England and Wales Care Standards Tribunal

LA v General Social Care Council [2007] EWCST 985(SW) (2 June 2008)

LA v General Social Care Council [2007] 985.SW BEFORE Mr. Simon Oliver, Deputy President Mrs. Lydia Gladwin, Specialist Member Mrs. Margaret Williams, Specialist Member
DECISION

Heard on 25^th January, 6^th, 7^th and 11^th March 2008

Representation

The Applicant was represented by Mr. Martin Weinbren of the British Association of Social Workers (BASW) on all days except 11^th March when the Applicant was represented by Ms D Tuck, a solicitor.

The Respondent was represented by Ms Eleanor Grey, of counsel

Appeal

1. Lisa Arthurworrey (the Appellant or LA) was the social worker named in the Victoria Climbié enquiry. This is an appeal against the Respondent's decision, dated 18^th December 2006, not to register the Appellant as a Social Worker. It is for the Care Standards Tribunal ("the CST") to endorse that decision or to direct that it shall not have effect: see section 68(2) of the Care Standards Act 2000. The CST may also impose conditions (s68(3)).

Preliminary matters

2. On 19^th November 2007 the Deputy President issued a written decision extending the time in which LA was able to appeal the decision of the General Social Care Council. The reason that an extension of time was given was that, as is known, on 18^th December 2006 the Respondent wrote to the Appellant giving her notice of its decision to refuse her registration as a social worker. The letter informed the Appellant of her right to appeal to this Tribunal within 3 months of service of that decision upon her. That would have been 19^th March 2007, if the letter from the Respondent was received the day after it was posted.
3. The Appellant appealed to this Tribunal on 7^th April 2007, received on 13^th April 2007. That was some 20 working days late. In her appeal form the Appellant stated that '[m]y application is late because I became distressed with the GSCC's decision and their assessment and was not able to take any further action. It has only been through the use of ongoing counselling from a clinical psychologist, that I am now in a position to submit this application. I can provide a medical report if required.' On 17^th April 2007 the Tribunal sought a copy medical report from the Appellant. That report did not materialise until September 2007.
4. The GSCC applied on 26^th April 2007 under Regulation 4A(1)(a)(i) of the Protection of Children and Vulnerable Adults and Care Standards Tribunal Regulations 2002 ('the Regulations') to strike out this appeal against the decision to refuse the registration of LA on the register of social workers because it was out of time. That application first came before the Deputy President on 7^th August 2007 although the medical report had still not been obtained by the applicant. At the August hearing Ms Grey, very fairly, suggested that the tribunal should consider the hearing as an application to extend time rather than as an application to strike out, even though she did not agree with the extension of time.
5. Although Regulation 35(3) expressly excludes Schedule 6 paragraph 1 from the Tribunal's general power to extend time, Regulation 35(4) provides that in relation to appeals under sub-paragraph (3A) of Paragraph 1 of Schedule 6, there is power to extend time under paragraph 1 of Regulation 35. Regulation 35(2) states that the President or nominated Chairman may extend any time limit if in the circumstances (a) it would be unreasonable to expect it to be, or to have been complied with; and (b) it would be unfair not to extend it. In the circumstances, the Tribunal may have power to extend the time limit for bringing this appeal.
6. Because the medical report was not available at that time the August hearing was adjourned and a time table set that required Dr. Wolgroch's report to be available by 7^th September 2007. In fact it did not arrive until 14^th September 2007.
7. At the hearing in September the Deputy President came to the conclusion that, on balance, the notional application to extend time would be allowed on the basis that, although it had been very hard work to obtain the medical report from LA – 5 months, in fact, and even then it was not as effective as it could have been - that actually worked in favour of LA. If it was this difficult to make her engage in obtaining something that she knew to be very important, it is clear that she was almost certainly just as unable to engage with the process for appealing in March 2007. The Deputy President was satisfied, therefore, that this delay in filing the Notice of Appeal was not a 'simple' failure to comply with the time limits but was because, given everything that had happened in the last few years, to receive notification of the Refusal to Register must have come as yet another shock and that, in the circumstances, it would be unfair to the appellant not to extend the time limit for appealing. The time limit in which to appeal was extended until 19^th April 2007.

The Law

8. The decision of the GSCC's Registration Committee (RC) was made under s58 of the Care Standards Act 2000, coupled with the General Social Care Council (Registration) Rules 2005 (Rule 4(10)). It is for the applicant to establish her suitability to be registered.
9. S58 states as follows;

(1) If the Council is satisfied that the applicant-

(a) is of good character

(b) is physically and mentally fit to perform the whole or part of the work of persons registered in any part of the register to which his application relates; and

(c) satisfies the following conditions

it shall grant the application, either unconditionally or subject to such conditions as it thinks fit; and in any other case it shall refuse it.

(2) The first condition is that-

in the case of an application for registration as a social worker-

(i) he has successfully completed a course approved by the Council under S63 for persons wishing to become social workers;

(j) (ii) he satisfies the requirements of Section 64; [qualifications gained outside England] or

(iii) he satisfies any requirements as to training which the Council may by Rules impose in relation to social workers.

(3) The second condition is that the applicant satisfies any requirements as to conduct and competence, which the Council may by rules, impose.

10. The Respondent asks the Tribunal to note that the decision in this case was made by the GSCC's Registration Committee. This is an independent body, made up of three (or sometimes five) members, with a lay majority. The committee has one person with relevant experience of the applicant's area of practice (see Rule 12(7) of the Registration Rules 2005).
11. The Respondent also asks us to bear in mind that, in carrying out its task in this appeal, we should have at the front of our minds, the fact that the primary purpose of the Care Standards Act 2000, and therefore the Tribunal, is to safeguard vulnerable members of the public. We are exhorted to ensure that we do not allow matters of livelihood and reputation to undermine the principle of safeguarding. See Miss Quigley (Kinderland Montessori School) v OFSTED [2004] 0285.EY. Ms Grey says that it is apparent that in the Laming Inquiry, the vulnerable (in the shape of Victoria Climbié) were at the forefront of the Inquiry's mind and concerns; the same should be equally true in this hearing.

The evidence heard and read

12. We heard from Mr. Robin Weekes on behalf of the GSCC and Ms LA. We had a bundle of about 1500 pages of documents to which we were referred. Those documents comprised, amongst other documents,

(1) the decision letter of the Registration Committee

(2) The submission to the GSCC's Registration Committee, which included a full evaluation of the available evidence and suggested conclusions

(3) The Report of Lord Laming, Chapter 6 [abbreviated as "LL" and then a paragraph number eg: LL 6.123 in this decision];

(4) Summary of LA's evidence to the Laming Inquiry [compiled by Mr Bernard Monaghan];

(5) The decision of the Care Standards Tribunal in [2004] 268.PC ("the 268 decision"); This was a previous Care Standards Tribunal hearing in May 2005 which concerned LA's inclusion on the Protection of Children Act (PoCA) Register.

(6) The Appellant's employment application form to Haringey Council.

The Registration Committee's decision

13. The Registration Committee set out its decision in considerable detail. We have to consider that decision and so we too set out what it said. This is not the whole contents of the decision letter, just that part of it which is relevant to our decision. The tribunal has considered those matters in detail and will need to make findings in relation to them.
14. The Registration Committee (RC) said that, in considering whether LA met the conditions for registration as to good character, conduct, and competence, the Committee fully recognised and took into account that there were a number of significant extenuating circumstances, which are referred to in detail by Lord Laming and the CST 268 appeal. These included her relative lack of experience for a case of this kind, the lack of supervision, the lack of training, the complexity of the case, the failure by Haringey Council to manage the reorganisation of the Children and Family Service appropriately, and the unsupportive, chaotic and demoralised office environment. We agree that there are significant extenuating circumstances and that they need to be taken into consideration in our decision making process.
15. The Committee was not satisfied that LA met the criterion set out in section 58(3) of the Care Standards Act 2000 ("the Act") and Rule 4 of the General Social Care Council (Registration) Rules 2005 ("the Rules), where the Council must be satisfied that she is of good conduct in that:

"Over the 211 days that you held the Victoria Climbié case, you failed to spend more than 30 minutes with Victoria at any one time during the 4 visits you made. On these occasions, the conversations between you and Victoria were no more than "hello, how are you?" The Committee has accepted the comments of Lord Laming in this respect [Laming 6.551]. There is a statutory duty within the Children Act 1989 on Local Authorities through their Children and Families Services to seek out and support those children that are in need and also to protect those children who have suffered or are at risk of being at significant harm. The housing conditions in which Victoria lived, non-school attendance, lack of adequate clothing, and the fact that she was not registered with a GP were indicators that she was a child in need and potentially at risk of significant harm. Even at initial assessment stage these factors were evident and should have indicated to a qualified Social Worker with your experience the need to undertake a properly planned and managed Core assessment. Your part in the failure to do this, which led to the death of Victoria evidences that you are not of good conduct. Lord Laming evidenced this in paragraph 6.557 as "this was characterised by a consistent failure to do basic things properly"."

16. The RC was also not satisfied that LA met the condition set out in Section 58(3) of the Act and Rule 4, where the Council must be satisfied that her competence is such as to make her suitable to perform the work of a social worker. In coming to this conclusion, the Committee has considered her submissions but accepted many of the criticisms of her practice identified in Lord Laming's Report (specified below). In particular, the Committee agreed with the observation of Lord Laming that many of these were basic failings on LA's part. The Committee noted that Bernard Monaghan formed essentially the same view in his report. The RC noted that LA had accepted that she made mistakes in her handling of Victoria's case as stated during her submissions to the Laming Inquiry and the CST 268 appeal. The Committee accepted the view of the CST that a number of these matters did not constitute misconduct, however, the Committee considered them relevant to the question of her competence.
17. The criticisms of LA's social work practice identified by Lord Laming which the Committee accepted, and the areas in her performance on which the Committee was not satisfied as to her competence, were as follows:

(1) "Your failure to consider evidence in that:

a) you failed to appreciate from the information given to you by North Middlesex Hospital in early August 1999 that it had concerns regarding deliberate emotional harm to Victoria together with "unresolved questions about old and possibly non-accidental injuries" on Victoria's body [Laming 6.220, 6.228]; and

b) you failed to read fully the Central Middlesex Hospital fax of 12 August 1999 and seek clarification of "the hard-to-read" contents from the hospital, and to discuss the implications of its contents for Victoria with staff from both the Central Middlesex and North Middlesex hospitals, which Lord Laming described as "poor social work practice in the extreme" (while also criticising Carole Baptiste in these respects) [Laming 6.272];

(2) Your failure to collect evidence/carry out investigations in that:

(a) on being allocated this case on 03 August 1999, you made the assumption that Victoria was "safe" in hospital. You then failed to speak to Ms Rogers especially in the light of the "urgent" message from Dr Schwartz that was on the file and you did not speak to the Chair of the Strategy meeting, Ms Kozinos to go through the recommendations of the meeting in detail [Laming 6.217].

