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January 25, 2003

Shieldfield doctor faces GMC hearing

The fact that the General Medical Council is due to hold its initial review of the complaint against Dr Camille san Lazaro soon (on the 28 and 29 January) may seem, to those who have followed the case closely, to mark the beginning of the end of Dr Lazaro's career as a forensic paediatrician. This may indeed turn out to be the case. However, recent developments in the Republic of Ireland suggest that it would be wrong to assume that professional bodies always act as robustly as the evidence suggests that they should.

In the case involving Dr Moira Woods, who for many years led the sexual assault treatment unit at the Rotunda Hospital in Dublin, the Irish Medical Council last year examined numerous complaints that Dr Woods had wrongly diagnosed sexual abuse. In a number of these cases children had been removed from their parents as a result. Although the Medical Council upheld many of these complaints and found Dr Woods guilty of professional misconduct, one of the supposed 'sanctions' it imposed on her was that she should in future engage in child protection work only as part of an expert multi-disciplinary team. In a fierce article written at the time, Irish Times columnist John Waters argued that this should have been happening anyway and that 'It is utterly incomprehensible to the layperson that investigations into allegations as serious as child sex abuse can be carried out by a single individual whose word becomes holy writ.'

Earlier this month, after the Medical Council had issued another report criticising the running of the hospital in question, Irish Medical News reported that Dr Woods was fighting back and had issued a statement:

I fully reject the committee's report and I stand by my judgments in the cases considered in the inquiry. This is not a matter of pride or defiance. No doctor is infallible. Mistakes and oversights are a daily risk for all doctors, and I am no exception. But as regards these cases, which have been under intensive review during this inquiry, I remain adamant that I had no option but to act as I did, on the evidence presented to me, and on my interviews with the children concerned. Regrettably, much of the media comment on the report reflected what I think is a fundamental misunderstanding of what is involved in investigating alleged child sexual abuse. Those charged with this responsibility are rarely able to establish proof of abuse to a standard required for criminal prosecution. This is especially true if the children are very young, which is often the case. Investigation of sexual abuse is about child protection. It is beyond doubt, given all the documented cases of sexual abuse we now know about, that the medical profession in all its disciplines was found wanting in this area in the past.

I am aware that some 50 doctors have protested to the council at the manner in which the cases brought against me were handled and the consequences of the unchecked inaccurate publicity. I am very grateful to them, and to the many doctors, social workers and others who have contacted me privately to express their support and solidarity.

The case relating to Dr Lazaro is by no means an exact parallel with that of Dr Woods. But we need not doubt that, given the issues which are at stake, she too will have professional supporters. However, those who believe that Dr Lazaro should be treated leniently when she faces the GMC would do well to recall why it is she has been summoned to appear before them in the first place.

At the Shieldfield libel trial last year it emerged that Dr Lazaro had played the central role in an investigation as a result of which two completely innocent nursery nurses had found themselves imprisoned on remand as suspected paedophiles. At their criminal trial in 1994 Dawn Reed and Chris Lillie were found not guilty. However, largely because of the medical evidence which had been supplied by Dr Lazaro, Newcastle City Council remained convinced of their guilt. They set up an independent inquiry. After the four child abuse experts who sat on the inquiry had taken evidence once again from Dr Lazaro, and from parents whose children she had examined, they found Reed and Lillie guilty over the heads of the Court.

Branded by the local and national media as wicked perverts who had systematically subjected the very young children in their care to horrific sexual abuse, Dawn Reed and Chris Lillie were forced into hiding in different parts of the country.

The only way they had of clearing their names was to take a libel action against Newcastle City Council and the four members of the Review Team. The case began in the High Court in London almost exactly a year ago on 9 January 2002. During the six-month trial the Court learned that on numerous occasions mothers had taken their children to be examined by Dr Lazaro principally in order to find reassurance. In many instances, however, they came away believing that their children had been abused. On a number of occasions Dr Lazaro had based her view that abuse had taken place not on any medical signs she had observed or claimed to observe but on her own interpretations of the child's reported behaviour.

On other occasions she said that she had found physical evidence of sexual abuse. However, because she did not arrange with any of her colleagues to conduct joint examinations of the children, and because she did not use the photographic equipment available to her to record the evidence she reported, there has never been any objective confirmation of Dr Lazaro's observations.

In many ordinary medical situations, of course, diagnoses frequently depend on the unverified observations of a particular doctor. However, this was not an ordinary situation. It was a criminal investigation of the gravest possible kind involving the most serious allegations which had ever been made in relation to any nursery in the UK. In such circumstances every precaution was clearly necessary in order to ensure the integrity and accuracy of the evidence which was reported. Yet still there were no joint examinations and no photographic records of the reported physical signs.

Everything therefore depended on the one hand on the clinical competence of Dr Lazaro, and on the other hand (and perhaps even more importantly) on her own integrity and on the accuracy, reliability and truthfulness of her medical reports.

During the libel trial some highly significant evidence was put forward which called Dr Lazaro's clinical competence into question. But, even more disturbingly, evidence emerged which suggested that her records and reported findings could not be relied on as truthful or accurate descriptions of what she had in fact observed.

