to the word, “file” and an arrow.  Is that 
your writing? 
A 
Yes, it is. 
Q 
Do you have a problem with the fact that that document was filed in the special cases 
file alone? 
B
A No. 
Q 
Page 75, please.  This is Dr Whiting to Professor Warner, 24 June 1997.  Looking at 
the bottom of the page, you are one of those copied into this correspondence, do you see? 
A 
Yes, I do. 
Q 
When we see the word, “file” on that document, is that your writing? 
C
A 
Yes, it is. 
Q 
This was found in the special cases file only, as we know.  What is the justification 
for that? 
A 
It is the policy following the discharge.  By itself though it does not contain, as far as
I can see, anything directly relating to child protection so there would be no problem if it was 
filed in the main hospital file as well. 
D
Q 
Looking at that particular document today, nine years later, what would you do with 
it?
A 
I would put it in the special case file.  I would not put it in the hospital main file 
myself, but I would not have a problem if somebody did. 
Q 
Page 70, please.  This is Professor Warner to Ms Davies at the social services, 
E
September 1997, and copied as we see on page 72 to a number of people, but not apparently 
copied to yourself. 
A 
Unless it went over the page.  I do not know. 
Q 
We have only just been supplied with page 72.  At any rate, it is in the special cases 
file. 
A Yes. 
F
Q 
Again, is there a justification for it being there? 
A 
Yes, the policy, plus it does describe the child protection co-ordinator.  That is who it 
is addressed to.  It is also copied to the mother and I considered it appropriate that it is in the 
special case file only, then and now. 
Q 
If we can just deal with that, that it is copied to the mother.  Is there any particular 
G
reason in those circumstances why it goes into the special cases file? 
A 
It is sensitive data.  It is highly sensitive.  If I was her, I would not want such a letter 
in a hospital record that could be seen by people who do not need to know. 
Q 
Then there are three pages, at pages 48 to 50.  This is a letter about Mrs D from 
somebody who was a nursing assistant. 
A Yes. 
H
T.A.  REED 
Day 11 -  17
 & CO. 

---

A
Q 
This is filed, as I understand it, solely in the special cases file.  Again, why would you 
seek to put that only in the special cases file? 
A 
Again, it is about the mother.  It is about her behaviour, not about anything to do with 
her child.  It could be linked to the child protection issue.  It mentions the child protection 
issue, so all in all, for policy reasons and also because of child protection then and now, it 
should be in the special cases file only. 
B
Q 
If you turn back to page 41, you will see a letter from Dr Macaulay, consultant 
psychiatrist, addressed to yourself. 
A Yes. 
Q 
Dr Macaulay writes – I do not know whether Dr Macaulay is male or female – 
“I am also enclosing a copy of an account by [name], the contents of which are self-
C
explanatory”.
Clearly the reference there is to pages 48 to 50. 
A 
Yes, it is. 
Q 
Did you understand why Dr Macaulay might be writing to you? 
A 
I think he understood how important that case conference had been to the child and he 
D
also, I think, knew that I was under fire over my work with this child. 
Q 
When you say, “under fire”, can you be a little bit more specific? 
A 
I think there were a lot of allegations being made about my involvement which were 
derogatory and were saying that I should not have been involved.  I think he, if I remember 
this rightly, was supportive, very much so, of what had happened and how the case 
conference and what had been revealed there had been so helpful to the child and to the 
E
family. 
Q 
When you talk about criticisms about your involvement, do you mean involvement 
after 1994? 
A 
Yes, after that. 
Q 
Can you now look, please, at page 31?  This is Professor Warner to you.  Is that your 
F
writing on the right hand side? 
A 
Yes, it is. 
Q 
Help us with the shorthand you use there, please. 
A 
“Can I have [name] hospital and S/C file asap”, as soon as possible. 
Q 
Who is that request made to? 
G
A 
That will be my secretary. 
Q 
Did she know you had SC files? 
A 
Yes, she was using them all the time. 
Q 
Professor Warner to yourself, 2 December 1997.  We are now three years down the 
line, almost exactly. 
H
A Yes. 
T.A.  REED 
Day 11 -  18
 & CO. 

---

A
Q 
The reason please for this being filed only in the special cases file? 
A 
The policy, however there is really nothing in it that would be a breach of confidence 
to the family.  The wheelchair question is really obscure to anybody who does not know the 
history, so it could have gone in both, and I have no problem with that at all. 
Q 
The next document is at page 25.  This is Professor Warner to Dr Smart and copied to 
B
you, Professor Strobel and, over the page at page 27, to another paediatrician, Dr Colby,
Ms Davies of social services, and Mrs D, the mother. 
A Yes. 
THE CHAIRMAN:  Can I just take the opportunity to remind the press that if a name should 
slip out, they should not report it. 
C
MR COONAN:  Dr Southall, if you look at this document from professor Warner to  
Dr Smart, copied, as we know, to Mrs D, can you tell us the reason why this was filed in the 
special cases file only? 
A 
The policy, and the very fact that it has got copied to a child protection coordinator, 
would mean that it should only be in the special case file because of its confidential nature. 
Q 
Turn back to page 21 please, Professor Strobel to yourself, December 1997.  Looking 
D
at the first line, he has seen copies of the letters of Dr Macaulay and the nursing assistant that 
we have already looked at.  What is the underlying reasoning for this being in the special 
cases file alone? 
A 
The policy and the discussions in, particularly, the first two paragraphs. 
Q 
You are directing particular attention to those two paragraphs? 
A 
Yes, I am. 
E
Q 
I should just ask for completeness, is that your writing where it says “File”? 
A 
Yes, it is. 
Q 
Then we go to page 16, Professor Warner in Southampton to Dr Smart.  Is that your 
writing where it says “File”? 
A 
Yes, it is. 
F
Q 
I just draw attention to the last paragraph: 
“However there appear to be continuing exchanges of correspondence between 
various individuals who have been involved with his management in the past, copies 
of which his parents have.  This obviously is having a major undermining effect and 
maintaining an acrimony which I feel ought now to be resolved.” 
G
Pause there.  Do you want to make any comment about those observations by
Professor Warner? 
A 
I completely support Professor Warner in that statement.  I think there was time to 
draw a line under it all.  The situation was improving, everything was going well, and so  
I agree completely with him. 
H
Q 
Why was this document filed solely in the special cases file? 
T.A.  REED 
Day 11 -  19
 & CO. 