(b) you failed to question and investigate Ms Kouao's account of the scalding injury to Victoria in early August 1999 or the reasons for the delay in seeking treatment [Laming 6.593];

(c) you should have sought plausible explanations for all the marks on Victoria's body from the medical professionals who were involved in the care of Victoria [Laming 6.235].

(d) you failed to seek information from Victoria about the other marks on her body or explore the hospitals concerns about neglect at the interview with her on 06 August 1999 to enable you to make a judgement about her safety at home [Laming 6.254 and 6.255].

(e) you failed to make any checks as to the suitability of the accommodation at the Kimbidimas home and whether it would be a safe place for Victoria to stay, which is something you should have known to do without been told and which is a basic check [Laming 6.403];

(f) you failed to carry out checks at Bruce Grove Primary School before January 2000 when Victoria could not be traced and when you had informed the Strategy meeting in November 1999 that she had been registered there [Laming 6.436, 6.501];

(g) you failed to make checks as to where Victoria was staying up to and including 05 November 1999 which was the date of the Strategy meeting [Laming 6.437];

(h) following the Strategy meeting on 05 November 1999, you delayed until 19 November 1999 writing to Ms Kouao to invite her to meet with you on 01 December 1999, notwithstanding the "urgency or seriousness with regard to sexual harm allegations and the outcome of the Strategy meeting" and you have accepted that this was wholly unacceptable delay [Laming 6.648]; and

(i) whilst acknowledging that Ms Kouoa and Mr Manning were deceitful people, you should have done more to validate the inconsistencies in the information that Ms Kouao was giving to Social Services and which needed to be resolved if an accurate picture of Victoria's situation was to be established [Laming 6.609 and 6.611].

(3) Your failure to keep an open mind in that:

(a) on 16 August 1999, you failed to ask Victoria and Ms Kouao or verify how Victoria spent the day, which we agree with Lord Laming is a crucial aspect of any child assessment [Laming 6.299];

(b) on the same occasion, you failed to properly pursue the concerns raised by North Middlesex Hospital around issues of neglect [Laming 6.296];

(c) you failed to keep an open mind about the possibility of deliberate physical harm to Victoria throughout August 1999 and to test out the concerns raised, which you accepted was part of your job [Laming 6.237, 6.295, 6.597, 6.601 and 6.602]; and

(d) you failed to speak to Victoria at all, other than to say "hello" and "how are you?" during the home visits on 16 August and 28 October 1999, as you have acknowledged [Laming 6.294, 6.296 and 6.369].

(4) You made inappropriate and unjustified assumptions in that:

(a) you assumed that the phrase 'fit for discharge' meant that the hospital no longer had any concerns about Victoria in the general sense and that it was safe for her to go home [Laming 6.219];

(b) you assumed that Ms Kouao and Victoria had returned to France around the end of November/early December 1999 which was a dangerous assumption to make and one you should not have made [Laming 6.471]; and

(c) you assumed that the concerns noted in the fax sent by Nurse Quinn, North Middlesex Hospital, summarised in their entirety the concerns of the hospital [Laming 6.228].

(5) You should have appreciated that the arrangements for keeping Victoria safe from sexual harm had broken down following the telephone conversation with the Kimbidimas' on 13 December 1999 [Laming 6.472].

(6) You failed to prepare adequately for the interview with Victoria Climbié on 06 August 1999 and decided against using an interpreter even though English was not Victoria's first language [Laming 6.251], which showed, in the Committee's opinion, a lack of reflective practice.

(7) You failed to communicate properly with Dr Rossiter in August 1999 by not forwarding her the Central Middlesex Hospital material for her opinion despite having agreed to do so [Laming 6.274].

18. In coming to its decision that you did not meet the condition as to competence, the Committee noted that, notwithstanding the deficiencies in your practice identified by Lord Laming and your own admission that you made mistakes, you have not submitted any evidence to show that you have addressed or plan to address those deficiencies. The Committee has noted the comment in your email to the Council of 3 June 2006 that you have not had an opportunity to address those deficiencies. The Committee has accepted that you have not been engaged in social work since leaving Haringey Council. What you have not told the Committee is whether you have done any private study or training courses pertaining to social work and in particular, Child Protection, and whether you have thought through how you would act as a competent social worker were you to be faced with similar circumstances in the future."

The issues before us

19. From the contents of the RC letter, therefore, the areas for consideration by the Tribunal are Conduct and Competence. However, since the decision of the RC was made other matters have come to the attention of the Respondents which have meant that we will also need to consider matters relating to Good Character and Health, as set out in Section 58(1) of the Act.

Our approach

20. We are acutely aware that the facts in this case have been exhaustively considered already. The case concerns the judgments to be made of the Appellant's social work practice when handling the case of Victoria Climbié ("VC"). The Appellant was her allocated social worker from 2^nd August 1999 until the child's death on 25^th February 2000. The primary facts are analysed in very great detail in the report of Lord Laming and are not the subject of dispute.
21. The first and best known consideration was by Lord Laming who made some 44 criticisms of the appellant's practice or competence. It is said by Ms Grey on behalf of the Respondents that LL also considered that the "answer [to the failings he identified] lies in doing relatively straightforward things well". It is noticeable, says Ms Grey, that Lord Laming did not accept that LA was dealing with a case of such complexity that this, coupled with her inexperience, etc, excused her failings.
22. It is contended by Ms Grey that similar conclusions were reached by the Appellant's employer at the time, which dismissed her for gross misconduct. This was the second detailed enquiry into the facts and one of the key documents in that process was a report complied by Mr. Monaghan. The decision to dismiss LA was upheld by the Employment Appeal Tribunal, on appeal, after a 5-day hearing.
23. The third analysis of the facts was undertaken by a different panel of this Tribunal. Three members of the Care Standards Tribunal, chaired by the President, heard the Appellant's appeal against the Secretary of State's decision to place the Appellant on the Protection of Children Act ("POCA") list. That panel decided that the Appellant was not guilty of "misconduct" which placed a child at risk of harm. This decision is relied upon by LA to challenge the refusal of registration. It is contended in her Skeleton that the CST's favourable decision means that the GSCC's decision cannot be sustained as misconduct was not found in the 268 appeal. We deal with that contention below.
24. Whilst we bear in mind all of the above, we are considering whether or not the criteria as set out in Section 58 of the Care Standards Act 2000 are met. We are not undertaking an inquiry into social work practice in Haringey as Lord Laming did, nor are we looking at an employment record as Mr. Monaghan did. We are also not considering the criteria for misconduct under the Protection of Children Act 1999. This was predicted by the President in the 268 appeal where he said (at paragraph 149):

"This Tribunal believes that to list a social worker under the Protection of Children Act list or indeed under the Protection of Vulnerable Adults list kept under section 81 of the Care Standards Act 2000, for professional mistakes should be an unusual occurrence, to be used only in the most clear cut of cases. The General Social Care Council now maintains a Register of social workers under section 56 of the Care Standards Act 2000, and a person will be capable of being removed from the Register under section 59. Decisions to remove are subject to a right of appeal to the Care Standards Tribunal under section 68. It is our view that this procedure is a more satisfactory procedure than listing a person as unsuitable to work with children, which carries with it far ranging implications for the individual as regards both employed and voluntary work for a period that can extend to ten years or more."

25. In those circumstances, we assess the evidence against the criteria we are considering and have to reach our own decisions on the facts before us. We can, of course, take note of what others found or decided but do not regard ourselves constrained by the findings of previous Inquiries or Tribunals.
26. As for the various allegations contained in the RC letter, we propose to consider each in turn, setting out the facts relied upon by each party, then make our findings on those facts and conclusions on each. That way it should be easy for those reading the decision to follow what our conclusions are on each point and why. We will then reach our overall conclusion at the end of the decision. Whilst the various matters were set out in the Registration Committee's letter in a certain way, during the hearing we decided that it was far more logical to consider the issues chronologically. This is what we have done. In her closing submission Ms Grey very kindly set out the criticisms made by the RC chronologically. We have used her template which is why there is an apparent randomness about the numbering of the concerns.

