As the full horror of Baby Peter's death unfolded last year at the trial of his abusers, one woman's missed opportunity to save him seemed particularly egregious. Dr Sabah al-Zayyat, a consultant paediatrician, had seen Peter at the child protection clinic at St Ann's Hospital, Haringey, on 1 August, 2007, two days before he died. She did not examine him, because he was "miserable and cranky", and remained unaware that he was "miserable and cranky" because he was sitting propped up in his pushchair, with fractured ribs and a broken back.
At the trial, Dr al-Zayyat testified that she had been given no patient records for Peter, and had no idea that he was on the at-risk register. She had had no contact with the toddler's social worker, before or after the appointment, and was given no details of his previous hospital admissions. A locum, she was one of only two consultants at the clinic, when there should have been four.
No doubt she will explain to the General Medical Council, which is carrying out an inquiry into her conduct, why she imagined that a boy about whom there was no cause for concern had been referred to a child protection clinic at all. Hopefully, too, someone from the GMC will point out to her that a policy of examining happy babies and not examining unhappy babies is breathtakingly counter-intuitive. However, there can be no doubt at all that Dr al-Zayyat, who has been suspended from practice, was by no means the only person who sat complacently in hell.
The Care Quality Commission, which has replaced the Healthcare Commission, this week published the findings of its investigation into the failings of the NHS in the Baby Peter case. It is pretty damning, and it suggests that the problem was systemic failure, rather than the "individual culpability" of doctors and other health professionals who had contact with the child 35 times. Sue Eardley, head of children's strategy and safeguarding at the Commission, suggested that: "If somebody had been particularly vigilant and gone beyond their scope, beyond what was required, any one of those could have picked it up."
Yet an article in the London Evening Standard yesterday reported that a number of people had in fact "gone beyond their scope". In June 2006 the clinic at St Ann's still did have its requisite four consultants, and they had been complaining fruitlessly for two years about the "chaotic" clinic, its "inadequate" and "inexperienced" staffing and their worries about at-risk children "waiting too long for appointments".
In June 2006 they felt compelled to write a joint letter to their Great Ormond Street management, which had been brought in after the Victoria Climbié scandal to employ the consultants, and their Haringey management, which funded and ran the clinic. Their letter warned that there was "a very high risk" that a child would die.
Two of the consultants resigned shortly after writing the letter, which they felt was not taken seriously, while another was told she was "unwell" and was put on paid leave. The last went on sick leave herself. The absurdity, it must be noted again, of a complex state-inspection regime that does not consider poor staff recruitment and retention and high levels of employee absence to be a prima facie signal of a troubled organisation, is staggering.
One of the four consultants, Dr Sethu Wariyar, who now works for an NHS trust in the north of England, alleges that in the month before he and his colleagues wrote the letter they had filled out more than 20 clinical incident reports, a form filled out by doctors to register serious concerns about patient care. Normally, a single form would trigger a special meeting. Instead, Dr Wariyar says, a manager at Haringey told the consultants to stop filling in the forms. In Haringey, it appears, "being particularly vigilant" and going beyond one's "scope" was not encouraged.
Yet this is not the first time that such attitudes have come to light during the Baby Peter scandal. The experienced social worker, Nevres Kemal, has also gone on the record to tell of her dismal treatment at the hands of Haringey, after she too had tried to challenge the lack of dynamism in the organisation.
When she arrived at the council in 2004, employed as a senior social worker on the referral and assessment team, she was handed a file on a group of children who their teachers and relatives suspected of being subjected to grave sexual, physical and emotional abuse. The allegations had been made months before, so Kemal was very keen to get things moving. Interviewing the group, she decided that they needed to be protected, and set about procuring the medical examinations she needed as evidence.
Kemal's manager, weirdly, did not appear to know whether authorisation was the responsibility of social services, police, or health officials, so she went over her manager's head, and emailed the department's chief, who ignored her enquiry. Moving beyond her "scope", Kemal then alerted a nurse consultant who raised the case at the Area Child Protection Committee, and moved the process along. The children were eventually taken into care.
Yet from then on Kemal, alleges, she was seen as a troublemaker, and hounded by her managers and colleagues. A trumped-up allegation of child abuse against a child of an old family friend led to an abortive child-protection investigation of Kemal's own daughter. She was suspended, then sacked, during this time. Haringey paid Kemal undisclosed compensation after an employment tribunal, though they have never publically admitted any mistakes.
So, that's five people who spoke out against the culture at Haringey. That's five people who went "beyond their scope". That's five people who either left their jobs, were fired sacked from them, or who went voluntarily or involuntarily, on paid sick leave.
Kemal says that when she joined the team at Haringey, she noted that of the 20 people who worked in her open-plan office, most were agency staff or newly-qualified social workers from abroad, brought to Britain by Haringey on relocation packages. The consultants say that the staff at the clinic were often trainees. One can only assume that such staff, unlike Kemal and unlike the four consultants at St Ann's, preferred not to ask questions. It rather looks like those were the kind of staff that Haringey wanted.