---

A
A 
Because of the policy and perhaps, in part, because of that last paragraph.  It would be 
best I think if that was only in the special case rather than main hospital file, but I do not feel 
very strongly about it.  It could be, or both – not either, both. 
Q 
The penultimate document I ask you to look at is on page 9.  Again, this is a letter 
from Professor Warner, once again to Dr Smart and several months later – three months later.  
This was found in the special cases file only.  Is that your writing where it says “File”? 
B
A 
Yes, it is. 
Q 
What is the reason why this was in the SC file alone? 
A 
This is nearly four years after.  It is part of the policy.  It does not contain anything 
about child protection, so there would be no problem if a copy was filed in both the special 
case and main hospital medical file. 
C
Q 
Finally, on page 2, nearly three months later, a further document from  
Professor Warner to the GP, copied to you.  We see that on page 4. 
A Yes. 
Q 
If I may say so, the same sort of structure set out as the previous one we have looked 
at?
A Yes. 
D
Q 
This is in the special cases file alone.  Is that your writing on page 2? 
A 
Yes, it is. 
Q 
What is the reason why this was filed in the special cases file alone? 
A 
The policy, but again, looking at the last paragraph, there is a reference to case 
conferences and so I think this should only be filed in the special case file. 
E
Q 
Dr Southall, I have taken you through each of the letters cited in Appendix One. 
A Yes. 
Q 
I just want to ask you this about the operation of, first of all, the policy, and in so far 
as you made an individual judgement in respect of a particular document, that these 
documents ended up in the special cases file.  Was there any time in your judgement, as a 
F
result of this policy or individual judgement being made, that Child D was or may be at risk 
in the future? 
A 
I cannot see any risk to the child at all. 
Q 
Did you treat this child at any time after December 1994? 
A 
No, I am not an expert in allergy.  The child protection problems had resolved.  There 
was no reason why he would ever return to our hospital in Stoke-on-Trent; it is about 100-
G
odd miles from Slough where they live.  If he did, just supposing he was in a motor accident 
going past –because that is the only thing I can think of, a road traffic accident on the M6 – 
and got brought into our hospital, the notes would be resurrected, the notes would have 
everything in about the risk of anaphylaxis and allergy. 
Q 
When you say the notes? 
H
T.A.  REED 
Day 11 -  20
 & CO. 

---

A
A 
I mean the main hospital records, and because he was under me I would be asked and 
I could also bring out the special case file and go through all that.  All this information would 
be available should it be needed. 
Q 
If another clinician, let us say in Southampton, or you have mentioned a town just 
outside London and the West of London, if any one or other of those paediatricians or 
clinicians wanted information about this child which they may or may not, rightly or 
B
wrongly, have had on their own files, for whatever reason, could they have got hold of it? 
A 
Yes, they could have written to me.  I would have been reluctant to have revealed to 
anybody, without permission of social services, anything to do with child protection.  That 
was my approach to this.  I felt that child protection is led by social services.  Even though
I am a doctor in a hospital involved in it, if somebody wanted access to these they could get 
the medical material but anything to do with child protection I would usually refer to social 
services.
C
THE CHAIRMAN:  Mr Coonan, would there be a convenient moment for us to take a break 
shortly?
MR COONAN:  Madam, yes, certainly. 
THE CHAIRMAN:  Is that satisfactory? 
D
MR COONAN:  Yes, indeed. 
THE CHAIRMAN:  Thank you.  We will break for twenty minutes now.  It is about twenty-
five to twelve.  That will take us to five to twelve.  I need to give you the usual warning, 
Dr Southall. 
E
THE WITNESS:  Yes.  Thank you, madam. 
MR TYSON:  Madam, can I just add something?  There has been a reference to the area 
where this mother lives and I wonder if a warning can be given when the press returns.
I notice one or two have left. 
THE CHAIRMAN:  That anonymity extends to the location as well as the name? 
F
MR TYSON:  One would assist the other. 
THE CHAIRMAN:  I will repeat that afterwards. 
(The Panel adjourned for a short time)
G
THE CHAIRMAN:  Mr Coonan, before we begin there are two matters.  First, I would like to 
remind any press present that the anonymity of the families involved in this case should be 
preserved in anything that is published, whether it is name or location.   
The second matter is that during the evidence before the break you asked Professor Southall a 
question which he said he was unable to answer in public session.  The Panel have asked that 
they would like to go into private session in order to enable Dr Southall to answer the 
H
question.  Do either of you have any comment on that proposal from the Panel? 
T.A.  REED 
Day 11 -  21
 & CO. 