LA's credibility as a witness

27. Before we do that, however, we need to consider LA's credibility as a witness. On this the GSCC state that the Appellant's evidence was frequently not credible, when tested; or her evidence was simply unsatisfactory. In particular Ms Grey says that LA's account of why the two criminal convictions had not been brought to the GSCC or CST's attention was unsatisfactory. Nor was her explanation of how the phrase "[the conviction] … is, according to Miss Arthurworrey, still subject to continuing adjudication and likely to be overturned", which appeared in her representative's Skeleton of 4^th January 2008, credible. (She suggested that there might have been a confusion about the "appeal" against the outcome of her complaint about PC Allgood; but the last piece of correspondence relating to that is dated 5 October 2007).On behalf of the GSCC Ms Grey continues that LA's statement that PC Allgood had been "reprimanded" was wholly unsupported by the documentary evidence (produced at the Respondent's request). We understood from Ms Arthurworrey that she believed that the officer had been reprimanded.
28. Ms Grey said that the documentary evidence also showed that LA was capable of significant exaggeration or carelessness, in the causative link she drew between the effects of the alleged assault and/or the police investigation of it, and the counselling she has received. These are monthly counselling sessions with Dr Wolgroch which had started in July 2003 and continued ever since. That, says Ms Grey, reflects very badly on LA's credit/character.
29. Ms Grey also contended that there was no satisfactory explanation of why LA's witness statement did not refer to the fact that she had been signed off sick since 10^th December 2007, and sought instead to rely on out of date medical evidence (that is, evidence which pre-dated 10^th December). It is also said by Ms Grey that on occasions, evidence which related to the Climbié events shifted in tack. For example, when discussing the strategy meeting recommendations of 5^th November 1999 in the context of the inaction thereafter, LA first claimed that they were "family support" recommendations. Then when taken back to them, LA conceded that they concerned child protection; but said that nevertheless it was not a "s47" investigation – although s47 is broadly worded and there was a statement that a child protection conference was needed. As another example, in the previous CST hearing, her QC (Mr. Jackson) accepted, on her behalf, Lord Laming's criticisms of the two home visits of 16^th August 1999 and 28^th October 1999. Although, as Ms Grey concedes, he made submissions, accepted by the CST, as to the mitigating factors which accompanied the two visits. (LL's criticisms being: poor preparation, failure to keep an open mind, lack of review of judgments and assumptions) – but in these proceedings she was not prepared to accept any of those criticisms.
30. Further, in general terms, it is argued on behalf of the GSCC, LA's account of why she disagreed with the contents of her witness statements to the Public Inquiry was unsatisfactory and (if true) highly unprofessional (given that social workers are frequently required to make statements for courts).
31. We are urged to consider that issues such as this should colour our approach to pieces of evidence which cannot be directly verified; eg, the issue of whether or not the "Purple Manual" was given to Miss Arthurworrey by Carole Baptiste (CB) in her first week, read quickly and then handed back (as she said to the CST in 268, and as it accepted), or whether it was in fact handed over and kept in her drawer. On this, Ms Grey urges us to bear in mind LA's first Inquiry statement, as well as her Second Statement where there is further information on the guidance available. Her Inquiry evidence was that a "Purple Book" was given to her by CB and kept in her drawer; in addition, the DIAT procedures were on her desk on her arrival. This was the subject of further questions and confirmation in oral evidence during the Inquiry. It makes no sense, says Ms Grey to say now that she was referring erroneously to the DIAT procedures when she spoke about the "Purple Book" being handed over – especially when the document she was referring too was plainly available at the time when the Inquiry statement was drawn up and/or signed.
32. Ms Grey suggests that the Tribunal will need to make its own assessment of the repeated acceptance of failures by Ms Arthurworrey "with the benefit of hindsight". She often accepted both that errors were made, but also that she could not have been expected to have avoided them at the time (eg, in failing to talk to Ms Rodgers, or Victoria's reluctance to speak to her and PC Jones), referring to factors such as workload, etc. It is contended that the Tribunal will need to assess whether the standards expected of a qualified social worker allow such qualifications to be accepted. The GSCC submits that they should not be.
33. It was unfortunate that we were not addressed about Ms Arthurworrey's credibility by Mr Weinbren either orally or in writing. We heard evidence on these matters from Ms Arthurworrey, of course and so we base our decision on that.
34. Dealing first with the convictions, the first was that on 14 December 2006, she was made subject to a Restraining Order by the Enfield Magistrates' Court following her conviction for harassing a third person, MS. She was conditionally discharged. On 13 December 2007, she was arrested after, in breach of the restraining order, she verbally abused MS without lawful excuse. She pleaded guilty and was fined. We have come to the conclusion that, in relation to these matters, it is significant that they occurred after the death of Victoria and Lord Laming's Inquiry. We have no doubt that Ms Arthurworrey was seen as a monster by many people as a result of Victoria's death and we believe that this almost certainly was at least part of the cause of the incident. We cannot and did not undertake a full review of the evidence in the criminal case so we cannot conclude that the conviction was wrong. We do note, however, that Ms Arthurworrey was advised to plead guilty.
35. Whatever the rights or wrongs of the conviction, the fact is that that Ms Arthurworrey DID have a conviction and DID fail to disclose it. There is no doubt that she should have disclosed it and the failure to disclose is a failing. Is Ms Arthurworrey wholly responsible for the failure to disclose? She was unrepresented at the time of her conviction in December 2006 and BASW only started to represent her from about August 2007. The GSCC application form makes it clear that a conviction should be notified. However the conviction occurred after the form was submitted. Whilst that does not excuse the non-disclosure it does make it a little more understandable that it was not picked up. Did or should BASW have known about it? We cannot be certain about that. We do think that BASW were less proactive in their representation of Ms Arthurworrey than, for example, Unison. We feel that had BASW known about the conviction they should have advised on its disclosure. The comments in the skeleton argument prepared by BASW on Ms Arthurworrey's behalf should have been more closely examined by her representatives and a full and clear explanation given rather than leaving the matter in an apparent state of confusion. Had it been made clearer earlier what was going on it might not have reflected so badly on Ms Arthurworrey.
36. The failure to mention the conviction does give us a cause for concern and does affect the way we consider Ms Arthurworrey's evidence. We are uneasy that, whilst not telling untruths about the officer being reprimanded, Ms Arthurworrey does appear to have latched on to this as the explanation for not making disclosure. It would seem that she was not advised, or not properly advised, in relation to this matter. Be that as it may, we are concerned about this and take the view that the non-disclosure is sufficiently disquieting to weaken Ms Arthurworrey's credibility. It does not destroy it but we will be more circumspect and place less reliance on what Ms Arthurworrey has told us as a result.
37. As for the counselling, this again was not properly covered on her behalf. Given that health was one of the matters the GSCC had to consider and given that it was Ms Arthurworrey's case that she was in such a poor mental health state between January and April 2007 it is not a surprise that it would be a matter that was going to be considered. As with the conviction, matters were only explored in cross-examination. We sensed that Ms Arthurworrey was selectively recalling matters but of course that could be because she had not been aware that questions on these matters might be asked of her. Had BASW properly represented Ms Arthurworrey from the start there may have been proper evidence properly produced by her rather than it emerging in the way it did. The way that this matter was presented meant that we were not able fully to understand what Ms Arthurworrey had to say about it.
38. Sadly, the same has to be said about Ms Arthurworrey being signed off sick since 10^th December 2007. That only emerged in cross examination as well. It must have been obvious that health was going to be a part of the case for the reasons already mentioned. Leaving the evidence to emerge in cross-examination does not help Ms Arthurworrey. In fact it positively hinders her because it gives the impression (whether accurate or not) that she is trying to hide this information. It also leads to adverse conclusions being drawn against her when it does not follow that they should. There are three possible explanations why we were not told about this. The first is that there was a deliberate failure to mention it. That would be serious because, for example, were we not told about being signed off sick because it was thought that it would affect our decision? If that is the case, the non-disclosure was deliberate deception and that raises two important questions: first, what else have we not been told about that we should be aware of and second, what reliance can we place on what we have been told given that it is clear information is being withheld so as to affect our judgment. Can we assume that everything we have been told is truthful rather than being told to us so as to create a certain impression?
39. The second and a more charitable explanation is that Ms Arthurworrey might not have seen the significance of the fact that she was signed off sick since December. The third explanation is that it appears that BASW did not see the significance of it when they drafted her skeleton argument or subsequently. There seems to have been no closeness of communication between client and representative. We cannot come to any firm conclusion as to which of these three possible explanations is the right one.
40. As to the question of why Ms Arthurworrey was disagreeing with the contents of statements she had signed, we are aware that lawyers DO draft statements on behalf of their clients. However, it is the client's obligation to read through those statements and correct any misinterpretation that might have crept into the draft especially if facts were expressed in a way that was not intended. So to sign a statement does imply that it is accepted. We conclude that to disagree with a written statement is trying to change the evidence to fit the situation.
41. In relation to the 'Purple Book', this is clearly a good practice guide. Use of it would be reflective practice. However, Ms Arthurworrey's practice was not reflective as she had no management support or encouragement to be reflective. If you do not know what to do or where to find help and assistance the availability of the Purple Book may have been of little relevance. The lack of its use is not entirely her responsibility and where it is was, to our mind, less important than the fact there was no departmental ethos to use it or apply its principles.
42. We accept the points that Ms Grey has made in respect of the contention that Ms Arthurworrey accepted failures "with the benefit of hindsight". There is the possibility that Ms Arthurworrey has simply accepted that the "benefit of hindsight" is an easy answer to difficult questions. The points made by Ms Grey are that some basic points were missed. We have certain views about those which we will express as we go along. We also bear in mind that Lord Laming acknowledged that the two adults in Victoria's life were "deviant".
43. So, putting all these points together, do they make a difference to the way we consider Ms Arthurworrey's evidence? We have come to the conclusion that we cannot go as far as Ms Grey wants us to. We do not see Ms Arthurworrey as a liar yet at the same time we cannot accept that she is entirely trustworthy. We regard Ms Arthurworrey as being a person who is currently affected by her state of health and mind as a consequence of what she has been through – the death of Victoria, the internal inquiry, Lord Laming's inquiry, the previous CST hearing and the attack by her neighbours. There is no doubt that Ms Arthurworrey wants to have her professionalism restored. We see her behaviour in relation to all the points made as being the acts of a person desperate to get back to square one and that of a person whose mental health is not as secure as it could be.

Ground 1: not of good conduct.

