Final Report > Chapter 10: Introduction to Concerns > Assessing the response to concerns > The approach adopted

The approach adopted

7 Analytically, the approach we adopt involves the following sequence:

• Were there grounds for concern?
• Was a concern raised, or should one have been?
• Was the concern raised recognised as such by the person to whom it was expressed?
• With whom was it (or should it have been) raised?
• Did the concern reach the person or body who could take action?
• What action, if any, could or should have been taken?
• What action was taken?
• If no action was taken, was this justified?
• If action was taken, was it appropriate and prompt?

8 While this analysis describes our task, we do not allow it to dictate what follows. We bear it in mind and seek to pay due regard to it, but do not follow it slavishly. This is because, as we have made clear from the outset, we were not conducting a trial. We must, therefore, avoid an approach which has the hallmark of a criminal indictment, with particular charges to be established. This is not how we conducted the Inquiry, nor is it how we propose to respond to the issue of concerns. And, this is not just a point about procedure. It goes to the essence of our approach to the Inquiry as a whole. We have referred frequently to the illusory picture of events which can be created by an Inquiry of the kind we have been asked to conduct. The blur of activity in a busy organisation is reduced to a series of ordered documents which appear to leave no room for doubt. Discussions among healthcare professionals and between them and parents and others are represented as if they were fully reproduced in a note in a file or a minute of a meeting. Recollections across years of time are represented as if they were accurate and complete accounts of what transpired. We must guard against this illusion.

9 To follow too closely the analysis suggested by one approach to our Terms of Reference would, therefore, prevent us from fulfilling what we see as our real duty. Thus, in what follows we will first set out the evidence which we received about concerns: to whom they were expressed, and in what way, for example, by letter or in conversation, and what action, if any, followed. In some instances there are differences in the various accounts which cannot be resolved. In such cases, we accept that there may be honestly held but differing recollections and interpretations of events. In the final section we will express our views on the appropriateness of these responses. Finally, we reiterate that we are required to focus on concerns expressed at the time, not on those which individuals have come to have with the benefit of hindsight.