---

A
MR COONAN:  Speaking for myself, on behalf of Dr Southall, I would have no objection to 
that, and if the Panel wish to hear it then of course they are entitled to hear it. 
THE CHAIRMAN:  Mr Tyson? 
MR TYSON:  I have got no problem with your route, madam.  Another way of dealing with 
B
it, which would be in semi-public session, is for him to write down on a piece of paper what 
those initials stand for, which is what I was planning to do when I asked him questions in 
order to deal precisely with that, and for that bit of paper to be shown to everybody in the 
Panel and to be recorded in the Panel’s list of documentation. 
THE CHAIRMAN:  I see, just looking at the Panel, that they would prefer the route for 
allowing Professor Southall to answer the question verbally.  Since this refers to evidence 
C
that was given before the break, before you move on now would seem to be as appropriate a 
time to deal with this matter as any.  In order to permit Dr Southall to answer the question the 
Panel will resolve to go into private session. 
MR COONAN:  Thank you, madam. 
THE CHAIRMAN:  The Panel is now going into private session.  We will call the public 
D
back as soon as this one matter has been dealt with. 
STRANGERS THEN, BY DIRECTION FROM THE CHAIR, WITHDREW
AND THE HEARING CONTINUED IN PRIVATE
(Please see separate transcript for hearing in private)
E
STRANGERS HAVING BEEN READMITTED
THE CHAIRMAN:   You can continue, Mr Coonan. 
MR COONAN:   Thank you, madam.  (To the witness)  Dr Southall, before leaving this 
document, could you just have a look at the original special cases file dealing with this 
material, please.  (Same handed)  I have had it handed to you deliberately open at that 
F
section.  Can you at the same time go back to our bundle C6 and open the bundle of 
photocopies at page 229.  I just want to clarify one point, please.  In our bundle at 229, 
following through to 244, there are a series of pages on which, as you have already explained, 
you have underlined various passages. 
A Yes. 
Q 
There were comments and marks in the margin.   
G
A Yes. 
Q 
Now, looking at the original file, which is in front of you, looking at that, are the 
markings and underlinings on a photocopy of the document or on a hard copy, or on a hard 
document, if I can put it that way? 
A 
A hard copy, I think. 
H
T.A.  REED 
Day 11 -  22
 & CO. 

---

A
Q 
Because if you go back to page 229 itself in bundle C6, you will see a reference to 
“S/C file” in your writing, as you have described it. 
A 
Yes.   
Q 
Do you see your original writing on that equivalent document? 
A 
Yes, I do. 
B
Q 
So can we assume, as you said earlier in your evidence, as I understand it, that was in 
fact on a hard copy? 
A 
I think so, yes. 
Q 
We also have in our bundle C6, at pages 245 to 261, what is in our bundle a 
photocopy.  Is there the same clip of correspondence in the original SC file? 
A Yes, 
there 
is. 
C
Q 
Is that a hard copy document, a photocopy or a fax? 
A 
Well, I think it is a copy, a photocopy. 
Q 
So the Panel can of course see the bundle for themselves, but pages 245 to 261, is that 
a photocopy, unmarked photocopy? 
A Yes. 
D
Q 
Thank you very much.  That is all I ask you about C6.  Can you just put the original 
file to one side. 
Now, Dr Southall, you were explaining to the Panel before we had the short adjournment in 
effect about access to these records. 
A Yes. 
E
Q 
Where in fact was this particular special cases file kept as far as you recall? 
A 
In the secure room in the Academic Department of Paediatrics. 
Q 
Where physically were the main hospital file notes kept in the hospital? 
A 
There are two sites to the hospital, and I think they are the site, not the site where the 
children’s unit is;  I think it is called the Sutherland Library. 
F
Q 
It may or may not matter, but when you say “two sites”, what is the difference 
between the two sites? 
A 
About half a mile. 
Q 
When you needed to get access to the main hospital file – I say “you”;  “one” needed 
to do that – what was the procedure that you had to adopt to go and get access to the notes? 
G
A 
Well, my secretary would request them from the medical records department and they 
would eventually arrive. 
Q 
When you say “eventually”? 
A 
It depends on the speed at which you wanted them.  Now, I cannot remember what it 
was like then.  Now it is good. If you want it in an emergency, you can get them.  I can only 
talk about now.  I cannot remember what it was like then, although I think it was not quite as 
H
good as it is now. 
T.A.  REED 
Day 11 -  23
 & CO. 

---

A
Q 
During the period when you were suspended, do you know what happened to these 
notes? 
A 
I am pretty sure that these notes were looked at as part of, and I know they were, they 
were looked at as part of the inquiry into my child protection work, this case. 
Q 
So how did it come about that they were looked at?  Did you get them and hand them 
B
over to those who were charged with carrying out the inquiry?  How did it happen? 
A 
Well, when I was suspended I had to leave the hospital immediately.  The next I knew 
about this was I think almost eighteen months later, when I realised that one of the cases 
being considered by the hospital, as part of their child protection inquiry, was this case.  So
I was sent some questions to answer, which I had to answer, and in answering I think I was 
given a copy of this file.
C
Q 
Of the SC file? 
A 
Yes.  I am pretty sure I was, because they were detailed questions and I would have 
needed to see it in order to answer their questions. 
Q 
So how did anybody get access to the file in your absence? 
A 
Oh, I mean, the hospital could access all of our – I mean, we are in the hospital itself.  
This is not a building, the Academic Department, which is somewhere else separate from the 
D
hospital, it is a hospital building with security, fire alarms, everything.  The hospital 
management had the secure room codes, they could access everything, but only certain 
obviously senior people would be able to do that. 
Q 
Can I ask you, please, to look at bundle C2, and if you go to tab 4 at (k).  This is a 
series of letters from pages 1 to 36 that we have looked at already, and I just want to ask you 
a number of questions arising out of that series of correspondence.  On page 1 we know that 
E
in October 1997 Mrs D requests a copy of her child’s notes.  That is self-evident from the 
first letter. 
A Yes. 
Q 
That is in 1997, but there is further correspondence involving Mrs D and the Trust, 
principally somebody called Mr Fillingham.  Did you know Mr Fillingham? 
A 
Yes, I did. 
F
Q 
If you go to page 16, that on 30 March 1998 Mr Fillingham writes to Mrs D, and says 
in the second paragraph: 
“You have already had access to [Child D’s] records under [the] unit number…”  
and the number is set out. That is the hospital number? 
G
A 
Yes, it is. 
Q 
“…some time ago.  As you are already aware there has been extensive 
correspondence and copy documentation from agencies such as ….. Social Services, 
Great Ormond Street ….. and [a] Health Authority.  The Trust is unable to disclose 
those documents as they are confidential and do not form part of [Child D’s] records.” 
H
T.A.  REED 
Day 11 -  24
 & CO. 