44. The RC of the GSCC was not satisfied that LA was of good conduct in that over the 211 days that she held the Victoria Climbié case, she failed to spend more than 30 minutes with Victoria at any one time during the 4 visits she made. On these occasions, the conversations between LA and Victoria were no more than "hello, how are you?" In reaching this conclusion the Committee accepted the comments of Lord Laming at paragraph 6.551.
45. The GSCC's case is as follows: the GSCC asks the Tribunal to note its view (expressed in its submissions to the Registration Committee) that LA was at fault in failing to read the case file to compile a list of information suggesting that VC was at risk of harm, and then to analyse that information. The GSCC observed that reading a file, and extracting information from it, were basic social work tasks (LL at 6.585 makes the same point). It is argued by Ms Grey that if the Appellant had not got the time to do this, then she had a responsibility to say so. It is said by Ms Grey that the GSCC considered that this was both a conduct and a competency issue. The GSCC also asks us to note the failure of the Applicant to carry forward the s47 investigation in any meaningful way.
46. In reply Ms Arthurworrey states that of the eleven issues of alleged misconduct, the Care Standards Tribunal found in case 268, after careful and detailed deliberation, that she was not guilty of misconduct on any of the issues. On behalf of LA the Tribunal was asked to recognise and endorse that analysis (in case 268) of Ms Arthurworrey's actions. It was submitted by Mr Weinbren that by the GSCC not agreeing with the findings of the Care Standards Tribunal, it was stating that she is not competent to perform the duties of a social worker. There is no evidence to support this contention says Mr. Weinbren because the findings of the Care Standards Tribunal are clear. If, as has been shown, he continues, there was no misconduct, and the actions acknowledged as failings by Ms Arthurworrey were based on her lack of experience, support and supervision without misconduct, then it follows that in a different setting, with appropriate professional and managerial support, there is no foundation to sustain the allegation of lack of competence.
47. Mr Weinbren continues that it is within the powers of the GSCC to impose conditions on registration and that this would seem appropriate in circumstances where the applicant has been denied the opportunity to practice for a significant amount of time. A range of options including specifying restricted areas of practice and continuing professional development and training requirements could and should have been considered in coming to a fair decision about the registration of the appellant, he argues.
48. We need to make findings as to the issue of conduct. The first finding is that we do not accept that view set out by Mr Weinbren. It is clear to us that we are considering a different case brought under a different statute and that the test we have to apply is completely different. We would be prepared to read across any findings of the Tribunal in case 268 if they were directly comparable. However none are and we are not prepared to conclude that just because it had been found in relation to the Protection of Children List appeal that Ms Arthurworrey was not guilty of misconduct it would follow that the same was automatically capable of application here. The statutes do not make a read across appropriate or possible. We refer to the decision of the President we quoted in Paragraph 24 above.
49. We have come to the conclusion that LA was not exemplary in her conduct. What we have to determine, however, is whether her conduct was SO poor that she should not be allowed to practice in the future. The key issue is whether, if registered, Ms Arthurworrey has the potential to grow professionally and overcome what she has been through. This is not easy to determine. It is not a situation where an individual's conduct had been exemplary except for a one-off incident. However, we also need to bear in mind the professional environment in which Ms Arthurworrey was operating: from what we read and heard the department was chaotic; she had no detailed supervision; there was no obvious benchmark against which she could self-assess and we assume that there was no appraisal scheme in place in the department. Whilst we acknowledge that carrying more cases than expected is often an indication of good competence, in this department it was just a question of cases being handed out and the staff being told to close them. In addition, we also need to bear in mind that there was no apparent criticism of LA's work in other cases, which suggests that she was not totally incompetent and must have been doing something right.
50. So what does 'good conduct' mean? Indeed, are the matters relied upon by the GSCC actually 'conduct' matters at all? Is 'good conduct' the opposite of 'gross misconduct'? We believe that conduct refers to character and not professional skills. Perhaps an example would be the deliberate act of deceit by withholding information. To overlook or ignore something is different from doing some thing that is wrong. Likewise unprofessionalism is not the same as capability in the performance of a job. We can see that, in principle, the matters relied upon by Ms Grey in relation to Ms Arthurworrey's credibility as a witness could go to issues of conduct but not those matters relied upon by the GSCC as set out in Paragraphs 44 and 45 above. In trying to determine this matter we have come to the conclusion that the matters relied upon by the GSCC are not, in fact, matters of good conduct but are matters of competence. As a result we conclude that the case against Ms Arthurworrey as to good conduct is NOT made out.
51. Whilst we may have come to the conclusion that misconduct is not appropriate here, it does not follow (as it did in case 268) that Ms Arthurworrey has succeeded since there are other matters set out in the act upon which the GSCC can, and do, rely.

Ground 2: not competent.

52. In general terms (before turning to consider specific matters), the RC of the GSCC states that, apart from matters of conduct, it was also not satisfied that LA's competence was such as to make her suitable to perform the work of a social worker. Mr Weinbren states in reply on behalf of LA that in relation to all competence matters that evidence was heard from Robin Weekes, Head of Conduct at the General Social Care Council. He was clear in his response to a question that incompetence means inability. Mr Weinbren says that although there was a reinterpretation of this evidence by Ms Grey when cross-examining Ms Arthurworrey, the evidence before the Tribunal is unequivocal and unambiguous. It was, Mr Weinbren continues, conceded during an exchange in cross-examination that Ms Arthurworrey has the capability to undertake the tasks that were required of her (such as communication), but it was put to her that her alleged failure to recognise the need to undertake those tasks was the issue in point. It is said by Mr Weinbren that this exchange does not detract from the evidence offered by the GSCC's Head of Conduct that what the GSCC looks for when judging the competence of an applicant in the context of applications to the register, is whether or not the applicant has the ability to perform the work of a social worker. Mr Weinbren submits that Ms Arthurworrey has clearly demonstrated that she does have that ability.
53. On behalf of LA it is also said that much time was spent in cross-examination of the Appellant looking at the failings in her practice in dealing with the case of Victoria Climbié. Section 58 of the 2000 Act, it is said, provides that application shall be granted if satisfied that the applicant is physically and mentally fit to perform the whole or part (emphasis added by Mr. Weinbren) of the work of persons registered in any part of the register to which his application relates, and satisfies two conditions. The second condition is that the applicant satisfies any requirements as to conduct and competence, which the Council may by rules, impose. The GSCC Registration Rules merely provide that in respect of competence, there must be satisfaction that the applicant's competence is such as to make him or her suitable to perform the work of a social worker. In Mr Weinbren's submission, this must be interpreted as the applicant being competent to perform the whole or part of the work of a social worker, just as in the S58 requirement for physical and mental fitness and that any other interpretation would not be logical. Mr Weinbren further submits that in hearing evidence, the areas of alleged incompetence have been about the applicant's failings in the case of Victoria Climbié and that there has been no suggestion that away from the areas of Child Protection, Ms Arthurworrey lacks competence as a social worker as was advanced before the Tribunal by Ms Grey. The Appellant's evidence, for example, that she could write a Section 37 Court report was specifically mentioned and not challenged. It is argued, therefore, that on the issue of competence, while the Respondents have attempted to demonstrate that Ms Arthurworrey has not the competence to undertake child protection social work in the light of the Victoria Climbié tragedy. It is contended that the effect of a registration refusal is to prevent LA from working as a social worker in any setting, whether in other children's settings such as foster carer approval applications or in any other setting such as Adolescent Mental Health Services, Mental Health, Elderly Persons or Disability.
54. We have to say that we feel this argument has missed the point. The issue of competence does not simply mean her physical ability to communicate or perform the work (as we understand it was being argued by Mr Weinbren) but whether she is professionally capable of doing the job. Competence is separate and distinct from physical and mental fitness, which is one of only three matters the GSCC has to be satisfied about. Section 58(1)(c) introduces the condition in section 58(3) – the condition of competence. The only way we can determine the matter of competence is to consider each and every criticism in turn.
55. The GSCC's broad case is that Lord Laming called the failings demonstrated by the Appellant's practice (amongst others) "basic" [6.556] and breaches of "fundamental aspects of sound social work practice" [6.557]. These failings, according to the GSCC's decision letter, included a number of matters.
56. The first detailed ground of criticism was that LA: (a)(i) failed to consider evidence from the North Middlesex Hospital. By 3 August 1999, LA should have been aware, from her conversation with Nurse Quinn [LL 6.220] that the hospital had concerns about old and possibly non-accidental old injuries, and deliberate emotional harm.

Findings

57. We start by reminding ourselves that at the time LA was allocated this Climbié case she was a social worker with 19 months experience who had undertaken other multi-professional cases. In general, therefore, these experiences should have been such that basic matters would alert her as being of sufficient concern to raise with her manager, Carol Baptiste. Of course, we acknowledge that Carol Baptiste might not have been of any help or given any advice in relation to any matters raised with her. There was no climate in the department of being able to test concerns. Therefore, whilst it may be correct that LA did fail to consider the evidence from NMH, we believe that this has to be seen in the context not only of the fact that LA only took on the case on 2^nd August and so it was her first day but also of the department's approach at the time. Carol Baptiste was clearly of the opinion that VC's case was one of family support and, indeed, that seemed to be the ethos of the whole department at the time. We can understand how LA, being a junior social worker in the team, may not have been confident enough to be persuasive in discussions (as LL also noted) so she was not able to ask the right questions.
58. We also remind ourselves that VC's case was not the only case LA was managing. We saw good practice in those other cases and note that one of her other cases was taken to full care proceedings. It may have been an easier case but it is also true that it required a lot of work and that she was part of a multi-disciplinary team working on it instead of being left to her own devices. Although there were two strategy meetings on VC's case one occurred before LA was appointed and she was never able to take the case to this to the care proceedings stage as she had done in another case. We have no doubt that the failure to consider the NMH evidence was as a result of the inherent weaknesses in the department and her relative inexperience. There was a pervasive culture of "close the file" from LA's managers which did not help LA manage the case the way she would have done if she had capable and competent managers asking appropriate questions and giving appropriate advice. In addition this information came after it had been agreed that Victoria should be discharged and Dr. Rossiter had concluded on 1^st August 1999 that the scalding injuries were self-inflicted.
59. We also bear in mind what is to us an important piece of evidence in this whole matter. There was a letter from a consultant paediatrician saying in unequivocal terms that Victoria's injuries were NOT non-accidental injuries. See, for example, LL 6.222 and in particular 6.267 where it is recorded that Dr Dempster recorded the views of Dr. Schwartz that "…it is no longer a child protection issue." In 1999 it is fair to say that the views of a consultant paediatrician were very influential. It would be difficult in the extreme for a junior social worker to contradict the opinion of such a senior professional. Matters have changed now, of course, with high profile cases questioning the infallibility of medical diagnoses. We have to judge the actions of Ms Arthurworrey not in the light of today's attitudes but in light of the attitudes of the time.

