| Dr. Moira Woods Found Guilty in
Ireland of Professional Misconduct Medical Council Statement on the Fitness to Practise Committee Inquiry concerning Dr K C M Woods November 2002 Introduction The Medical Practitioners Act 1978 requires the Medical Council to examine all complaints in relation to the conduct of a doctor. When a complaint is received, complainant and doctor are asked to comment, following which the Fitness to Practise Committee makes a decision on whether an inquiry should be held. Inquiries are normally are held before a team of five members of the Committee. The Registrar - who presents the evidence and the practitioner are legally represented and the standard of proof is usually beyond reasonable doubt. The Medical Council initially received a complaint in 1992 in relation to the management by Dr. KCM Woods of alleged child sexual abuse cases and made a decision in 1995 that an inquiry should be held. Following protracted proceedings in the High Court, the Medical Council was in a position to proceed with the inquiry in 1999. The Fitness to Practice inquiry team heard 43 days of evidence from 60 witnesses and issued its report to the Medical Council in 2001. The inquiry process was subject to rigorous confidentiality measures imposed by the High Court. The Medical Council was granted permission to publish the findings of the inquiry provided that the anonymity of the children and parents involved would be suitably preserved. It is the view of the Medical Council that in assessing and treating children Dr. Woods was obliged to follow basic and well-recognised medical principles and to ensure that the process of differential diagnosis was followed. In certain cases, Council found that Dr. Woods failed to show and apply the standards of clinical judgement and competence required of a doctor in her position. Specifically, the Fitness to Practise Committee found that Dr. Woods failed to gather all the available evidence and/or did not follow the protocols established by SATU and/or failed to review additional information received after preliminary findings had been reached. Dr. Woods faced 55 charges of which 13 were found to have been proven. In January 2002, the Medical Council accepted the finding of professional misconduct made by the Fitness to Practise Committee. The Medical Council censured Dr. Woods and imposed conditions on her registration. BACKGROUND In March 1984, the Department of Health issued a circular letter to all acute hospitals dealing with reports alleging inadequate treatment for victims of rape. Between May and June 1984, informal discussions between the Department of Health and the Rotunda Hospital led to a proposal for a Sexual Assault Treatment Unit (SATU) at the Rotunda Hospital. In June 1984, the proposal was agreed in principle by the Joint Maternity Hospitals Committee. In October 1984, a Working Group was established with membership from the Department of Health, the Rotunda Hospital and the Eastern Health Board (EHB). Its brief was to: • Establish a Sexual Assault Treatment Unit at the Rotunda Hospital • Report on the operation of the Unit after six months The first meeting of the Working Group agreed that doctors working at the SATU would be employed by the Rotunda Hospital and would operate under the direction of the Master of the hospital. The SATU began work in January 1985; its work was envisaged as undertaking the forensic examination and medical treatment of adult victims of suspected sexual assault in the EHB area. Little consideration was given to the possibility of the treatment or examination of children within the unit. Within a month of its establishment, the issue of the treatment of children was considered at the third meeting of the Working Group. That meeting considered that a children's unit would be required with special expertise and training and that relevant children's hospitals should be consulted about establishing such a unit. Such units ultimately came into being in 1988. Between 1985 and 1988, the SATU found that the numbers of children being treated increased rapidly until they represented the vast majority of those attending the unit. Thus a situation evolved where very substantial numbers of children were being examined in a unit which had originally been established for the purpose of examining adult victims of sexual assault. Year Number of children examined 1985 190 1986 530 1987 600 Once the SATU was established it continued to operate almost independently of the Rotunda Hospital. Dr. Woods began work there in 1985 and was effectively in sole charge of the unit. There is little evidence of any other medical supervision of what occurred in the unit after its establishment. Dr. Woods had been engaged in limited general practice from 1979 to 1985 and had, around the same time, worked in Dublin with victims of sexual assault. Dr. Woods had some, but limited, practical or clinical experience with children. The diagnosis and management of sexual assaults involving children was not a well developed area of medicine in the 1980s, in Ireland or elsewhere. However, international expertise