Every so often an article appears in the media that I cannot possibly pass up the opportunity of commenting on, and one such article, a spectacularly self-serving commentary on the GMC’s decision to strike off child protection ‘expert’ Professor David Southall for serious professional misconduct, appeared in the Indy this week.
Southall has long been a controversial figure, although mostly outside the public’s gaze and attention.
He is regarded by some as an expert in fabricated or induced illness, commonly known as Munchausen Syndrome by Proxy, in which a caregiver (sometimes a parent) causes deliberate harm to a person most often to gain attention, although in some cases this kind of behaviour has been noted in cases of health care fraud – such cases occur mainly outside the UK, where insurance-based health care systems make the notion of health care fraud meaningful although there are analogies to be drawn with fraudulent personal injury claims, which are an issue in the UK – and carried out pioneering work using covert video surveillance to detect cases of caregivers causing harm to young patients at the Royal Brompton Hospital and North Staffordshire Royal Infirmary between 1986 and 1994, as a consequence of which 33 parents/step-parents were prosecuted, with 23 being ‘diagnosed’ with FII.
I should say at this point that while its clear that some parents do fabricate or induce illnesses in their children I am rather more sceptical about the whole Munchausen’s by Proxy designation, in part because there is little evidence of a consistent psychopathology in cases where MSbP has been cited as a diagnosis, and less still any signs of understand its cause(s) or identifying possible treatment regimes, and rather more inclined to the view that FII is less a distinct disorder in its own right and more a behavioural pattern that can arise in any of a range of several well-defined and understood disorders.
So far as getting himself in the public eye is concerned, Southall’s main claim to notoriety prior to his recent striking off arose out his actions in the Sally Clark case, a case which resulted in the professional downfall of another noted paediatrician, Sir Roy Meadow, whose erroneous use of inaccurate statistical data on sudden infant death syndrome resulted in the late Mrs Clark being wrongly convicted of murdering two of her own infant children, a conviction that was later overturned on appeal, but only after Clark spent four years in prison.
Southall’s attempted ‘intervention’ in this case, for which he was quite rightly sanctioned by the GMC after being found guilty of serious professional misconduct in 2004 and barred from carrying out child protection work for three years, was to lodge a complaint with Staffordshire police alleging that Clark’s husband had, in fact, murdered the children on the strength of having watch a television documentary about the case.
That said, the case that led directly to Southall being struck off was not that of the Clarks but one that occurred nine years ago in which Southall, while acting as an expert witness for a family court, was asked to assess the safety/vulnerability of a child in a household where the child’s older sibling had been found hanging from a curtain rail two years previously. The child who died was just 10 years old.
What happened next is both contentious and contested. According the complainant, the mother of both children, during the course of an assessment interview Southall accused her of drugging and murdering her son – although not stated in any of the coverage of the case, one would assume that the coroner’s verdict on the child’s cause of death was most likely to have been suicide or, at the outside, misadventure as no charges appear to have even been brought against the mother. Southall, in his defence, asserts that he only raised the idea that the older sibling may have been murdered as ‘a possibility’, an account supported by the social worker who attended the interview and who served as Southall’s ‘independent’ professional witness.
So far as one can see, the GMC accepted the complainant’s account – although as we will see in due course there are other matters relating to Southall’s general conduct that appear to have been a factor – and acted accordingly in striking Southall off the medical register – all of which scene setting finally brings us to the article in the Indy by Jeremy Laurance, which begins with an all too predictable opening gambit:
One outcome of last week’s decision by the General Medical Council to strike Professor David Southall off the medical register is certain. Children living in abusive families will now be at greater risk.
Those who recall the aftermath of the GMC’s decision to strike off Sir Roy Meadow will find this line of argument all too familiar – if the GMC insists on striking off paediatricians in cases such as this then paediatricians will take their ball home and stop taking on child protection issues for fear of risking their professional reputations, in not their careers.
In short, don’t try and hold us to account or we won’t do the work.