Conclusion

60. We are in no doubt whatsoever that even had LA been alerted by the conversation with Nurse Quinn it would have made little difference given the consultant's written view and the fact that the decision to send Victoria home was taken before Ms Arthurworrey was 'allocated' the file, it being just placed on her desk. It seems to us that there was a lack of appropriate communication between the medics and the social work team. LL's report at paragraphs 6.194 to 6.222 shows that others were equally responsible for the decisions (or lack of decisions) taken at that time. To blame everything on Ms Arthurworrey is, we believe, to make her a scapegoat for the failings of a number of people.
61. The next criticism under the heading of competence was (a)(ii): Failure to consider evidence from the Central Middlesex Hospital. The GSCC state that Lord Laming considered the failure to read the full contents of the fax from the CMH, and to discuss its contents with staff, to be "poor social work in the extreme" (LL, 6.272). If a manifestly significant document is unclear, a legible copy must be sought it is said by the GSCC.
62. The GSCC say that there are three matters we need to bear in mind. The first is that in decision 268 the Care Standards Tribunal decided that this failure did not constitute misconduct and that LA was entitled to rely on the views of Dr Dempster and Dr Schwartz of CMH, which was to the effect that this was no longer a child protection issue (LL, 6.267, CST paras 120, 121). The GSCC disagrees with this conclusion and state that issue is in fact whether or not the covering letter absolved LA from the duty to read the remaining material fully or properly. They say that it cannot and it was not as if LA was being sent a lever arch file full of medical notes.
63. The second matter for us to consider, it is argued, is that it is for the social worker to make an assessment as to whether or not there are child protection issues, not medical personnel as this is set out within the Children Act 1989 – see the text of s47 - which clearly establishes that it is the responsibility of the local authority to investigate, and make judgments upon, the risk of significant harm to a child. The GSCC also referred us to LL at 6.273, which comments on the limitations of relying on earlier information to allay concerns raised at a latter date. It was also said by Ms Grey during the course of the hearing that the additional material (contained in the faxed documents) may cast light on whether or not the doctor's opinion needs further exploration or clarification – or even challenge.
64. The third matter to bear in mind, it is said is that in this case there were serious "parenting" issues, or issues relating to emotional neglect. Even if the scratch marks were due to scabies, as Dr Dempster said, the fax could clearly have contained (as indeed it did – see the evidence of the childminder's involvement) significant new material which touched upon these issues.
65. In relation to these matters we bear in mind Ms Arthurworrey evidence to LL (paras 6.267 to 6.270) and what she said during the hearing that she did only flick through the fax because of the clear letter from Dr Dempster. She also said that she thought that it was dangerous for a social worker to interpret medical evidence. Indeed, LA said that after reading the letter from the paediatrician, her assessment of Kouao's parenting skills went up, something she accepted was a mistake.

Findings

66. We are aware that although the fax was sent before LA took over on 3^rd August, it did not reach her until 12^th August, Victoria having already been returned home on 6^th August. Obviously, as the key worker LA would have been the hub of the information and there would be an expectation that she would have been able to pull all the evidence together. However, there was a clear opinion of a doctor on the front of the fax.
67. Further, although child protection is a social work responsibility there needs to be the support of doctors (and police) to share concerns. Here the fax indicated that there were no further concerns. If a doctor says that there are no child protection concerns, if the question 'is the child at risk of significant harm' is asked, the rug is rather pulled from under the questioner's feet. We believe that to have challenged Dr Dempster's decision at that stage would have required a confident and experienced social worker.
68. Lord Laming's criticisms at 6.267 are not a failure to read the fax but a failure to talk to the doctors at CMH. The fax set out the situation on 14^th July 1999 and not at the 5^th or 13^th August. In other words, although the fax was sent while Victoria was still in hospital it was not received by LA (because of failings elsewhere in the department) until after VC has been discharged home on 6^th August. It is possible that no-one realised the significance of that fax on 12^th August. All of this poses the question that appears not to have been considered elsewhere: should the contents of the fax have alerted LA to concerns and/or worries even though they would not have affected the discharge? If the contents of the fax had been clearly read on or after 12^th, if LA had discussed the matter with the doctors what would have happened? Would Victoria have been made the subject of an interim care order? There was a plan (of sorts) in place as a result of the strategy meeting. Would any information have changed the direction of the 18 points set out in the note of that meeting? It is impossible to answer any of these questions but it is obvious that it is not certain that a different course of action would have been taken.
69. In any event, even if there were concerning matters in the notes attached to the fax (namely the report from the childminder), is it not reasonable to assume that they had been considered and discounted by Dr Dempster's letter citing Dr Schwartz? If there were concerns these should have been raised by the doctors. They identified scabies. There was no medical identification of non accidental injuries by neither NMH nor CMH. See, for example, paragraph 6.222 LL. A social worker is not a doctor and so has to defer to medical opinion. We are not sure that matters are quite as clear cut as Lord Laming suggests they might be.

Conclusions

70. It is fair to say that reliance on expert medical opinion has been eroded between 1999 and 2008 after some high profile cases. Casting our minds back to 1999 we wonder whether it would have been accepted as appropriate for a junior social worker to question the opinion of at least 2 consultant paediatricians at least one of whom who was ALSO in possession of the information from the childminder. If that information was in the fax from the hospital would it not have been reasonable for any one receiving it to assume that it had been considered as part of the doctor's assessment that it was no longer a child protection issue? At this time Victoria Climbié was in NMH and they regarded her "fit for discharge". The CMH fax containing Dr. Dempster's letter simply confirmed the overall situation.
71. We have come to the conclusion that we do not regard this matter as a failing by Ms Arthurworrey. As we commented above, the doctors were in command of all the information at the time the fax was sent, albeit that there were two hospitals involved. Should not, for example, the paediatricians have spoken to one another if they had serious concerns? If the contents was sufficient to cause concern they should have been the ones to raise them. The role played by the medical profession in the tragedy has, as far as we are aware, never been analysed in the same detail as the role of the social workers. However, we do not accept that they are totally absolved from any responsibility. If the evidence from the child minder was of such concern we have no doubt that an experienced paediatrician would have seen its significance and reviewed the recommendation as to the scabies.
72. Likewise, we fail to see how the information from the child minder would have actually made any difference to the approach being taken in the department because, as we comment below, this case was by this time regarded as 'family assistance' and those concerns raised by LA were effectively dismissed by Carol Baptiste.
73. The next concern is (b)(i)Failure to carry out adequate investigations: Ms Grey contends that LA assumed that VC was "safe" in hospital, when allocated the file (this was an explanation for LA's "initial 'inaction'", LL 6.213, 217). She then failed to speak to Ms Rodgers, or carry out any adequate review of the recommendations of the Strategy Meeting by speaking to its Chair, Ms Kozinos [LL 6.217]. See too the failure to review all the tasks set by the Strategy Meeting (LL 6.215).
74. Ms Grey notes that the CST in case 268 was prepared to accept that the lack of the proper investigation at this stage was due to inexperience, lack of guidance and a heavy workload (para 113) but that the GSCC disagreed. In particular, the Respondent observes that if the Appellant was conscious of her own inexperience, then the most obvious thing to have done would have been to speak to Ms Kozinos for guidance. The failure to speak to the duty social worker Ms Rodgers (in the light of the message from Dr Schwartz) was one of many failures to look critically at a file, and pick up on, and follow through, missing information, so as to ensure that a file is complete and up to date.
75. In evidence, Ms Arthurworrey suggested that the need to speak to the NMH was not evident on the file; but it was one of the 18 strategy meeting recommendations. Ms Grey also referred to the Strategy Meeting's failure to allocate tasks clearly, or to set deadlines for review; but it was plain that, in the absence of any other designated person, it fell to Ms Arthurworrey to arrange for each of the recommendations to be followed through.

Findings

76. We are aware that LA was not asked to take the case but that the file was put on her desk. Without a handover note or discussion it is difficult to see how LA could have known what matters were being dealt with by others. As Ms Rogers knew more than anyone else as at 2^nd August (see LL 6.210) she would have been best placed to inform LA what was happening. In the event LA went to speak to her manager, Carol Baptiste, who did not generate an attitude of urgency or concern. It is an open question whether or not LA should have begun by this time to form the opinion that Carol Baptiste was not very capable. It is easy in hindsight for an objective observer to see that she was performing poorly but it might be a different matter in the pressure and chaos of the department at that time and when you need to believe that someone is there to help and capable of doing so. We are concerned that although there was the eighteen action points arising from the strategy meeting none of them indicated by whom they were to be taken or within what time frame. The procedures (or rather lack of them) are clearly set out in LL 6.205. There was no systematic approach to anything in this social work department at that time.

Conclusion

77. We cannot accept that the failure to speak was one sided. Surely someone (whether Ms Rogers or a manager or strategy meeting chairman, Ms Kozinos) should have spoken to LA about the case and what needed to be done. Someone needed to ensure that the information available at the time of the handover was properly communicated to the person taking over conduct of the matter. The responsibility for the failure to carry out adequate investigations does not lie with LA alone. Managers and others share that failure since adequate investigations presuppose an adequate understanding of the case, of the steps taken thus far, the reasons for those steps being taken and the concerns being expressed (and the basis for them).
78. Chronologically, the next ground of concern was (d) (iii): Made inappropriate and unjustified assumptions. The GSCC rely on the fact that Ms Arthurworrey assumed that the concerns noted in the fax sent by Nurse Quinn, North Middlesex Hospital, summarised in their entirety the concerns of the hospital [LL 6.228]. This, says Ms Grey, is a straight "quote" from the evidence to the Inquiry at 6.228, and overlaps with the point at paragraph 56. It is about reaching conclusions too quickly, without proper care, says Ms Grey.
79. Further it is contended by the GSCC that LA accepted that she did not notice the date of the forms, and that therefore they pre-dated the strategy meeting and could not be an up to date report. This is one of number of occasions when LA's failure to read things carefully and note details (or when she "flicks" through material) is significant.
80. In her evidence to us LA accepted that she did assume that the fax summarised the hospital's concerns.

Findings and Conclusions

81. We have considered this more fully above in paragraphs 57 to 60 inclusive and adopt here our findings and conclusions set out there.
82. (b)(iii): Failure to carry out adequate investigations. The GSCC's case in this respect is that LA failed to seek plausible explanations for all the marks on VC's body from the medical professionals involved in her care [LL, 6.235]. For example, Dr Rossier noted two unexplained thumb marks on VC's body [LL 6.232] but LA did not seek to question the medical professionals about all the marks on the child's body [LL 6.235].
83. In evidence, LA first said that she was reasonably entitled to rely on the expertise of a paediatrician. When it was put to her that what was at issue was her ability to get the relevant information/commentary from the doctor in the first place, she suggested that her understanding at the time of what needed to be done might have been deficient but she now knew what would need to be done as a result of her discussions with Ms Liz Davies. However, says Ms Grey, it is not unreasonable to have expected her to be systematic and thorough, when dealing with issues as serious as belt buckle marks and thumb marks.

Findings

84. We accept that there were no searching conversations with the doctors. Indeed, that is confirmed at LL 6.235. However LA could not get hold of the doctors and they thought that there were no child protection issues. This is not excusing her but the evidence has to be considered. Dr Rossiter had already accepted on 1^st August 1999 [LL 6.221] that the scalding injuries were self-inflicted.