---

A
Were you aware of this correspondence passing to and from Mrs D and Mr Fillingham up to 
that date? 
A 
I cannot remember.  I might have been, but I cannot remember. 
Q 
If you move to page 23, Mrs D in January 1999 is writing to the Ombudsman, and at 
the latter part of that letter Mrs D expresses this: 
B
 
“It is my view that Professor Southall at North Staffordshire has not acceded to my 
request for access to all my son’s medical records, as the hospital claims that some of 
these are the property of Professor Southall, as they form part of his research.” 
I pause there.  Whatever may have been a view expressed by the hospital, were you at this 
stage expressing the view that she could not have access to these records because they were 
your property? 
C
A No. 
Q 
Were you expressing the view to anybody that she could not have access to these 
notes because they formed part of research? 
A 
No, there is no way there was any research going on on this child at all at any stage. 
Q 
Then on page 26, in March 1999, Mr Blythin writes to Mrs D and says, in the second 
D
line,
“I confirm that there is no additional documentation other than that which was sent to 
you on 30 March 1998.  There is however copy documentation from agencies such as 
social services, a community health authority and a general hospital which the trust is 
unable to disclose”. 
E
There is a reference in the next paragraph to computerised records, to which I shall come 
back.  Dealing with that main paragraph, insofar as the trust was taking that stance, was that 
stance on your instructions or not? 
A 
No, it was not. 
Q 
Still in the same bundle, C2, I want you now to move please to Section 6 and turn in 
that to Tab (b).  Bear in mind that the last letter I drew your attention to was in March 1999 
F
and we are now in April.  Although we have this document here, which we have been 
supplied with, as an unsigned copy, I do not know, do you accept that you sent this to  
Mrs Dawson? 
A 
Yes, I accept that.  
Q 
Did you know Mrs Dawson at that time? 
A 
Yes, I did. 
G
Q 
Had you had dealings with her before April 1999? 
A 
Lots of dealings, yes.  She was our manager. 
Q 
When you say, “our manager”, what does that mean? 
A 
Child health directorate manager.  She was one of them anyway. 
H
T.A.  REED 
Day 11 -  25
 & CO. 

---

A
Q 
Again, for those who do not operate in hospital settings, how did she fulfil managerial 
functions vis a vis clinicians? 
A 
She looked after the management side.  She was the deputy business manager so she 
would attend consultant meetings.  She would relate to us with regard to any tertiary hospital 
admissions, for instance.  We had a lot of dealings with her. 
Q 
Did she know about the security arrangements? 
B
A 
Yes.  She was involved in setting them up, I think. 
Q 
She was involved in setting them up? 
A 
I think so.  I mean, you would have to ask her, but I would have thought she was, yes. 
Q 
Did she know about the existence of special cases files? 
A Yes. 
C
Q 
How did she fit into the management tree, if I can put it that way?  We have in our 
minds, for the minute, Mr Fillingham, then Mr Blythin.  Where did Mrs Dawson fit into that? 
A 
Mr Fillingham was the chief executive.  Mr Blythin was the chief nurse at the 
hospital.  Then there was a business manager and she was the deputy business manager. 
Q 
Who was the business manager? 
D
A 
I cannot remember when it changed, but Peter MacAloon was one of them.  I think he 
was earlier.  I cannot remember who it was at this time. 
Q 
On a day to day basis, in so far as there needed to be a managerial interface between 
clinicians and an administrative structure, who did you deal with? 
A 
I think Mrs Dawson was pretty much the key person. 
E
Q 
This letter – can I take you to it, please – 
“Dear Diane, re Child D complaint:  In no way was D subject to any form of research 
in my department”. 
Was that true? 
A 
Yes, it is. 
F
Q 
You go on, 
 
“I enclose his special case file”. 
I will stop there.  Did you enclose his file? 
A 
It says I did. 
G
Q 
Is there any reason why you would not? 
A No. 
Q Continuing, 
“so that you can look through it and decide how you describe the various contents of 
H
this”.
T.A.  REED 
Day 11 -  26
 & CO. 

---

A
I pause there.  What were you inviting her to do exactly? 
A 
Well, look at the different letters and the different bits of correspondence and decide 
whether they were social services, which hospital they came from and so on. 
Q 
For what purpose? 
A 
For the complaint. 
B
Q 
Who was going to make the decision as to which, if any, of these documents should 
be disclosed? 
A The 
hospital. 
Q 
Then you go on, 
C
“My view is that they are part of social services and other hospital records rather than 
being directly related to his admission to the North Staffordshire Hospital under my 
care as consultant paediatrician”. 
Can you help the Panel, please, about that sentence: 
 
“My view is that they are part of social services and other hospital records”? 
D
What did you mean by those two elements? 
A 
There were documents in there relating to confidential issues such as case conferences 
and strategy meetings, and then there was the correspondence that we went through this 
morning from other consultants to me or me to other consultants. 
Q 
When you used the expression, “other hospital records”, is the emphasis on the 
E
hospital or the total phrase? 
A 
I see what you mean. 
Q 
Well help the Panel, please. 
A 
Other hospitals, I think that is what I meant. 
Q 
We have seen, with your assistance this morning, the other hospitals involved with 
F
this young child. 
A Yes. 
Q 
I am not going to mention them in open session.  What is your view, Dr Southall, 
about the accuracy of the view you were then expressing in April 1999?  Are you happy with 
that?
A 
Yes, I am happy with it, yes. 
G
Q 
Was there any stage during the relevant period in relation to Child D or Mrs D when 
you prevented, or obstructed or were reluctant to disclose any of the documentation in the 
special cases file? 
A No. 
Q 
Dr Southall, I am going to turn to the subject of computers.  Can you have, please, in 
H
front of you Appendix Two of the Notice of Hearing and Bundle C10?  During the course of 
T.A.  REED 
Day 11 -  27
 & CO. 