It’s an argument, that one can say, but its one that needs to backed up with evidence if its to stand up to scrutiny, i.e. it hinges on the question of whether in the cases of Meadow and Southall, these individuals have been unduly and unjustly punished for actions that while erroneous – and seriously so – were undertaken in good faith and with the best of motives.
That’s the nub of the issue. Has the GMC disciplined two otherwise diligent professionals for making what amounts to genuine but honest mistakes in what is, admitting, a very difficult field of clinical practice? If yes, then other paediatricians in the field have something to fear as the GMC is (arguably) setting unfeasibly high standards for clinical practice in this field giving doctors the options of perfection or nothing. If no, then the argument fails to stand up.
So let’s take a good close look at Laurance’s arguments:
His [Southall’s] account was backed by the social worker, who gave evidence to the GMC over two days based on handwritten notes made at the time. But the GMC chose to believe the evidence of the mother, dismissing the social worker’s account.
This has, unsurprisingly, alarmed other paediatricians working in child protection, who feel a key part of their defence against false accusations – the presence of an independent professional witness – has been demolished by the decision. Thirty-nine of them wrote a joint letter to the press setting out their anxieties about what many describe as a “perverse” decision.
On the face it, this seems a reasonable point. Southall had a witness to corroborate his account of the interview, the parent didn’t, so you’d expect the GMC to take the corroborated account over the uncorroborated account… or would you?
In the context of a child protection interview you could certainly take the view that a social worker is a professional witness – let’s not get on a downer about social work – but in what exact sense is this professional witness also ‘independent’?
The social worker may be considered independent in one sense. They may not be assign to this particular case, but otherwise the scenario here appears to one of a mother being interviewed by two individuals who have a clear professional interest in child protection, a two on one situation in which it appears that the least ‘qualified’ person in the room, the mother, has neither representation nor a witness to the interview who does not have at least some measure of interest in proceedings.
Surely, the correct response here is not to complain that the GMC has undermined the role of the ‘independent’ professional witness but rather to question whether the system under which these interviews could not be improved in such a way that it does not rely solely on the verbal testimony of an observer who may conceivably develop a bias towards one of the two main parties in the course of their observation, if such a bias is not present from the outset. In criminal proceedings, where a suspect is interviewed by the police, it has been standard practice for many years that all such interview are recorded, initially on audio tape but more recently using video technology. The camera doesn’t lie nor does it provide a biased account of events, at least not without some form of outside intervention which can be forensically identified if there is a suspicion that a recording has been tampered with.
As such, the only sensible and reasonable response to doubts over the status of ‘professional’ witness is the introduction of contemporaneous recording of interviews, recording which can then be used as evidence both in court and in proceeding such as those undertaken by the GMC in regards to the conduct of David Southall.
And with that, one of the key planks of Laurance’s ‘taking our ball home’ arguments falls flat on its face.
Laurance’s next point is a particularly poor and unworthy one, notable only for its abject intellectual dishonesty:
Behind this coded message lies growing concern about what paediatricians say is a witch-hunt against them orchestrated by a small group of affected parents, aided by certain parts of the media. They refer to the “concerted campaign to deny the reality of child abuse” and point to the fact that while cases on the child abuse register fell by 28 per cent between 1995 and 2005 (so fewer children had protection), criminal convictions for abuse and neglect rose by 245 per cent (from 1998 to 2005).
Sadly, in the field of child protection, we’ve seen the ‘no smoke without fire’ argument deployed too often before with devastating effect on innocent families. Remember Cleveland, where the use of an unverified and unscientific method of ‘diagnosing’ sexual abuse in children by a single paediatrician, Marietta Higgs, resulting in a stream of innocent families having their children taken forcibly into care? Or what about the all too Salem-like qualities of the ‘Satanic abuse’ scares in Rochdale and the Orkneys?