Conclusions

85. If there were concerns about the 2 old unexplained thumb marks, was it not Dr. Rossiter's position to raise the alarm and question whether they were indicative of non-accidental injury? In any event, at LL 6.228 it is noted that "… anyone reading the documentation provided by North Middlesex Hospital would have been very hard pressed to find any indication that the hospital suspected deliberate physical harm…." We draw the same conclusion here as we did in relation to the other matters concerning the medical evidence in the paragraphs above.
86. (d)(i): Made inappropriate and unjustified assumptions. The basis of this complaint by the GSCC is that it is said that LA assumed that the phrase "fit for discharge" meant that the hospital no longer had any concerns about VC in the general sense [LL 6.219]. In evidence, LA denied that she had had that understanding – saying, in effect, that LL had got it wrong. Ms Grey says that the credibility of that assertion is a matter for the Tribunal suggesting that we will need to look at Lord Laming's report as well as the submissions from her Counsel to Lord Laming – which, Ms Grey say, strongly suggest that she gave evidence that she misconstrued the phrase at the time.
87. She said to us during the hearing that she now realises what it means (that is, that Victoria was ok to be discharged and that the hospital did not have any concerns) but did not do so at the time.

Findings and conclusions

88. The case was designated in the department as a 'family assistance case', not care proceedings. In those circumstances, we return to the point that even if Ms Arthurworrey was concerned about matters, what was she able to do? The strategy meeting held before she became responsible for the case had reached certain conclusions, and the doctors had stated that there were no concerns about non-accidental injuries. The doctors did not qualify the statement 'fit for discharge' in any way, for example by saying that although she was able to be discharged they would be concerned if she returned home for x or y reason or that if she did go home there would need to be close monitoring. Even if LA did misconstrue the phrase, the decision had already been taken to discharge Victoria. How would a proper construction of the phrase have changed the situation on 6^th August 1999? We cannot see that it would.
89. (d)(ii) Failure to carry out adequate investigations, in that LA failed to question and investigate Kouao's account of the scalding injury to Victoria in early August 1999, or the delay in seeking treatment. [LL.6.593]. LA's own account of what she was told by Kouao was in her statement to Lord Laming's Inquiry. It is said by Ms Grey that Kouao's statement is full of discrepancies that were not explored or challenged by LA. Even if the hospital accepted that the scalding injuries were accidental, there were serious "parenting" issues which were not explored, it is contended.
90. It is said by Ms Grey that LA's response has been that she realised that Kouao was being evasive in child protection issues, took that to her manager and was told to see Victoria. However, it is contended that it simply does not excuse the lack of proper planning of the interview and the failure to "press" Kouao by exploring her accounts more deeply. It does not seem that the inadequacies of the interview with Kouao were then borne in mind when judgments were reached on the nature of the interview with VC.
91. Generally, the GSCC's case is that interviewing is a basic tool for social workers. A more inexperienced social worker should be doing more, not less, by way of preparation and planning. The fact that Kouao was deceitful is not a proper excuse for the failure to cover all the areas of concern more systematically.
92. In response, Ms Arthurworrey said that at the time she did not think that she was out of her depth and she thought that she could do it. LA said she pressed on because she thought that she was doing it right and she trusted the judgments of the people supervising her. LA accepted in cross-examination that the meeting on 16^th August was to address social issues and that she deeply regrets not speaking to Victoria on that day. However, Ms Arthurworrey said that, as far as she was concerned, she was trying to wok in partnership with Kouao and the letter from the paediatrician did accord with what Kouao was telling her. Ms Arthurworrey accepted that she should have taken a police officer with her on 16^th August. LA said that she was impressed by the environment she saw and as for planning the meeting that day it was not normal to have a discussion with CB although she did have a plan in mind. Ms Arthurworrey accepted that she did not raise matters such as anxious attachments, VC's fear of being undressed and the fact that she was frightened of Manning. What LA did observe, however, was that VC seemed relaxed and happy in front of Kouao and Manning.

Findings

93. We are aware that LA was appointed to the case on 2^nd August and that VC was discharged home on the afternoon of 6^th August, the interview of Victoria taking place on the morning of 6^th August. The interview of Kouao took place on 5^th August. We bear in mind LL 6.244 and in particular the fact that Dr Rossiter had concluded on 1^st August that the scalding injury was self-inflicted. We must not look at this with the benefit of hindsight.

Conclusions

94. It seems to us that LA did ask about the scalding. We need to bear in mind that, as LL said at 6.246, Kouao was very plausible. We also bear in mind LA's first statement to LL's Inquiry where she said that there were concerns expressed by her that Kouao was avoiding child protection issues and also LL at 6.235
95. (d)(iv): Failure to carry out adequate investigations. The complaint here is that Ms Arthurworrey failed to question Victoria about the injuries other than those caused by the scabies [LL 6.255], in the interview of 6^th August 1999.
96. Ms Grey says that the CST was prepared to accept (in case 628) that LA's failure to conduct a proper interview on 6 August did not amount to misconduct (para 115). She was not "memorandum trained". The GSCC commented on this finding at paragraph 59 of its submission to the Committee. It noted the Appellant's previous assertion that she had worked "directly" with children and families. Even if she had not been memorandum trained, she should have been able to talk to Victoria about her everyday life and experiences. She should also (in the absence of supervision, etc) have sought assistance from departmental policies and procedures, and colleagues. She had asserted in her application to Haringey that she understood the importance of following such procedures. Furthermore, had she read the file by this date, she would have been better equipped to know what issues needed to be explored. It was not only the scalding injuries that required an explanation. This tribunal was taken to the report of Mr Monaghan for an account of the interview.
97. Generally, it is submitted by Ms Grey that Memorandum training is something of a "red herring". There was never a suggestion that a formal video-taped interview needed to be conducted at this stage.

Findings

98. The interview took place in hospital and without the assistance of an interpreter. In her statement to the Laming Inquiry LA said that she did not have a chat about the marks. Scabies is a parasite that can be found in warm dirty beds and so the fact that Kouao did not have any scabies marks did not necessarily raise suspicions since Victoria could have been sleeping in a different bed from Ms Kouao.
99. It is a valid point that it would have been much better to have an interpreter present. However it is also fair to say that it did seem that Victoria understood what was being said. We are not convinced that even if LA had questioned VC about the injuries she would have gleaned much information that would assist since it seems that VC was cautious about saying anything. We also question whether it was ever established that the other marks were caused by abuse as there are no medical findings to that effect.

Conclusions

100. Again, the issue was about injuries caused other than by scratching where scabies had been. To have started an investigation about matters soon after the doctors had stated that there was no non-accidental injury would have been perverse in the extreme. At 6^th August 1999 there was no obvious reason to carry out an investigation. If there was the doctors should have raised the alarm. Again we are concerned that LA's behaviour is being seen with the benefit of hindsight rather than looking at whether, at the time in question, it was appropriate or not to have investigated as was suggested. This was the first time that Ms Arthurworrey had met Victoria, she had only had the case for 4 days and she had had what she thought was an appropriate conversation with Kouao the previous day. Standing at 6^th August 1999, we ask ourselves this question: was it appropriate, on that day with the information that was then to hand, to question Victoria about the injuries other than the scabies? We answer it unequivocally: No. On the first meeting we believe that the objective of a social worker is to get acceptance so that (s)he can have continuing access to the family and child.
101. Once trust is established and future access assured there would have been no reason why the questions could not have been asked at a later stage. We know in hindsight that Kouao did not allow much further access to Victoria. Although it can only be speculation, had the questions been asked on 6^th August, it is unlikely that Victoria would have been seen again as Kouao would have suspected that the authorities were 'on to' her.
102. (e): The preparation for the interview of 6 August was inadequate and showed a lack of reflective practice. It is apparent from the decision letter that the GSCC's Committee's members were critical of the decision not to take an interpreter along, even though the GSCC had reached the view that the decision was "perhaps understandable". It was submitted by Ms Grey that there was (again) a failure to think through the nature of the interview and what was being required of a very young girl.
103. In her evidence to us LA said that she did prepare for the interview. This took place with PC Jones and the questioning was shared.

Findings

104. There was evidence that VC could speak and understand English and it is unclear if anyone in hospital who had had contact with VC prior to 6^th August had ever used an interpreter to communicate with VC. We can find no record that says that an interpreter was required to be present to speak to Victoria.

Conclusions

105. We wonder how Victoria might have reacted to the presence of an interpreter. It could be seen to have been an overreaction. We also bear in mind our conclusions in paragraphs 100 and 101 above. We do not believe that detailed questioning was appropriate on 6^th August and so we cannot accept that the preparation was inadequate. We agree with the GSCC's view, rather than the Committee's view.
106. The Committee criticised the overall failure of LA to carry out an adequate assessment of VC's situation The decision letter refers to Laming 6.551: "four simple facts" highlight how Victoria's plight was "so disastrously overlooked for so long". He then referred to the fact that she was seen only 4 times, never for more than 30 minutes, and "On none of those occasions did the conversation between the social worker and Victoria extend much further than "hello, how are you?" At 6.557: there was a "consistent failure to do basic things properly". Lord Laming spoke of the need for staff to "shoulder responsibility" for failing to carry out "a basic element" of a job [LL, 6.559]. There was a failure, said the Committee, to act on indicators which should have revealed the need to "undertake a properly planned and managed Core Assessment". It considered that this failing demonstrated a lack of good conduct.
107. It was said by Ms Grey that, in general, the decision to allow VC to be discharged from hospital was not the subject of direct criticism from the Committee. In evidence, LA said much about the fact that the decision was made (or at least endorsed) by her manager. But this was not a case where all the relevant information has been gathered and considered, but the wrong "judgment call" follows. The concern is that the investigation which preceded the decision was seriously flawed.