---

A
your evidence on Friday, you explained to the Panel that there had been a computer at the 
Royal Brompton and that had come with you to Stoke. 
A Yes. 
Q 
Secondly, there was a stand-alone computer in the academic department, but that that 
had been taken, or had access to it during the period of your suspension, and you came back 
and found that the password had changed. 
B
A Yes. 
Q 
Let us go back, please, because this is very much a stand alone topic in itself.  In 
respect of the data on the Brompton computer, was that data at any stage transferred across to 
the Stoke computer? 
A Yes. 
C
Q 
I am speaking generally now. 
A Yes. 
MR COONAN:  What was the purpose in transferring the data? 
MR TYSON:  I was muttering under my breath, but my understanding of the evidence was 
that it was the same computer that went from Brompton to Stoke. 
D
MR COONAN:  That is right. 
MR TYSON:  So he did not have to transfer the evidence because it was on the same 
computer. 
MR COONAN:  I am sorry, I will deal with this in my own way.  You had the computer from 
E
Brompton to Stoke. 
A Yes. 
Q 
On Friday you spoke about that computer being an Apple. 
A 
Yes, an Apple Mac. 
Q 
And the Stoke computer having a Windows system. 
F
A 
That is right, yes. 
Q 
And at some stage there was some transfer.  You referred to that. 
A Yes. 
Q 
I am now going to ask you about that topic.  Did you, or others under your direction 
or control, transfer all the data from the Brompton computer to the Stoke computer? 
G
A Yes. 
Q 
The reason why you did that? 
A 
I think – I cannot remember the exact reason – that it must be something to do with 
the operating systems being compatible with the hospital operating system, because almost 
everything was becoming Windows driven rather than Apple driven.  It is something like 
that, but I cannot really remember why. 
H
T.A.  REED 
Day 11 -  28
 & CO. 

---

A
Q 
Was the Brompton computer which ended up in Stoke, was that used to store Stoke 
data? 
A Yes. 
Q 
The Brompton computer. 
A Yes. 
B
Q 
Whatever was operating at any particular time may or may not be a matter for further 
scrutiny, but I am concerned now with particular data which appears in C10.  We know from 
the evidence given by Ms Ellson, which was read to the Panel, that on the Stoke computer 
there were two databases, SC and recordings. 
A Yes. 
Q 
Looking at the Stoke computer, what do we understand to be the intrinsic difference 
C
between the two databases? 
A 
The SC patient data file is just a summary of the name, address, numbers; very basic 
information to help us with clinical audit and for getting the patient up and finding that 
patient, if you like. 
Q 
The recordings database? 
A 
That was different.  That is a database for sending out information on the analysis 
D
made of the recordings.  Either sending it to the hospital main file or sending it out to others, 
depending on the stage and development of the computer database system. 
Q 
Let us deal with each individual patient first and then we will deal with a number of 
general matters at the end.  Let us go straightaway to deal with child D.  If you look at C10, 
pages 1 and 2, two preliminary matters, please.  Do you see in the top left hand corner, “SC 
File 314”? 
E
A Yes. 
Q 
In the left hand margin, where we see, “Records 4449”, can you help from your 
standpoint with what that number means? 
A 
I think that means the total number of special case files. 
Q 
Held in effect by you at that stage in Stoke? 
F
A Yes. 
Q 
Did that include Royal Brompton SC files? 
A Yes. 
Q 
This document is headed, “Patient’s data”.  What was the purpose of this? 
A 
It is to summarise issues such as the name and address, the GP’s name and address, 
G
the diagnosis summary and admissions summary.  It is for us to search a patient if we needed 
to do a clinical audit.  Suppose we wanted to know every patient with, say, upper airway 
obstruction.  We could put that in under the diagnosis, possibly, and bring out 20-odd 
patients, perhaps.  It depends what it was, but it is a database. 
Q 
The information which is in this document as we see it, is that information to be found 
elsewhere in the notes? 
H
T.A.  REED 
Day 11 -  29
 & CO. 

---

A
A 
Yes.  This is already in the hospital main medical record collected by the admissions 
clerk plus the nursing staff, plus the medical staff. 
Q 
Can we look, please, at two non-exclusive – I emphasise this – examples of that?  
Look, please, at C2, Tab 4 at (g).  Dr Southall, I do not want to spend over long on this, but if 
one was to look for the information contained on page 1 of C10, would one find it in the body 
of these notes? 
B
A Yes. 
Q 
In particular, would one find the diagnosis? 
A Yes. 
Q 
Look, please, at page 601 and following.  Can you help us with that? 
A 
In the middle of the page, the two phrases from the patient data form are actually 
C
written in the clerking-in notes there, 
 
“Low body temperature.  Multiple allergies”. 
Q 
Others may wish to do so, but I am not going to take over long on this.  You say the 
information is in these notes. 
A I 
do. 
D
Q 
The other aspect of this – can I ask you now to go back to C6, the SC file, to page 
313?  Help the Panel, please, by looking at page 1 of C10 on the one hand.  Just pause for a 
minute, by looking at page 1 of C10 and page 313, would you like to comment on each of 
these documents? 
A 
They are the same document except in different format. 
E
Q 
Thank you.  If you go to the second page in C10, as a document is it different from or 
the same as page 1? 
A 
It is the same, but you can see there are some problems with this.  It is not printing 
correctly.  There is something gone wrong with the linkage to the printer, I think. 
Q 
This was a document which was printed for Field Fisher Waterhouse on 31 October 
this year.  Is that right? 
F
A 
Yes, it is. 
Q 
Did you have any difficulty printing that off? 
A 
I did, yes, that is why I took a screen shot. 
Q 
Just so we understand it, is the first page of C10, what has been called a “screen shot”, 
you did the printing off, so I am going to ask you, how did that come about? 
G
A 
It is a button you press to print the screen and then it saves it to a clipboard and then 
you print it. 
Q 
That is page 1.  How does page 2 differ? 
A 
Page 2 is straight from the computer to the printer.  It should come out like 313. 
Q 
Leaving aside the difficulty in printing page 2 in a clearer format, so far as page 1 is 
H
concerned, did you have any difficulty taking a screen shot there? 
T.A.  REED 
Day 11 -  30
 & CO. 