was growing and broad principles of care were being established. In addition, at all times basic and well-recognised medical principles and sound procedures were required of practising doctors. Procedures were established within the SATU for the diagnosis and management of children, influenced by work carried out in other countries. The SATU was subjected to very substantial work pressures within a short time, but with very limited resources. It is noteworthy that SATU did not have access to in-patient facilities and could not therefore admit children to a hospital setting. This limited the options for the investigation and management of these cases. However, the weight placed by the Courts and Health Boards on reports issued by SATU was substantial and significant decisions regarding children and their families were based to a certain extent on these reports. Medical Council Concerns - Management and doctors Patients are entitled to expect and receive safe, competent care from doctors. When children or their parents receive care which is inadequate, as in this case, doctors must take responsibility for not meeting the standards set by their peers and which can reasonably be expected to apply in those circumstances. However, those who plan, fund and oversee medical services have separate responsibilities to the doctors whom they employ. Medical Council disciplinary proceedings have no authority to investigate management structures in Irish medicine. Nonetheless, where management structures appear not to have fully played their part, it is essential that a distinction be drawn between the responsibilities of individual doctors and the responsibilities of the agencies for which they work. It is now well recognised that Clinical Governance sets out the responsibilities of employers and service providers to create a safe and effective working environment for patients and health carers. Although the terminology was not in use in the mid-1980s, it is clear that a range of Clinical Governance issues have not been addressed in this case. 1. The role of supervisory structures / bodies Although a high level Working Group and links to the Rotunda Hospital had been established, there is little evidence of the effective functioning of these structures/bodies. Management activities in funding, staffing and monitoring services within SATU are unclear. However, the responsibility for these activities clearly rested with management structures and not with individual employees of SATU. It is inappropriate to conclude that Dr. Woods' employment at SATU relieved the Working Group or the hospital of these responsibilities. The training and professional background of staff selected to work at SATU should have been of paramount importance when the service was being established. Dr. Woods was employed without formal training or experience in the management of paediatric victims of sexual assault. While other qualities may have made Dr. Woods the right candidate for the post, her relative inexperience should have alerted management to the need for supervisory structures. This would have been particularly important when Dr. Woods' role changed dramatically to focus on children who had been abused. 2. Role and resource allocation in the establishment of services/ The inappropriate use of services The SATU was established with a specific purpose - the care of adult women. Within a short time, it found its work dominated by the care of children, a role for which it was unprepared. This change in focus was apparently quite unexpected. Management in turn should have been highly conscious of the implications of the change and should have identified and obtained the personnel and resources needed to meet these demands. Services constructed for one purpose which then expand into other roles, always face the potential to grow beyond the expertise and capacities available. No real changes appear to have occurred in the profile of SATU after its role began to be dominated by children, rather than women. The appropriateness of services established in an adult setting for the care of children must be questioned. 3. The difficulties facing doctors when there are few or no peers practising in Ireland/ Maintaining standards in very specialised areas The innovative and rapidly evolving service provided at SATU should have alerted all involved to the need for audit and review structures linked to best practice overseas. While individual links were established - mainly by Dr. Woods - no systematic assurance was offered to the public of the standards in use at SATU. Without equivalent services or colleagues in this jurisdiction, the difficulties facing Dr. Woods and her staff in maintaining competence should have been obvious to all. Structures to assure competence may not have been commonplace at the time but were essential given the unique service involved at SATU. 4. Significant legal decisions based on the views of an unsupported doctor The Court decisions resulting from SATU reports were of great significance for many children and their parents. Dr. Woods was operating in an environment perhaps unique to Irish doctors, in which prompt and dramatic change could affect entire families based on her clinical decisions. In retrospect, it would have been appropriate to introduce validation procedures and to cross-check even a sample of cases. 