Protecting children has to be our prime concern

It was with a degree of trepidation that I agreed to write this article. Its subject matter is highly controversial and one that potentially attracts intense emotional responses. As I prepared my first draft, a quick glance at the internet reminded me of how polarised the debate was '“ and remains. I wondered whether a balanced conclusion was possible or whether this was a black-and-white issue with no room for grey.

It is an issue that forced each side to raise the stakes to their highest: the false accusation of mothers of committing the most heinous of crimes against their children pitted against the failure to protect those same vulnerable children from the worst types of parental abuse and, in the most extreme of cases, prevent their deaths.

It is worth stating the key background facts, which have perhaps been lost in the media furore. Professor David Southall was struck off the medical register on 4 December 2007 after being found guilty of serious professional misconduct by the General Medical Council (GMC), which judged that he had 'deep-seated attitudinal problems' and that his conduct was so serious as to be 'fundamentally incompatible' with continuing to be a medical practitioner.

The panel found that he had directly accused a mother of killing her 10-year-old son and, in making that finding, preferred the mother's evidence to that of Southall's, despite his version of events being supported by a social worker who witnessed the exchange, took contemporaneous notes and confirmed that no such accusation had taken place.

The decision to strike him off, as opposed to imposing some lesser sanction, caused shockwaves throughout the child-protection field. I understand that Southall has appealed the decision, although no date for that appeal has been fixed.

Southall was, of course, a well-known UK paediatrician who is regarded by some as a leading expert in fabricated or induced illness (FII), and who had performed significant research into sudden infant death syndrome. He is, in fact, widely acknowledged as having contributed significantly to the development of child protection.

But his work has often been controversial. Between 1986 and 1994, Southall led a pilot research project into FII involving video surveillance of young hospital patients in an effort to observe their carers (such as parents or guardians) harming them. The project observed carers using methods such as suffocation and poisoning to harm the children. The project sharply divided opinions for its methods and for the ethical implications of the research.

In 2004, Southall had been found guilty of serious professional misconduct by the GMC, after alleging to the police, having watched a television programme on the subject, that the husband of Sally Clark was responsible for murdering the couple's children. The GMC banned Southall from child-protection work for three years, but the Council for Healthcare Regulatory Excellence challenged that decision as insufficient and argued that he should be deregistered. A High Court of Justice decision in 2005 held that the sanction was not unduly lenient.

In February 2007, Attorney-General Lord Goldsmith announced that a review would be held into several criminal cases in which Southall gave evidence for the prosecution, following allegations that he kept up to 4,450 personal case files on child patients, which were kept separate from the official hospital records. I understand that review has not yet reported.

When Southall was struck off in December 2007, 39 senior paediatricians wrote to the press complaining about his treatment. They said Southall cared passionately about the welfare of children. 'Given the sensitivity around discussing possible life-threatening abuse, paediatricians appear to have no defence against complaints from aggrieved parents who may have abused their children,' they said. 'This will mean many more paediatricians will avoid engagement in this work. The decision is thus a major injustice'¦ to vulnerable children.' One of the signatories said doctors were 'absolutely petrified' of engaging in child-protection work and that 'that could result in a tragedy such as the Victoria Climbie case'. Having been instructed by one of the local authorities in that case and knowing the fatal consequences of professionals not expressing opinions, I share that latter concern.

'Statutory duties'

The Royal College of Paediatrics and Child Health also issued a statement

following the decision to strike Professor Southall off, saying: 'Sadly there are

circumstances where parents may have harmed their children, and in these situations, health professionals have a statutory duty to act on their concerns and look after the child's best interests. This is clearly defined in the government's Working Together to Safeguard Children document. We are very concerned that paediatricians and social workers will be deterred from undertaking child-protection work and that children and young people may come to harm.'

I concur with these predictions that as a consequence of the Southall and earlier Meadows cases, paediatricians, and perhaps also social workers, will be less willing to risk their professional reputations in the field of child-protection work. As a consequence, children living in abusive families will be at greater risk as a result of professionals' increasing caution in expressing opinions.