---

A
A No. 
Q 
In relation to data stored in the computer coming up on the screen, would there have 
been any difficulty for anybody with access to the computer having a problem? 
A No. 
Q 
Just remind us, who did have access to this computer storing this data? 
B
A 
Myself, Dr Samuels, the clinical nurse specialist, the computer department.  Maybe a 
nurse on the ward, a senior nurse, if they wanted to we would show them. 
Q 
That is all I ask about Child D.  We move on to Child H please.  We have been 
supplied in C10 with pages 3 running through to 9.  Leaving aside pages 3, 4 and 5, can I ask 
you for your comments on pages 6, 7, 8 and carried on over to 9?  Do those relate in any way, 
and if so what, to pages 3, 4 and 5? 
C
A 
They are the same patient.  He was not a patient in Stoke.  He was a patient at the 
Brompton Hospital.  Pages 6, 7 and 8 are the equivalent of the patient data form we discussed 
for Child D.  Sorry, page 7 is equivalent to the patient data form – it says it at the top.  Pages 
7 and 8 are letters but they are on the Academic Department of Paediatrics heading -- 
Q 
Why is that? 
A 
Because they are imported data from the Brompton, which I think – I am not sure – 
D
whether at the time we were in the Brompton we had a letter going automatically.  It looks as 
if we did, but of course it has got the wrong header on it.  It should have the Brompton 
heading.
Q 
If we take, for example, page 4, is there any other document in this clip which is in 
terms of the data in it, the same or similar to it?  Looking at page 4 and page 6, can I invite 
your comment on those two, please? 
E
A 
I think page 4 is the screen shot and page 6 is the physiological recording result. 
Q 
Within the computer? 
A 
Within the computer. 
Q 
Look at pages 5 and 7? 
A 
That is the same again.   
F
Q 
Spell it out? 
A 
The 5 is the screen shot, and page 7 is the direct printout. 
Q 
Look at page 3 and page 8? 
A 
Page 3 is the screen shot, page 8 is the direct computer printout. 
G
Q 
I am going to concentrate on pages 3, 4 and 5.  This, as you have explained, is a 
document which is capable of being seen on a screen, obviously because you have got it up 
on the screen for Field Fisher Waterhouse? 
A Yes. 
Q 
The data in there which we see in screen form, should that data in documentary form 
have been filed elsewhere? 
H
A Yes. 
T.A.  REED 
Day 11 -  31
 & CO. 

---

A
Q 
Where should it have been filed? 
A 
In the main medical record file. 
Q 
The fact that it was not, can I have your comment on that please? 
A 
It was policy at the Brompton for that to have been done.  I directed it to be done.  If it 
was not done there could be a number of reasons, but I do not know what they are. 
B
Q 
That is page 3.  Page 3 of course referring to September 1989 and page 4 relating to 
March 1990. 
A 
Those are the two admissions. 
Q 
The two admissions? 
A Yes. 
C
Q 
In respect of page 4, insofar as that represents data in that form stored in the 
computer, should that data have been printed off and stored in the medical records? 
A 
Yes, the same principle applies. 
Q 
Page 5 is in a different form in the sense that it is not addressed to anybody, and it 
does not have “Dear X”? 
D
A No. 
Q 
It is headed “Patient’s Data.”  Insofar as the information stored in the computer which 
is manifest in this screen shot and is capable of being printed, should that have been printed 
off and placed in the main medical records? 
A 
It could have been but there was not a policy for it to be so placed because that 
information is all available in the medical record anyway.  This is for our purposes, as was 
E
the case with Child D.  We talked about that. 
Q 
I am going to ask you please just to look at a very small clip of medical notes from 
Child H’s notes for you to comment.  Perhaps those may be distributed.   
THE CHAIRMAN:  This is D15.n  (Same handed and so marked)
F
MR COONAN:  Thank you very much.  (To the witness)  Dr Southall, I am looking, first of 
all, at page 3 of C10.  This limited exercise is just to invite you to comment, please, to the 
extent that the material is to be found in the hospital notes. 
A Sure. 
Q 
With page 3 on one side, if you look please at page 12, which may be the last page in 
the clip, page 12 at the bottom? 
G
A Yes. 
Q 
Is that associated with page 3 in any way? 
A 
Page 12 is the equivalent of page 3, but in a different kind of format.  It is a proforma 
that is hand filled in rather that computer entered. 
H
T.A.  REED 
Day 11 -  32
 & CO. 