5. Multi-disciplinary working The development of current multi-disciplinary services to deal with child sexual abuse clearly acknowledges the need for such components within a functioning service. It is clear that towards the end of the period in question, a range of dedicated paediatric facilities was being established, involving a multi-disciplinary approach. It is not clear what measures were taken to establish communication and collaboration between these services and disciplines in relation to provision of service, audit or training issues. Conclusions The Medical Council issues this report to ensure that a matter of significant public importance is brought to the attention of the public, profession and those responsible for Clinical Governance. It is clear that many lessons can be learned from the setting up of SATU in relation to the establishment of new clinical services. While doctors have a fundamental role in such services, lessons should be learned from the wide range of governance issues which appears not to have been addressed. Doctors must at all times be responsible for their behaviour in caring for patients. However, if a doctor works in an environment which is underfunded, poorly staffed, without relevant expertise and not under the management of a proper supervisory body, then responsibility for incidents of patient harm should be shared by all involved. The problems identified in SATU have the potential to recur. Isolated, specialised or reactive health agencies may be established without the planning or resources needed to ensure that they remain within the mainstream of clinical quality assurance systems. It is the responsibility of all involved in running these services to ensure these issues are addressed. *** http://www.falseallegations.com/dr-moira-woods-guilty-professional-misconduct.htm Dr. Moira Woods Found Guilty in Ireland of Professional Misconduct DR. KATHLEEN C. M.WOODS REGISTRATION NO. 09464 Dr Kathleen Cecilia Moira Woods MB BCh U Dubl 1st July, 1957 Registered Address: c/o Timothy Woods Registration Number: 09464 One Microsoft Way Redmond Certificate Number: 301092 WA 98052 United States Of America Registration granted from: 1st July 1980 Date of issues of Certificate: 10th December 2001 FINDING OF THE FITNESS TO PRACTISE COMMITTEE OF THE IRISH MEDICAL COUNCIL ON DR. K.C.M.WOODS This Inquiry took place under Section 45 of the Medical Practitioners Act 1978 into the conduct of Dr. Woods on grounds of her alleged professional misconduct. The hearing lasted 43 days. 49 witnesses were heard. In addition detailed submissions were heard from Counsel. The hearing took place subject to the conditions laid down by Mr. Justice Barr in the Proceedings taken by the Medical Council against the Eastern Health Board. Such conditions continue to have effect. The allegations were set out in the Notice of Inquiry in the following terms: - "(a) You failed to show and apply the standards of clinical judgement and competence required of a person in your position in relation to one or some or all of Cherie Eustace, Michelle Flynn, Nicola Smith, Hilda Flynn, Monica Flynn, Martina Flynn, Samuel Ralph, Matthew Ralph, John Ralph, Karen Ralph and Claire Ralph and/or (a) You advised the Eastern and South Eastern Health Boards and other parties that one or some or all of Cherie Eustace, Michelle Flynn, Nicola Smith, Hilda Flynn, Monica Flynn, Martina Flynn, Samuel Ralph, Matthew Ralph, John Ralph, Karen Ralph and Clare Ralph were or might have been sexually abused by a relative when you knew or ought to have known that there was insufficient foundation to or basis for such advice and/or (b) You failed to show the standards of judgment and competence required of a person in your position in respect of the investigations and court hearings relating to one or some or all of Cherie Eustace, Michelle Flynn, Nicola Smith, Hilda Flynn, Monica Flynn, Martina Flynn, Samuel Ralph, Matthew Ralph, John Ralph, Karen Ralph and Claire Ralph and/or You failed to act in the best interests of the aforementioned children and/or (c) You acted in a manner which was derogatory to the reputation of the medical profession" The Factual Background: On the 23rd March 1984, following reports alleging inadequate treatment for victims of rape, the Department of Health issued a circular letter to all acute hospitals. During the period of Many to June 1984 informal discussions took place between the Department of Health and the then Master of the Rotunda Hospital, Dr. George Henry. It was agreed that a Sexual Assault Treatment Unit should be established in the Rotunda Hospital. In June of 1984 the Joint Maternity Hospitals Committee agreed in principle to the proposal. In October 1984 a Working Group had been established with terms of reference to organise the establishment of a Sexual Assault Treatment Unit at the Rotunda Hospital