It is still too early to see whether this concern is borne out because no relevant statistical information is available. There have not been any specific surveys undertaken. However, given the current climate, it is easy to see why doctors and social workers (and, in fact, any professional on the front line of child protection) would be loath to stick their necks out by expressing an opinion on possible child abuse without being absolutely certain. One has to wonder whether this approach is in the best interests of the child concerned. Is it not preferable to express a concern about the causation of a child's injury or presentation even if abuse is only a possibility, in order that other professionals and the court can consider that possibility and take whatever further action is appropriate? Is that approach not preferable to expressing a concern only if the cause is probable or certain? Current guidance from the courts seems to suggest that what they find of most assistance is experts outlining the full differential diagnosis, highlighting every possible cause of the child's injury and identifying all features of the case which point to and against one such cause being the most likely.

Grave consequences

Given that about 50 children die each year in the UK as a result of abuse or neglect by their families, and that criminal convictions for child abuse and neglect rose by 245 per cent between 1998 and 2005, the failure to inform other professionals and the court of a possible cause has potentially grave consequences.

Doctors in this field must not just be entitled, but positively encouraged, to raise with parents any concerns they hold that their children are being abused. They must be able to do so without the fear that those aggrieved parents will make complaints that could lead to them losing their livelihoods. Inevitably, some of those concerns will prove well founded, while others will not. But it is imperative that doctors feel that they are able to raise them, so long as they are acting in good faith. If paediatricians stop doing this work because of this risk, the most vulnerable children will inevitably be less protected than they are now. Those children depend on doctors and social workers being concerned with their welfare and safety, and not being inhibited by fear of complaints and possible loss of livelihood. Those professionals need to be able to present their views to other professionals involved, as well as to a court which ultimately will decide whether the opinion evidence is reliable.

Over-zealous experts

I appreciate that what is of particular concern here is not the expert who expresses the guarded opinion that a possible cause of a child's injury is parental infliction, while also outlining any other possibilities. It is the over-zealous expert who misguidedly and wrongly, albeit convincingly, expresses the opinion that the cause is very likely to be parental infliction, without raising the other possibilities. However, it must be remembered that there are checks and balances within the system to prevent the court being over-influenced by this one expert, which include the instruction of a further expert to provide a second opinion, and the views of other professionals in the case, such as the social worker and guardian.

If the choice is as simple as having either an over-zealous doctor whose concerns for the protection of children occasionally lead to the false accusation of parents, or an over-cautious doctor who in cases of possible child abuse fails to make the relevant referrals and fails to have that conversation with the suspected parents, I know which I would make. The interests of children require paediatricians to be willing to come forward. The courts need such expert evidence. Surely the primary interest must be the protection of children and the balance of protection in their favour.

A case I am working on involves precisely that simple choice. A paediatrician failed to diagnose on more than oneoccasion multiple bruising as being non-accidentally caused. The doctor was prepared to accept, without much investigation and without proper consideration of the full picture, the parents' innocent explanations as to causation. Weeks later, the child died as a result of continuing and escalating abuse from its carers. Post-mortem reports revealed numerous non-accidentally caused bony and non-bony injuries.

Of course, between those stark choices there is the full spectrum of fact-specific situations. There is no simple solution to the problem. I do not suggest that doctors are required to be over-zealous, always suspicious that a child's injuries have been caused by its parents. But they are required to be constantly vigilant and remember the shocking figure that one child a week dies at the hands of their family. It is a difficult thing even to moot the possibility of a parent abusing their child. To most people, even doctors, it is an abhorrent, unthinkable crime. But it happens again and again, and must be considered a possibility whenever a child has an unusual injury.

The treatment of Professor Southall and the publicity surrounding it will not only deter doctors from specialising in this field, but also deter those who do from expressing opinions forcefully. There is already a shortage of suitably qualified experts for medico-legal work in child cases, and this is likely to lead to the pool shrinking further, with the risk that the court will be deprived of such essential evidence. And it won't be the judges, barristers or parents who suffer. It will be vulnerable children.