---

A
Q 
That may be, but the nature of the exercise is to see the extent to which there may or 
may not be information in another document compared with what is on the screen or in the 
computer.  Do you follow? 
A 
I do, yes. 
Q 
In relation to that question, what do you say about page 12? 
A 
Right.  If we start at the top, the name and date of birth are both there.  The hospital 
B
number is not filled in on this computer one but it is on the proforma.  The special case 
number is filled in on both.  The date of tape is filled in on both.  The referring doctor is filled 
in only on the proforma, as is the referring hospital, only on the proforma.  The reason for the 
recording is filled in only on the proforma, and then the results …  There is a blanket one 
under “Results” on the computer but details on the four “Normals” under the results.  Then 
recommendations is nil on the computer and “To re-admit when having cyanotic episodes for 
repeat recordings” comes under the “Follow-up” bit, not the “Recommendation” bit, on the 
C
computer. 
Q 
Again, it may be obvious, but which is the fuller record? 
A 
The one that is filled in the medical record.  This is the proforma, and of course I am 
asking myself, looking again at this, how come there is a difference?  I mean, what is this 
one, the computer record?  How was it created?  I cannot remember, I really cannot be sure. 
D
Q 
I will ask you, please, whilst we have the clip of correspondence available, to look at 
page 5 of C10.  If you go to the clip you will see page 1 at the bottom? 
A Yes. 
Q 
You will also see a medical report by you? 
A Yes. 
E
Q 
Pages 27 to 31. 
A Yes. 
Q 
Just taking those two documents alone for the minute, to what extent can you help the 
Panel?  Do they underpin, if at all, the contents of the document at page 5 of C10? 
A 
I think they are completely replicated in the medical record, all of the information on 
the computer, patient data. 
F
Q 
Finally just two references, in C1, tab 2(d).  These are admission notes in March 
1990? 
A Yes. 
Q 
Again, forgive me, I am not going to go through this process laboriously.  What, if 
anything, do you say to the Panel about these records in the main medical records, C1/2(d)?  
G
To what extent do they underpin the material on page 5 of C10? 
A 
Again, the information is all there in different places in the medical record, but here 
there is quite a lot of information that is repeated on page 5, such as developmental delay 
listed under (4), and is on here as well. 
Q 
That is page 5.  Therefore, finally I ask you about page 4 in C10.  You have just 
drawn the attention of the Panel to the admission notes for March 1990 and I am not going to 
H
T.A.  REED 
Day 11 -  33
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A
go back to those, but in addition can I ask you please to look at C2(f)?  Looking at page 4 in 
C10 and this entry in tab (f), is there any linkage between the two in any way? 
A 
Yes.  The date, name, special case number is there.  It is the recording result for 24 
September. 
Q 
That is the date of birth? 
A 
I am sorry, yes. 
B
Q 16 
March. 
A 
16 March, sorry.  The date on here is 16 March, yes.  There is a link, yes. 
Q 
More than just a link with the name and date of birth.  What about the results? 
A 
Yes, the results are far more comprehensive than is in the normal recording bit and the 
recommendations are more comprehensive than is in the – or different, even, too. 
C
Q 
Should this page, in so far as it represents data stored within the computer, in fact 
have been filed in the medical notes? 
A This 
one? 
Q 
Yes, page 4 in C10? 
A 
Yes, that was the policy, but I am not convinced …  Because of this proforma, this is 
D
the one that --- 
Q 
You say “this.”  Can you refer to which one? 
A 
I am sorry, page 14.  This is the one that should be in the medical records for certain.  
This one is just the same but our computer format, so the fact that this, if this is in the medical 
records --- 
E
Q 
Which it is. 
A 
Which it is, then this is what matters.  This is the original recording result for the child 
signed off by me, handwritten into a proforma.  This is a computer data, probably a copy 
made by somebody to complete the records in the computer system.  (witness indicated)
MR COONAN:  Thank you very much.  Madam, that might be a convenient moment. 
F
THE CHAIRMAN:  Thank you very much, Mr Coonan.  It is now five past one, so we will 
break for one hour till five past two.  I am obliged to repeat the usual warning, Dr Southall. 
THE WITNESS:  Thank you. 
(Luncheon Adjournment)
G
THE CHAIRMAN:  Good afternoon.  I understand, Mr Tyson, you have found that material 
that Mrs Lloyd was referring to this morning. 
MR TYSON:   That is right, madam.  We were looking at C6 at page 238, and we see that in 
August 93 Child D was admitted to the hospital there mentioned, and Mrs Lloyd enquired as 
to whether there were any other words recorded in the notes, and I have the clinical note for 
that entry from those hospital records, and perhaps it would be easiest if I were to pass it 
H
round.  (Document shown to the witness and the Panel)
T.A.  REED 
Day 11 -  34
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A
MR COONAN:   Dr Southall, can we look at the last two cases in C10, please.  First of all, 
Child A.  Would you look at page 10 and page 11.  These two refer to Child A.   First of all, 
there is on page 11 what appears to be, using your description, a screen shot. 
A 
Yes, of page 10. 
Q 
On page 11 is a screen shot, is that right? 
B
A 
Yes, that is right. 
Q 
The data form is on page 10, is that right? 
A 
Yes, it is. 
Q 
Is there actually any useful information in either of these two documents? 
A 
Well, not much.  There is the name, the case number and the date of referral, but the 
C
date of referral is the same as the date, and I just have a feeling this is not really a proper 
record, remembering this was a long time earlier in the sequence, and I suspect that some of 
the data was transferred to the computer, but only a little bit of it, if you like.
Q 
The ultimate question is whether or not the data in this form, in other words either the 
form that we see on page 10 or in the form on page 11, or both, whether such a document if 
printed off should have been in the medical records? 
D
A 
Well, there is so little on it.  I mean, in theory, if you follow the original ruling, yes, 
but this was a long time earlier than the Dr Jawad letter for instance, so I think this is – I do 
not know what to say about it.  It just does not contain much information at all, so it is not 
going to make any difference to the record, except to make it bigger by virtue of one page. 
Q 
Is it going to assist any clinician at any time? 
A No. 
E
Q 