and to report on the operation of the Unit after six months. The first meeting of the Working Group took place on the 31st October of that year. The Report of that Meeting indicated that it was agreed that the doctors selected to work in the Unit would be paid by the Rotunda Hospital and would be under the direction of the Master. The Unit opened in January of 1985. At that time it was envisaged that the Unit was to be made available to undertake the forensic examination and medical treatment of suspected victims of sexual assault in the Eastern Health Board area. Little consideration was given to the possibility of the treatment or examination of children with the Unit. Given the presence of the Unit within a maternity hospital, it is apparent that it was envisaged that it would be dealing with adult women and few children. Within less than a month of the establishment of the Sexual Assault Treatment Unit (SATU), the question of children and their treatment was considered at the third Meeting of the Working Group. It was ‘considered that a unit, similar to the one at the Rotunda Hospital might be required in one of the children’s hospitals to cater for children who had been victims of incest. It was felt that a special expertise and training would be required to deal with these cases. Dr. G. Henry agreed to ask Dr. Matthews, consultant paediatrician to the Rotunda and to Temple Street Hospital, to initiate discussions between Temple Street and Crumlin Hospitals regarding the establishment of a unit to treat children who had been sexually assaulted.’ (See Minutes of the Working Group, Divider 12 of the Sexual Assault Treatment Unit Book of Documents, Exhibit A). Clearly the establishment of a unit of this type would take time. It took a number of years for the specialist units to be set up in Temple Street and Crumlin Hospitals. Indeed such units were not truly available until 1988. In the intervening period the evidence establishes that SATU at the Rotunda was left to deal with children who were the alleged victims of sexual assault. The statistical evidence which has been adduced indicates that children attended SATU from the very beginning and within a relatively short period the numbers of children attending increased rapidly until they represented the vast bulk of those attending the Unit. Thus, a situation evolved very rapidly where very substantial numbers of children were being examined in a unit which had originally been established for the purpose of examining women victims of sexual assault. Dr. Woods’ Medical Background The expertise and training of Dr. Woods was outlined in her curriculum vitae (Exhibit G1) and in her direct evidence (Day 28) and in cross-examination (Day 32). She was engaged in general practice in Leicester in 1959/60. She was then involved in limited practice from her home from 1979 up to and after the establishment of SATU in 1985. During the period 1979 to 1985 a substantial part of Dr. Woods’ practice related to adults and not to children. She acknowledged (Day 32, Question 83) that during that period she would only have been exposed to a handful of young children. She was not exposed to the general range of young children which would fall within the experience of an ordinary general practitioner. The evidence established that she had some, but rather limited, practical or clinical experience of dealing with children. In fairness to Dr. Woods, it is essential to point out that the treatment of children victims of sexual assault was not well developed during the period in question. Dr. Woods, both in her evidence and within her statement, indicates that the approach which most influenced her was the model identified in the literature of Dr. Suzanne Sgroi. While acknowledging that the number of children which arrived at the Unit was far greater than anticipated, the Unit did treat such children. It is the view of the Committee that in treating and assessing children Dr. Woods was obliged to follow basic and well recognised medical principles and sound standards and to ensure that the process of differential diagnosis was followed and that such obligation was all the greater given the forensic nature of the assessment and reporting at SATU. A number of steps were taken by the Unit as a basis for such examinations of children. These included the establishment of protocols and the identification of a validation process. It is noteworthy that in Dr. Sgroi’s work it was envisaged that generally children would be interviewed in the presence of accompanying adults. It is also quite clear to the Committee that in interviewing children and in obtaining background material it was absolutely essential to obtain a full and accurate history, particularly having regard to the very serious consequences of a finding of sexual assault, particularly by a family member. It is important in this context to recognise that not only might there be the potential for criminal proceedings; but also there existed a very substantial risk that application for a ‘fit person order’ might be made by the District Court which might have the consequences