Laurance is, here, using a combination of statistics, emotive language (‘witch hunt’) and innuendo to imply that those parents who do protest their innocence and complain, vocally, that the present system is unjust, unfair and lacking in transparency and accountability, are in reality nothing more than abusers seeking to undermine the system to cover up their crimes. If that is what he genuinely thinks then one wonder quite how he managed to restrain himself from going the whole hog and alleging that this is all the work of a mass, UK-wide, paedophile ring.
It’s a despicable line of argument, the more so for deploying statistics on trends in the child abuse register and criminal convictions for abuse and neglect as if they establish a causal relationship when, at best, they show only a bare correlation and, at worst, there may even be no direct connection between the two trends – the number of cases on the child abuse register may be falling because social workers and other child protection specialists are becoming more expert in weeding out ‘false positives’, cases in which the possibility of abuse has been raised and which might previously have gone onto the register ‘just in case’ but which are now being disposed of by use of better investigative techniques. Such improvements in investigative practices would naturally result in fewer cases appearing on the register and, equally, more prosecutions for abuse and neglect as in the latter such enhancements would provide a better standard of evidence for the police and CPS to work with.
Now, to be clear, I am not suggesting that that is what is actually happening. It is equally possible that reductions in the number of cases appearing on the child protection register is a function of cases falling through the cracks in an overworked and under-resourced system and that the increase in prosecutions is no more than a function of greater awareness, of sexual abuse in particular, leading to greater levels of reporting of such case to the police.
The point I am making is that in the absence of detailed evidence to explain why these trends are occurring, the statistics that Laurance cites are wholly ambiguous and wide open to a range of very different, and even opposing, interpretations to the extent that unless one understands the scope and limitations of statistical evidence one cannot infer anything from this ‘evidence’ anything other than that which Laurance intend the reader to understand from his innuendo-laden preamble about witch-hunts and campaigns to ‘deny the reality of child abuse’.
This is a serious issue and on that deserves, in fact demands, that we consider the factual evidence on all sides and not descend into the realms of trading conspiracy theories, which is all that Laurance advances here.
Moving on, Laurance’s next line of argument displays everything that is wrong with the present system under which child protection issues are investigated:
A second plank of the GMC’s decision referred to Professor Southall’s habit of keeping separate files on child abuse cases – he was found guilty of doing so in seven instances. This, according to Cassandra Jardine, writing in the Daily Telegraph, was an even more heinous crime: “A doctor who removes or destroys records cannot by any stretch of the imagination be said to be acting in the best interests of the child.”
Yet, the keeping of separate medico-legal notes, although not sanctioned, is widespread for the obvious reason that it is difficult to record sensitive information in a file to which the parents have access. Again, paediatric colleagues consider the GMC’s verdict perverse. The chief requirement is that the records are clearly signposted so that professionals can locate one set from the other. The failure to do so was a key reason why Victoria Climbie, who suffered months of abuse before she was killed by her carers, slipped through the net.
Laurance’s argument, frankly, beggars belief.
It is a fundamental principle of justice, and not just the justice system, that the ‘accused’ has the right to confront their accuser and challenge the evidence against them in the full knowledge and understanding of the nature of that evidence. That is why we have rules of disclosure within the legal system which, in the case of criminal trials, require the prosecution to provide the defendant, and their legal advocate, with a complete record of all the evidence that is to laid against them in court and why the discovery that evidence has been withheld is the basis for a mistrial ruling and, at the very least, a retrial in which the full evidence is disclosed and subject to challenge.
To withhold evidence, by keeping a separate and secret set of medico-legal notes carefully sequestered away where they cannot be accessed by the individuals to which the relate is to turn the family courts, who ultimate rule on child protection issues, into a star chamber and afford families who find themselves before such courts nothing more that star chamber justice.
What is perverse here is not the GMC’s decision, nor indeed the decision of the Attorney General to review a number of past cases in which Southall gave evidence in light of the discovery of these secret note, but the fact that Laurance can happily defend such a practice that it is ‘difficult’ to record sensitive information in files to which parents may have a right of access, an argument that appears to suggest that Laurance considers it only right and properly that paediatricians working in the field of child protection should be permitted to operate outside and above the law and be accountable only to their own judgement as to what information parents may or may not be permitted to have access to.