Findings and Conclusions

108. We are concerned about the chronology relied upon in the preceding paragraphs and in particular the fact that the concern was that the investigation which preceded the decision to discharge Victoria was seriously flawed. If the RC is relying on LL paragraphs 6.551 and 6.557, the RC's criticism is an overall view rather than a criticism of a single matter. The assumption is that there should have been an investigation before Victoria was discharged. If that is the case, no blame can be laid at Ms Arthurworrey's feet. LA was presented with the decision to discharge when she took over on 3^rd August. The decision had been reached on 18^th July at the strategy meeting. From what we have read it is clear that no real investigation had been undertaken at that time. Had the 18 recommendations been time-bound, allocated and properly reviewed much of the information would have been available before discharge. The lack of focus of the strategy meeting meant that, thereafter, there was no coherent framework into which to feed and assess any information. A failure to investigate as at 6^th August was not LA's fault.
109. (g): LA failed to communicate properly with Dr Rossiter by failing to send on the CMH material for her opinion, despite having agreed to do so [LL 6.274]. This is self-explanatory. The fax was not sent on until 19 October 1999, when it was sent on by Ms Kitchman (not LA): LL 6.334.
110. This criticism is accepted by LA as recorded in paragraph 6.274 LL and so we do not need to make any findings one way or the other.
111. (c)(i): Failure to keep an open mind: on 16 August 1999, LA failed to ask how VC spent the day. It is said by the GSCC that LA failed to use the opportunity of the visit to question VC. She "did not speak to Victoria at all during the visit" (LL 6.294); she "never asked Kouao, let alone Victoria, how she spent the day – a crucial aspect of any child assessment" (LL 6.299). In evidence, LA says that she accepted Kouao's statement that VC spent the days looking for housing with Kouao. If Ms Arthurworrey had read the Central Middlesex Hospital fax properly (with its reference to childminders, etc), it is said, she might not have been so ready to accept that statement. She did not talk to VC at all.
112. We have recited the evidence Ms Arthurworrey gave about this at paragraph 92 above. MS Arthurworrey saw the visit as part of an ongoing process as she was looking at why Victoria was not attending school and the housing issues, LA also stated that by 16^th April VC's case had been designated 'family support' rather than 'child abuse'. In cross-examination LA did accept that had proper mechanisms been in place it would never have been designated 'family support'. At the time of the visit LA knew that Kouao had been looking for accommodation and taking Victoria with her. Because LA knew that Victoria had been spending most of the day 'trudging behind her' LA recommended to Kouao that she used registered childminders.

Findings and conclusions

113. The home visit on 16^th August was a planned visit and Victoria was smartly dressed. LA said (LL6.294) that she deeply regrets not asking VC anything. It may be, of course, that there are different ways of asking the same information (such as what she does with her time, what toys she plays with). We accept that discussions of this sort are a routine way of gathering information and so to not do so is a major failure. We anticipate that Ms Arthurworrey was not experienced in using drawings and play material as a way of working with children so as to obtain information. We accept that Ms Arthurworrey failed to find out what life was like for Victoria and did not engage in any meaningful way with her. It is possible, of course, that it might have been difficult for this to take place because Kouao was there but it would have at least been worth trying to ask to speak to Victoria alone for a while. We are concerned that LA did accept that she seems to have accepted the fact that Kouao said that Victoria was looking for housing with her rather than starting to go to school. We have no doubt that to others this would have raised concerns and perhaps led to closer attention being paid to the family. The housing search begged serious questions which could not have been totally ameliorated by the fact that Victoria was well turned out.
114. (c)(ii): Failure to keep an open mind: it is said by GSCC that on 16 August, LA failed properly to pursue the concerns of neglect raised by North Middlesex Hospital. [LL 6.296]. Only 3 of the NMH's concerns about neglect were raised.
115. Both this and the preceding concern relate to the events of 16 August 1999. Here, the CST found (in case 268) that although the interview was inadequate and inadequately planned (see para 124), and the Appellant was "naïve in the extreme", there was no misconduct (para 125). Ms Grey says that "it might respectfully be doubted whether the extremes of naivety are consistent with competence." The GSCC observed in its submissions to the Committee that although the appellant was relatively inexperienced, had she read the file properly before the interview, she would have approached it very differently. Ms Grey says that Ms Arthurworrey failed to appreciate from the file that this was a child protection case. "In addition, a social worker is required to be probing and ... have "respectful uncertainty", a concept that the applicant failed at the time to understand. This is a competency issue." (It should also be noted that Mr Jackson QC, (who acted for LA in CST 268), accepted LL's conclusions at 6.597 in respect of both home visits. These failings were discussed in more detail at LL 6.598 – 6.606, where the importance of proper planning, keeping an open mind and reviewing information were discussed. In relation to the latter, "Even such simple questions as "How was Victoria?", "What did she say?", or "How does she spend her days?" might have revealed Ms Arthurworrey's failure to focus on the needs of her client", Lord Laming wrote).

Findings and conclusions

116. We have to bear in mind that by 16^th August this case had been designated 'family support'. That did not obviate the continuing need to know about what was happening in the family. LA has accepted her failings. This is a fairly basic part of the job. It seems that she relied on observation. Maybe the failure to get into the conversational side of eliciting information was because of the language differences? We also think that LA was not sure what she was doing and, in reality, out of her depth. She should have been able to express these concerns but that was not possible in the climate and environment she was working in. Whilst "respectful uncertainty" should be present, this was clouded by the ethos of the department and Ms Arthurworrey's lack of suspicion. She was too trusting.
117. (c)(iii): Failure to keep an open mind about the possibility of deliberate physical harm to VC throughout August 1999, and to test out concerns raised [LL 6.237, 6.295, 6.597, 6.601, 6.602], as mentioned above.

Findings and conclusions

118. This is, of course, a general criticism rather than a general complaint. We have already discussed this in relation to the Central Middlesex Hospital fax, above. We believe that LA did keep an open mind to some extent but we also bear in mind that Dr Rossiter's letter and the fact that Carol Baptiste had suggested it was a family support case meant that the focus was off this as a critical concern. If LA had kept a fully open mind she would have been alerted to matters and this would have applied even if the case was designated 'family assistance'. We were unable to elicit from LA how she tried to keep an open mind. The responsibility for the lack of an open mind has to be shared with those senior to LA in the department. Unfortunately they were not capable.
119. (c)(iv): Failure to keep an open mind Failed to speak to VC at all, during home visits of 16 August and 28 October 1999, as LA acknowledged [LL 6.294, 6.296, 6.369]. See above.

Findings and Conclusions

120. LA accepts that she was observing and not questioning – not particularly helpful when it was accepted by everyone (albeit in hindsight) that Kouao was very plausible. It is self-evident in hindsight that it would have been beneficial if LA had spoken to VC on both home visits. Whilst we do not go so far as to say that there is a need to be memorandum trained to speak to a child, we do take the view that a conversation with a child is a skill in itself. Into this mix has to be added the fact that there is the control of the situation by Kouao and the language barrier is not helpful. Whilst the failure to speak can be seen as regrettable, because the case had been recategorised as family support rather than child protection, at that time the value of talking to Victoria was not appreciated as being part of a process of establishing whether or not this was a child protection case. Of course in general terms, we believe that no one wants to believe that there is a serious child protection issue and so instinctively there is a resistance to seeing it as Child Protection. To that extent there was a failure to keep an open mind and a failure to look and see if there was any warmth and happiness between Victoria and Kouao
121. (b)(v): Failure to carry out adequate investigations, in that LA failed to check the suitability of the accommodation at the Kimbidimas home, which was a basic check which she should not have needed instruction to do [LL 6.403]. LA pointed out that since she was on duty she would have needed to have been released, and that Ms Kozinos did not advise her to make any such checks (see LL 6.404). The Committee felt that it should not have needed such advice – she should have seen the need for herself and made arrangements.

Findings and Conclusions

122. Victoria was not in care so there was no statutory duty to check the suitability of the premises. Since proceedings were not being taken, this was good practice rather than required practice. That LA might have needed advice to make the check suggests to us that she was out of her depth in this type of work and that she was inexperienced rather than incompetent. It is not suggested that the Kimbidimas' house was unsuitable. What we find of greater concern is that LA made no checks to see if VC was at the Kimbidimas' house between 1^st and 5^th November. (LL6.437) If she had done so she would have become aware that Victoria spent NO nights there. That would have been a cause for concern if it had been ascertained.
123. (b)(vii): Failure to carry out adequate investigations, in that LA failed to make checks about where VC was staying up to and including 5 November 1999 [LL 6.437]. A check was made on 1^st November 1999 but not thereafter, before the strategy meeting. LA was away on training for three days, however she did not think to make any arrangements to ensure that checks were made on VC whilst she was away.

Findings and Conclusions

124. We have already made our concerns know in Paragraph 122. We are aware that there is evidence that LA tried to make some checks. She made calls to a mobile number but was not able to contact Kouao at all. What more could she do? This was only 1 of 20 cases LA had to deal with at the time so she could not devote all her energies to this. Linked to this is the supposed disclosure by VC of sexual abuse by Manning. If it happened it was serious. If it was fabricated it was serious. (LL6.407). By not even contacting the Kimbidimas' and if LA was having difficulty contacting Kouao there was a problem. Unknown to LA at that stage there was a missing child who was not at the house she was supposed to be at. Link that with the allegation of sexual abuse and the fact that 1½ hours after Kouao was at the social services getting VC to make the allegation she was seen laughing and chatting with Manning and the concerns should have been very high. Each of these points are not, of themselves, pivotal matters but each of them adds to the concern. Again, it is easy to see all of this in hindsight. This criticism is not a ground of itself to refuse registration.
125. (b)(viii): Failure to carry out adequate investigations, in that following the strategy meeting of 5^th November 1999, LA failed to write to Kouao until 19^th November, to invite her to a meeting on 1^st December. The Committee noted that LA had accepted that this was a wholly unacceptable delay [LL 6.648]. The CST (in case 268) had exonerated the appellant of misconduct in relation to this issue (see paragraphs 133 – 136 of its decision, especially 136). However, the GSCC was more critical in that the Committee considered that the information available to the strategy meeting should have rung "alarm bells" and that the "lack of urgency" (the CST's phrase) about VC's case was not justified. The 18 recommendations did not focus solely on the sexual abuse concerns. There was a statement that "Yes a Child Protection Case Conference is required" (See LL 6.442). 'Workload issues' demand action, whether by prioritisation, seeking to delegate or asking for help/reallocation of files. Generally, it is submitted that the emphasis on workload issues disguises the true reason for the lack of urgency: the perceived lack of need for action. The sexual abuse allegations were not believed and LA regarded VC as a happy child (LL 6.444).
126. In her evidence Ms Arthurworrey said that November was a difficult time for her. There was the departmental reorganisation going on, between 5^th and 15^th November she had no idea who her manager was. On 5^th CB was there but on 15^th she was given Angela Mairs. LA said that she was trying to manage competing priorities with one case going to care proceedings. LA described herself as being "totally brain dead, burnt out" at this time. Ms Arthurworrey said that she felt "quite disempowered and deskilled at that point". She said that she could not ask for help because everyone was under pressure because of the case load and restructuring. Although alarm bells were ringing she said that she felt overwhelmed and needed help at that time.