In a report which she had submitted to the Criminal Injuries Compensation Authority she had made claims about horrific abuse allegedly suffered by a number of children. Yet these claims were, according to her own earlier findings, untrue. The crucial fact here is not that Dr Lazaro herself admitted under cross-examination that her report was 'overstated and exaggerated'. The crucial fact is that her own records established beyond doubt that she made claims in her report which were flatly contradicted by her own earlier reported findings.

This was by no means the most grave example of Dr Lazaro's conduct which emerged in the trial. As Bob Woffinden and I noted in the article we wrote in the Guardian to mark the conclusion of the libel trial:

The case of four-year-old Tracy, who had made the allegation of rape only after three video interviews, was the most disturbing of all. Dr Lazaro examined the child on 8 October and said she had found a partial tear in the hymen; however, normal variants are sometimes misinterpreted as partial tears. On 22 October, after Tracy had been cajoled into making the rape allegation, the police paid an urgent visit to Dr Lazaro. Without having seen the child in the meantime, she now produced a statement claiming that she had found a complete transection of the hymen. This finding was indeed consistent with the allegation freshly made by the child. But it was not consistent with the paediatrician’s own medical records.

The evidence which emerged in the trial, in other words, clearly showed that the medical findings originally made in relation to Tracy had subsequently been changed by Dr Lazaro without there being any new medical examination of the child to warrant this. There are only two possible explanations of this. The first explanation is that Dr Lazaro acted with gross and inexcusable recklessness in circumstances whose gravity demanded that she show the greatest possible caution and the most meticulous attention to detail. The other explanation is that Dr Lazaro deliberately ratcheted up her findings in a possibly well-intentioned, but thoroughly dishonest attempt to oblige the police by affording medical 'corroboration' for an allegation which would eventually be found to be without any substance at all.

It might be tempting for the GMC to opt for the first of these two explanations. However, when it is placed alongside the clear evidence afforded by the false report which Dr Lazaro submitted to the CICA (and other examples of false or misleading information which was given out by Dr Lazaro), the incident involving the 're-diagnosis' of Tracy is extremely disturbing.

Whichever view is ultimately taken of Dr Lazaro’s conduct in regard to Tracy there can be no doubt at all that, either through dishonesty or recklessness, she made a decisive contribution to the terrible injustice which was inflicted on Dawn Reed and Chris Lillie and to bringing about the nine-year ordeal which they subsequently suffered.

The General Medical Council, in seeking to deal with Dr Lazaro both fairly and firmly, faces a difficult and sensitive task. In the past it has frequently been accused of 'looking after its own'. It is right and proper that it should look after its own in any case where false or exaggerated allegations have been made against a medical practitioner. But in this case the evidence which was available to the Court even before Dr Lazaro's disastrous appearance in the witness box, suggests that the only false and exaggerated claims which are in question were those made by the medical practitioner herself.

Above all it should be clear, and the GMC should itself recognise this at the outset of its inquiry, that this is not a case which turns on whether medical signs whose objective presence has never been in doubt have been correctly interpreted. That would be a matter for specialists and one on which writers, journalists or members of the public who are not medically trained would have no authority to pronounce.

This, however, is an inquiry which concerns, or should concern, the credibility and reliability of the reports which Dr Lazaro made of medical signs which she said she observed but which may not in fact have been present at all.

When, some four years ago, Bob Woffinden and I compiled our 70,000 word case analysis which eventually led to the bringing of the libel trial, we reached our own assessment of the medical evidence only after we had discussed it in detail with five experienced paediatricians or police surgeons. However, one of the main effects of these  discussions was to confirm the view that the most important issue in the case was the reliability of Dr Lazaro’s original reports and not the manner in which other medical practitioners might now construe the evidence they purported to record. It was this view which we set out at the time:

The only reasonable conclusion it is possible to reach is that Dr Lazaro’s findings, unsupported as they are by photographic evidence, or by the opinion of fellow clinicians, should properly be treated as subjective opinions, rather than as clinical facts. There is no objective evidence that any of the children in the Shieldfield case had been sexually abused. There is only Dr Lazaro’s stated belief that she had discovered such evidence [in some children] at the time of her examinations. For all the reasons given above her reports should never have been relied on in the way that they were either by social services or by the police.

This view was subsequently vindicated in the libel trial itself. It should be noted that it is not a medical conclusion; it is a conclusion about the reliability and proneness to error of an individual human being.

This is the issue on which the GMC will shortly have to deliberate. Ultimately the question they have to address is one which no amount of medical knowledge can help them to resolve. It is nothing other than the question of whether Dr Lazaro's reports of what she said she saw can be relied on as accurate and truthful.

In assessing this question the GMC panel should above all remember two things. They should remember that doctors are human beings and that human beings - even though they may be qualified doctors - are not always reliable and do not always tell the truth.

If they attempt to resolve the issue in any other way, or to present it as though it turned on questions of medical interpretation, they will themselves be guilty of seriously misrepresenting the evidence which has been placed before them. Were they to do that they would destroy at a stroke the confidence which the GMC now has reposed in it by members of the public.

It is to be hoped that, for the good both of that public, and of the medical profession itself, the GMC will face the issue which now confronts it squarely and without flinching. If it does not, it will itself succeed in bringing into grave disrepute the very profession it was set up to protect.