Several things occur to me here.
First and foremost, if there is any truth in Laurance’s suggestion that the keeping separate medico-legal notes is widespread amongst paediatricians working in child protection then that is matter that necessitates a full inquiry by the Information Commissioner to assess the full extent to which this practice has been adopted.
Second, this raises a number of serious questions in regards to the government’s ‘ContactPoint’ database in terms both of the nature of the information it will contain, who has access to that information and the overall viability of the project as a whole. On the one hand, if paediatricians are maintaining secret files as a matter of routine then this would appear to undermine entirely the central premise of the database – there is no point in having a system that is intended to ‘share’ critical child protection-related information amongst professionals if one group of those professionals unilaterally and arbitrarily excuses themselves from adding information to the system for fear that it may be obtained by parents using either the Data Protection Act or the process of ‘discovery’ in the course of preparing for legal proceedings. On the other hand, if this information is deemed to be so sensitive that it must be maintained separately from other files but is, under the provisions of the Children’s Act, uploaded to the ContactPoint system then just exactly who will have access to it via the system, on what basis and under what safeguards.
This is something I feel sufficiently concerned about that I am considering referring the matter to the Information Commissioner, with the request that he carry out a full scale inquiry into the implications of the Southall case and Laurance’s intimation that such practices may be widespread amongst practitioners in the sector.
Finally, Laurance’s remarks call into question the wisdom of permitting paediatricians to continue to maintain case notes under their own recognisance. I am, admittedly, no great fan of the current trend to towards the mass proliferation of centralised, government information systems but clearly of a mind to think that if doctors cannot be trusted not to bypass long established and fundamental rules of disclosure then some other procedure for maintaining case notes should be implemented – not a centralised database but a secure, escrow-based system under which case files are lodged with and under the jurisdiction of the courts perhaps. I need, I must admit, time to think over the practicalities of such a system but one thing is clear and that is that is the maintenance of secret and inaccessible files on individuals, outside of the limited scope of national security, is fundamentally unacceptable and wholly incompatible with a free and democratic society operating under the rule of law and with due regard to natural justice.
All of which brings me to Laurance’s final line of argument:
A third black mark against Professor Southall was that he had form. Three years ago he was found guilty of serious professional misconduct after he accused the husband of solicitor Sally Clark of murdering their children. He had seen Stephen Clark give a TV interview in which he said his two-month-old son, Christopher, had developed a nosebleed while in bed in a hotel room. Based on his experience of child abuse, Professor Southall believed that spontaneous nosebleeds were rare and often associated with trauma, such as that caused by attempted suffocation, and raised his concerns with the police.
If spontaneous nosebleeds are rare and often associated with trauma then I have a cousin who would have spent his entire childhood in and out of social services interviews every time the weather changed.
No, seriously. He’s long since had the problem fixed as an adult by way of cauterisation of the small – and in his case, very weak – blood vessels in and around the bridge of the nose but I can assure you from personal experience that the one thing almost guaranteed to set him off were sudden and rapid changes in atmospheric pressure. I’m not suggesting anything so daft as that you could predict the weather by whether his nose was bleeding or not, it is simply a matter of observable fact that any significant change in atmospheric conditions, a change from low to high pressure or vice versa, was enough to trigger off one or two days of spontaneous nosebleeds.
Again, as with Laurance’s citation of statistics for trends in the child protection register and prosecutions for child abuse, there are other potential, and plausible, explanations for observable phenomena – in this case nosebleeds – that do not rely on or provide evidence of abuse.
In the new case, the GMC cited his failure to apologise for this episode, which lent support to their overall conclusion that he had “a deep-seated attitudinal problem”. But he has made clear in interviews since 2004 that he still believes he was right to raise concerns about Stephen Clark, and he was backed by 53 UK paediatricians in a paper in the American journal Pediatrics, which argued that the GMC’s 2004 verdict “conflicted with child protection laws and guidance for professionals”.