Findings and Conclusions

127. Because of the sexual abuse allegation LA should have been more sensitive to setting up a meeting as soon as possible. The sexual abuse allegation should have given the case a different direction and the failure to act with urgency is NOT justified, the matter had become serious. We accept that this criticism is appropriately made.
128. (d)(ii): Made inappropriate and unjustified assumptions, insofar as she assumed that VC and Kouao had returned to France in around the end of November/early December 1999 [LL 6.471].

Findings and conclusions

129. We bear in mind LL 468 to 473 and 497 to 501. Hindsight is not enough. There was a fair amount of effort put in by LA. She, like everyone else, was taken in by Kouao. It is clear in hindsight that once the allegation of abuse had been raised, Kouao did not want Victoria to be seen. LA did not stop trying to find Victoria. There were 2 home visits but LA was not able to get hold of Kouao. If the door and telephone were not being answered, what more can be done at that time? We conclude that it was not inappropriate to make a reasonable assumption on the information she had at that time. More information might have led to a different conclusion but that was not possible by that time.
130. (e): LA should have appreciated that the arrangements for keeping VC safe from sexual harm had broken down following the telephone conversation of 13^th December 1999 [LL 6.472].

Findings and Conclusion

131. It was only at this time that LA realised that VC had gone back home on the night of 1^st November. There is some evidence that Victoria had been in and out of the country. Ms Arthurworrey was trying to find Victoria, as we note in paragraph 129 above. Even when LA did appreciate that the arrangements had broken down what, at that time and without the benefit of hindsight could she have done? Once LA started to get worried she was not able to contact Kouao or Victoria. If LA had gone to a senior officer who was competent there could have been a case conference but that was not possible. The department lost the impetus and ability to manage the situation once the sexual abuse allegation was made.
132. (b)(vi): Failure to carry out adequate investigations, in that LA failed to carry out checks at the Bruce Grove Primary School before January 2000, although she had informed the Strategy Meeting of November 1999 that VC had been registered there [LL 6.436, 6.500 - 501].

Findings and conclusions

133. The lack of links with the education department is of serious concern. If there had been any appropriate links the education welfare service and welfare officer would have become involved. This was point 9 on the strategy meeting 18 point plan. LA should have contacted the school but as VC had never been to that school and was in effect of no fixed abode there would have been little to report other than VC was not registered. It is the failure to engage with education professionals that causes us the concern. A link with the education department would have meant that there was another professional available to have oversight of what was happening. It is another example of the failure of the department to look at the wider picture.
134. (b)(ix): Failure to carry out adequate investigations, in that LA failed to take adequate steps to validate the information being given by Kouao to Social Services, so as to expose and explore its inconsistencies [6.609, 6.611].

Findings and Conclusions

135. This criticism is easy to make in hindsight and with the assessment that Kouao was 'deviant'. As a result of Carol Baptiste's decision, this was treated as a family support case. Had it remained as child protection there would have been a need to look at inconsistencies more immediately. Of course that does not mean that accurate clarification would have been forthcoming from Kouao given that she was being deceitful. The strategy meeting did set as a task (LL 6.431) this as one of the things to do. An investigation of the inconsistencies would have affected Kouao's credibility in Ms Arthurworrey's eyes and would have shown that she was manipulating the system - which would have raised additional concerns.

Conclusions on the Appellant's Performance.

136. Ms Grey asks the Tribunal to look at the Appellant's performance in the round, taking into account both the various errors and failings identified above and also the mitigating factors (which are set out in paragraph 3 of the decision letter). It is submitted by Ms Grey that, overall, the Registration Committee had ample material to support the conclusion that the Appellant had not satisfied them of her conduct and competence as a social worker.
137. In relation to the mitigating factors Ms Grey says that if a relatively inexperienced social worker feels out of her depth, there is a special responsibility to seek guidance. If not provided by managers, then alternative sources of help include manuals and/or procedure guidelines, and colleagues. The "Purple Book" sat unconsulted (whether in Carol Baptiste's office or LA's desk). LA gave evidence to the Laming Inquiry that she "put her head down" rather than forging relationships with other colleagues.
138. Ms Grey continues that although supervision is important, it may take place only once a month or so (less in this case, of course). To the extent that LA refers to the advice she was given at such sessions, she must have been aware of how crucially it depended on what she herself was reporting. More generally, a qualified social worker is expected to be able to operate independently and form sound judgments on risk, etc, without constant supervisory input.
139. Ms Grey continues that issues such as reading files and faxes have been referred to in relation to specific matters. So too has the issue of conducting interviews. In general, it is not accepted that the skills which were needed in this s47 investigation were so remote from the "ordinary" work of a social worker that they could not have been reasonably competently carried out.
140. The issue of workload is a recurring theme in social work practice. Tasks have to be prioritised, and help sought if there are problems. For example, if there was an urgent interview in a s47 investigation needed, it was not acceptable to delay it whilst the allocated social worker went on leave (here, from 22 – 28 November) or on training courses – arrangements for cover have to be made (or attempts made to do so).

Findings and Conclusions

141. We accept that it is responsible to seek guidance from a manager. A case cannot simply be 'dumped' on a 'coal face' worker and that person left to get on with it. Managers are equally responsible for the conduct of cases. We have already stated that we find that Ms Arthurworrey faced difficulties with adequate managers since, it appears, neither her line managers nor the specialist child protection manager engaged with her in any meaningful way.
142. The frequency of supervision can vary and it can be as often as once a week. There is also the benefit of having a general collective discussion with managers and colleagues to reflect on the information obtained. Sound judgments can only be formed on experience and so we doubt if a social worker such as Ms Arthurworrey with only two years experience would have sufficient experience to make sound judgments on child protection matters or in cases such as this in terms of adult behaviour without management input.
143. This department was in chaos. It was being reorganised with effect from 8^th November (according to Mr. Monaghan's chronology). There were other features that were of general concern. First LA did not realise that this case was a section 47 investigation. Second, the lack of a positive ethos in the department led to a lack of urgency in the case. Within the department we see that there was a lack of a management strategy; a lack of exercise of duty; a lack of proper systems; a lack of monitoring of serious cases; a pressure to reduce the work loads by trying to close cases and a lack of proper professional systems and responsibility.
144. So, is the poor practice we have found of itself sufficient to refuse Ms Arthurworrey registration? We are not convinced that it is. We have made it abundantly clear above that we believe that in most instances the failings identified and relied upon were either as a result of medical advice which was effectively unchallengeable or as a result of a lack of supportive and competent managers giving LA the guidance she needed. We do not regard the failings we have identified as so serious that we would not permit Ms Arthurworrey to be registered. However, that does not mean that we would authorise an unrestricted registration.
145. Before considering any final recommendation we have to consider those matters which have arisen since the decision letter.
146. The other matters we need to take into consideration are character and health. These were not part of the GSCC's Committee's decision as they only emerged during the course of LA's appeal to this tribunal. In reaching our decision we are able to take into account matters that were not before the decision maker at the time the decision was taken. We are not reviewing the decision taken but are conducting a fresh decision making process at the time of the hearing with the evidence available at that time.
147. In relation to Ms Arthurworrey's character, we have considered the criminal conviction she received in Paragraphs 34-36 of this decision. We do not regard that as of sufficiently serious a nature, bearing everything in mind so that it would prevent LA from being registered.
148. The matter that gives us more cause for concern is Ms Arthurworrey's current mental health. There is nothing to suggest that prior to 1999 Ms Arthurworrey had any mental health problems. We were aware that Ms Arthurworrey was having difficulties in early 2007, as recorded above, and that she was seeking professional help. We were not aware until during the hearing that LA was still (in March) signed off sick from work. We appreciate that she may get better once the appeal is out of the way and if she is successful. However, we are concerned whether Ms Arthurworrey would be able to cope if she was under stress. We do not doubt that LA has been under considerable pressure over the last few years and that there has been an effect as a result of these proceedings too. We particularly bear in mind the series of inappropriate e-mails. We are concerned that she has not been able to manage things very well and that she has not demonstrated to us that she is able to cope under stress. Given that being a social worker is stressful, we believe that it would not be appropriate for Ms Arthurworrey to be registered as a social worker until she has had a proper psychiatric assessment from an occupational psychologist.
149. Whilst there are doubts over LA's mental health there should be no attempt at registration. Although it is Ms Arthurworrey's duty to prove that she is fit to practice, given the nature of the case a joint instruction might be appropriate.
150. Apart from the need to be satisfied that Ms Arthurworrey's mental health is stable, we indicated that we would not consider it appropriate for the GSCC to register Ms Arthurworrey with out conditions. We cannot impose conditions on any registration, just recommend that they are imposed. However, by us allowing the appeal we believe that the GSCC really HAS to impose conditions. Having given this matter considerable thought we recommend that the GSCC registers Ms Arthurworrey (once her mental health is shown to be stable) but subject to some stringent stipulations. We recommended that Ms Arthurworrey:

should have to undergo a period of retraining given that she has not been in practice for some time;

is the subject of intensive supervision;

should serve a probationary period and

should be regularly assessed for at least 3 years.

151. Unfortunately we cannot conclude this decision without commenting on the representation Ms Arthurworrey received from BASW. Given the importance of this case to Ms Arthurworrey we were surprised that the case was presented by a BASW case worker, rather than a lawyer albeit we understand that Mr Weinbren is a qualified social worker. BASW have the ability to instruct lawyers (as was shown when Mr Weinbren said that he had another commitment on the last day of the hearing). Social workers are entitled to the best possible representation and not feel that they are being let down. We felt that in this case Ms Arthurworrey did not receive strong advice focussing on the issues and we have indicated above that there were gaps in the submissions and evidence adduced to make her case. If ever there was a case for BASW to instruct a QC this was it. In the end, Ms Arthurworrey has succeeded despite not because of her representation.

APPEAL ALLOWED

WE DIRECT THAT THE DECISION TO REFUSE REGISTRATION SHALL NOT HAVE EFFECT

This is an unanimous decision

Mr. Simon Oliver, Deputy President

Mrs. Lydia Gladwin

Mrs. Margaret Williams

Date: 2^nd June 2008