I now turn to Child B, and I want to look with you, please, at pages 12, 13 and 14.
Page 13, is that a screen shot? 
A 
Yes, I think that is a screen shot of page 14, yes, it is. 
Q 
Screen shot of page 14.  What is page 12? 
A 
That is the patient data form as before, summary for the computer. 
F
Q 
Before we look at the body of this material, we heard evidence from Ms Ellson that 
on 31 October you had been able to first of all have up on the screen and print off material in 
relation to the other three cases, but that you had some difficulty getting into the computer, if 
I can put it that way, in relation to case B. 
A Yes, 
exactly. 
G
Q 
Is that right? 
A 
It is.  I tried to put the name in and the number, and I could not get it to link anywhere 
in the computer.  Then I tried it through the first name rather than the surname, that was later 
though, and then it did link.  I do not understand why. 
Q 
Did you think of the reason at the time? 
A 
I think I suggested there may have been some corruption of the database. 
H
T.A.  REED 
Day 11 -  35
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A
Q 
Resulting from what? 
A 
Well, it had gone away, passwords had been changed, it did not fit the printer.  There 
was something about it that was not right, but it is speculation;  I have no idea why. 
Q 
At any rate, there was printed off pages 14 and 12. 
A 
Yes, 12, 13, 14. 
B
Q 
Well, 13 is a screen shot, so--- 
A Yes, 
true. 
Q 
---we are looking at 12 and 14 in relation to printing off the data in the computer. 
A Yes. 
Q 
The first question is this:  so far as page 12 is concerned, the patient data document as 
C
printed, should a document in that form have gone on to the main hospital records? 
A 
No, not really.  It is already in there. 
Q 
When you say “already in there”, where? 
A 
All of the data that is on this form should be as part of the standard hospital admission 
main record.  It could have gone in, there would not have been a problem with it, but it was 
not necessary. 
D
Q 
Can I just ask you to look at one sheet from main notes, please.  Madam, may this be 
D16?  (Document handed)
THE CHAIRMAN:   D16, yes. 
MR COONAN:   At the same time, if you have available, Dr Southall, C2, tab 5(c)(ii).  Find 
E
that first, if you can, C2/5(c)(ii), and then go into the body of those notes and I think you will 
find it three pages in with number 33 at the bottom. 
A Got 
it. 
Q 
This tab that I have just drawn your attention to, (ii), is in the main hospital records, 
right?
A Yes. 
F
Q 
Now, just looking at the two documents that I have drawn your attention to, page 33 
at the bottom and this additional document D16, is that of any assistance at all in identifying 
data which may or may not be in the printed document at our page 12 of C10? 
MR TYSON:   Sorry, perhaps you can assist, I have not followed what page you are taking 
him to. 
G
MR COONAN:   Sorry, it is 33 of that tab, which is (ii). 
MR TYSON:   I have got it. 
MR COONAN:   Good.  It is out of sequence, 33.  (To the witness)  Dr Southall, did you 
follow the question? 
H
A 
Yes, just looking through--- 
T.A.  REED 
Day 11 -  36
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A
Q 
Well, take your time and just look through it. 
A 
---the only thing that I can see that is not is the word “Bradycardia”, “recurrent 
apnoea” and “Bradycardia”.  I am just looking for the word “Crawley”. 
Q 
Well, can we just take two examples.  The health visitor is mentioned on C12, do you 
see her name? 
B
A Yes. 
Q 
Her name is on page 33 at that time. 
A 
Yes, it is. 
Q 
Is the GP’s name referred to? 
A 
Yes, the GP’s name is there.  I am just looking for the address though.  The GP’s 
C
address is not on there, but it is on this one.  (Indicated)
Q 
Dr Southall, again, I am not going to go painstakingly through all the hospital medical 
notes, but what is your central point that you make about the material on page 12? 
A 
This is for the clinical audit work for finding the special case files, it is a computer 
generated document as part of the database which assists with that kind of function, but the 
data within in is reproduced in various different places in the hospital medical record, which 
D
is probably where this was derived from;  in other words, in forming this patient data a 
technician would have gone into the main medical records and obtained the data that we are 
talking about. 
Q 
A hospital technician would do that.  Would you do that on occasion? 
A No. 
E
Q 
What was the form of instruction to a hospital technician to do that? 
A 
It would be “Fill in this form and then take it to the computer and enter the data so 
that we have a complete record for every case”, something like that, and of course that 
developed over time.  It started off scantily right at the beginning and gradually built up.  
This is the most frequent patient we have seen, so this is probably a bit more detailed than, 
say, Child A – well, it is more detailed than Child A. 
F
Q 
Turn over the page to page 13.  I just set the scene, please, by looking at two aspects:
first of all, the reference on the third line of the typed text, “Your patient was referred with 
recurrent apnoea – Crawley”, and then the date 1 September 1993. 
A Yes. 
Q 
At the bottom of the print the reference to the GP’s name and his address or her 
address.
G
A Yes. 
Q 
Looking at that for a minute, and then looking at page 14, what is the relationship 
between 13 and 14? 
A 
13 is a screen shot of 14. 
Q 
Just keep 13 open and at the same time go to C2, please, back to tab 5, and go to 
H
(c)(iii), and there should be a 16 on the bottom of the page. 
T.A.  REED 
Day 11 -  37
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A
A Yes, 
there 
is. 
Q 
Just pause for a moment, please.  The document at (iii), that I have just drawn your 
attention to, you can take as being in the main hospital records. 
A Yes. 
Q 
Just help us, please, what is the relationship, if any, between that document with 16 at 
B
the bottom and page 13 in C10? 
A 
It is the same document, except that at the bottom the copies are different in the sense 
that Dr Issler has also been copied in on the one that went out into the medical records, 
whereas the one on the computer for some reason has missed off her name. 
Q 
What I want to ask you is this:  is there anything in the computer screen shot, the 
same question applies to the printed version at 14 in C10, any difference in content between 
C
either of those and the document which was in fact in the medical records? 
A No 
difference. 
Q 
It is said, by way of allegation, Dr Southall, that these computer medical records were, 
as records on the computer, not in the best interests of the individual children.  What do you 
say about that? 
A 
Well, I d