‘Deep-seated attitudinal problem’ in regards to Southall is a term I’m inclined to interpret as a long-winded way of saying that he has a very bad case of hubris, an inalienable belief in his own expertise to the extent that he cannot conceive of the possibility of being wrong or making simple but very human mistakes.
The simple fact here is that he made an extremely serious allegation against Stephen Clark on the strength of a single comment in a television documentary and acting on the unshakable belief that he know best and without any evidence to support his opinion he then attempted to initiate a police inquiry. Never mind that he was disciplined by the GMC over this, it’s a wonder he wasn’t also charged with wasting police time.
However, the GMC’s diagnosis of an attitudinal problem goes to the heart of the case. Every profession needs its pioneers, those who are prepared to test the boundaries and advance medicine. In the field of child protection, Professor Southall was that man, doing groundbreaking work in the 1980s and 1990s in developing the technique of covert video surveillance that secured the conviction of dozens of abusive parents.
That he did, but not without sailing very close to the wind in regards to professional ethics and the legality of his actions in conducting this research. The use of covert surveillance is not generally considered to be ethical and the surveillance was carried out in a manner and set of circumstances in which the police would not have been permitted to carry out this kind of surveillance as they almost certainly would not have been able to obtain a warrant to cover the kind of ‘fishing expedition’ that Southall conducted in the name of research. That Southall’s project did not result in either disciplinary or legal action seems, on the face of it, to be the result of the ends – a series of prosecutions against parents – being accepted as having justified the means and had his project no delivered those results its questionable as to whether Southall might not have found himself in serious difficulties much earlier in his career.
But his critics say he did not merely test the boundaries but crossed them, in his overzealous belief that children must be protected at all costs. A senior paediatrician and expert in child protection said: “It is a matter of personality. Other people would have approached the interview [with the mother, Mrs M] differently. You are dealing with disturbed, distressed and anxious people and it is about communication – how do you tackle a very difficult conversation and come out of it without making them feel worse?”
By displaying a measure of sensitivity – what in the medical profession would generally be called an appropriate ‘bedside manner’.
In any case in which a child dies in the home in unfortunate or unclear circumstances there must inevitably be some considerable of the possibility that the child may have been harmed by a third party, particularly a parent. However, when it comes to conducting an interview with a parent who has experienced the death of a child in such circumstances the fact that murder, for example, has to be considered a possibility does not provide carte blanche for a doctor or any other child professional to start asking questions alluding to such a possibility or which may be interpreted as suggesting that they may suspect the parent of having undertaken such a course of action.
Possibilities and even suspicions have to be supported by and backed up with evidence and it should be self-evident to all but the most hubristic and insensitive fool then even the merest suggestion that one considers murder a possibility when interviewing a parent who has lost a child in tragic circumstances is very likely to interpreted not as a professional exploring options that may be readily discarded as being without foundation – look I don’t buy this for a moment but I have to raise it as a possibility so it can be rule out – but as an indication that the parent is under some direct suspicion.
It’s hardly a surprise that the parent in this case made a complaint, in fact it was probably only the fear that her reaction would be misinterpreted as providing evidence of possessing a violent nature that prevented the mother in this case from diving over the table and making a concerted effort to batter the living shit out of Southall for suggesting that she may have murdered her son – even though that would only be a very human and understandable reaction on the part of a grieving parent and a genuine murderer would, in all likelihood, make every effort either to stay calm to ensure they don’t give themselves away or, possibly, feign outrage.
The point being that such interviews are not a normal environment and one has, therefore, to be very carefully in assessing how people react in such situations and what one might legitimately infer from their reactions. Southall is a paediatrician and child protection ‘expert’ – what is not clear from his professional background is precisely what experience or grounding he possessed in psychology and, therefore, the extent to which he may be stepping outside his professional field and competence in attempting to evaluate the mental state of adults. I’m not suggesting that he is unqualified, merely noting that his recorded qualifications provide insufficient information to make such an assessment.
It appears to be Professor Southall’s personality, combined with his “lack of insight into the multiplicity” of his failings, that most alarmed the members of the GMC’s Fitness to Practise panel. They found him guilty of serious professional misconduct and could have issued him with a reprimand or suspension (he is already suspended from work in child protection, since the 2004 case). Instead, they struck him off, eschewing the lesser sentences. Even those who think the verdict right were shocked by the severity of the punishment, which has been widely criticised as disproportionate.
Whether one feels that the punishment meted out to Southall is disproportionate to the ‘crime’ is a matter of opinion, although one half suspects that the GMC may have felt that his hubristic behaviour had reached a point at which he was at serious risk of becoming a liability to the profession if not a danger to those he dealt with in a professional capacity and determined, therefore, that the appropriate response was to tailor the punishment to fit the ‘criminal’ – one who might reasonably be thought to have become psychologically unsuited to his professional role – even if this meant dealing with him more severely that than the case, itself, merited.
Whether this is fair or just is a matter that may, in due course, come before a court of law but the individual circumstances of Southall’s case should in no sense be allowed to obscure a wider and much more fundamental and important issue.
If one looks at the series of high profile child protection cases over the last twenty to thirty years in which there have been serious miscarriages of justice; Rochdale, Cleveland, The Orkneys, Sally Clark and others; all these many cases have one thing in common over and above the fact that they relate to parental abuse of children.
That point of commonality is that in all these cases the injustice meted out to individual families – and let’s not forget that when child protection services get it wrong it’s not just parents but children who are the victims – can be traced back to professional hubris, to doctors and social workers exhibiting a clear and unshakable belief in the ‘rightness’ of their interpretation of a particular situation or set of circumstances, even in the face of a total absence of supporting evidence. In all these cases, where the system failed, it failed because of personal and professional hubris in an individual.
Marietta Higgs believed, absolutely, that she had discovered a foolproof method of diagnosis child sexual abuse from physical ‘symptoms’, a method that has since been discredited and proven to be unscientific.
Roy Meadow elevated an inaccurate set of statistics to the status of an immutable ‘law’.
And David Southall’s belief is his own status as an ‘expert’ led him to believe that his word was as good as law.
One might argue that each of them failed in the end by virtue of being overzealous in their efforts to uncover child abuse. I disagree – one can never be overzealous in the pursuit of truth is that zeal leads one to demand exacting standards of evidence and to healthy respect for the possibility of error.
I would argue instead that each failed because in their hubris they took onto themselves the mantle of a god and ceased to act as they should as doctors and as trained scientists – they elevated personal opinion to the status of fact and forget the golden rule of all science, that any theory or hypothesis is only ever as good and its supporting evidence.
The GMC has a duty to protect patients but as Professor Southall is already banned from child protection work it is difficult to see how this is an issue. He is now considering an appeal and the GMC says it cannot comment pending that possibility. But whatever the outcome, the febrile atmosphere generated around child protection means children are already the losers in this unhappy case.
Laurance may, unfortunately, be correct in suggesting that [some] children will be the losers should anxiety at the GMC’s actions lead some paediatricians to shy away from child protection work.
Should that happen, however, he and others like him will be fundamentally wrong in both their reasoning and he response to the GMC’s verdict; wrong because they have failed to understand the real issues that are raised by cases such as those of David Southall and Roy Meadow and wrong because they are taking a narrow and hubristic view of these cases in which considerations of personal and professional reputation are being allowed to override those of delivering as system that protects children while always being mindful that justice must, in all case, prevail.
What Laurance has failed to recognise is that there are, quiet clearly, systemic failings in the present system of dealing with allegations of child abuse and neglect, failing that, if addressed, would secure and protect the reputations and careers of honest and diligent professions while weeding out those whose personal hubris comes to overtake their professional judgement before they can do serious harm to themselves, to children and families and to public perceptions of the professional standing of their colleagues and, for the most part, the means of addressing these failings requires nothing more than a clear adherence to a set of principles that one would expect should be second nature to any doctor – the scientific method.