of the removal of children from the custody and care of their parents for an indefinite or unspecified period. This, of course, reinforced the absolute necessity of ensuring that all available sources of information were tapped, particularly in view of the fact that Dr. Woods’ conclusions were regarded as being well nigh conclusive by the Health Boards. Once a conclusion was arrived at by Dr. Woods it was most unlikely to be reversed by the Health Board. In the view of the Committee this demonstrated the need for very considerable care to ensure that all relevant evidence was collected and assessed, particularly having regard to the most serious consequences of a finding of child sex abuse. There was a critical need or each report to be detached, factual, objective and comprehensive. If matters were unclear or not investigated, this should have been stated, while at all times protecting the right of a practitioner to state their findings and opinion. In a number of cases to which reference is made below, it is clear that the protocols adopted were not followed. Nor was the appropriate approach to validation adopted. The Committee fully recognises that the entire question of sexual assault on children was not a well-developed area of medicine in the 1980’s. However, in a number of cases it has concluded by a majority that Dr. Woods failed to follow the ordinary requirements of general medicine, failed in her obligations to properly gather all the evidence which was available; in certain cases, did not follow the protocols which were laid down by SATU itself and in other cases failed to review cases or findings when not all the available information had been gathered after preliminary conclusions were reached. This is of critical importance in view of the evidence, such as that from Dr. Helen Leader (Transcript 10, Question 312) where she confirmed that it was her memory that in child psychiatry people accepted the diagnosis of SATU without question. It is also confirmed by the approach taken by the Health Boards where health workers apparently accepted without question the conclusions of SATU. Evidence was adduced before the Committee as to the number of children seen at SATU. These figures show that in 1985 190 children were examined of which 51 were seen in the first six months; in 1986 530 were examined and in 1987 600. The figures for the first six months of 1985 are to be found in a Report for the Department of Health Working Group (Divider 19 in the SATI Book of Documents, Exhibit A). Page 7 of that document deals with children aged under 16 years and indicates that 51 children were seen and also indicates in paragraph 11 on the same page that in all 51 cases SATU was able to identify the relationship of the assailant to the victim and indeed in all 51 cases could identify the place of assault. It is true that there was some lack of clarity regarding these statistics. Explanations were given that at a start-up stage the figures will be distorted or lopsided. It is still noteworthy, however, that during this period SATU arrived at an apparent 100 per cent validation rate. It will be noted that this process involved not just validation but identification of the relationship of the assailant to the victim. The 1987 figures (Divider 23 in the SATU Book of Documents, Exhibit A, commencing at internal page 5) show that there was some deviation in later years. In 1987 600 children under 16 were examined. Of these, a total of 511 offenders were identified and this was stated to be confirmed by the fact that the sex of 511 perpetrators were identified and the relationship of the perpetrators to the victims were also identified in 511 cases. This would tend to indicate a very high rate of validation and identification. It is the view of the majority of the Committee that such figures, even if they did no purport to be entirely scientific or conclusive, should have placed Dr. Woods and the other persons involved in SATU on notice of the risks of excessive certainty and an excessive rate of validation, i.e. a finding that abuse occurred in these instances. It will be noted that once SATU was established it apparently continued to operate almost independently of the remainder of the Rotunda Hospital. Dr. Woods was effectively in sole charge of the Unit. There was little evidence of any other medical supervision of what occurred in the Unit after its establishment. The Committee has had regard to the evidence of experts in child sexual assault. Dr. Wozencroft gave evidence on behalf of the Registrar. Dr. Baderman gave evidence on behalf of Dr, Woods. The Committee has given substantial consideration to much of Dr, Baderman’s evidence. It noted that the process he envisaged for appropriate examination in cases of alleged child sexual assault involved a careful distinction and division into a number of separate stages including analysis of the physical findings, the identification of background evidence and a gradual and staged process prior to any final conclusion. Such a procedure was not followed in the SATU in the Rotunda however. Instead, what was well nigh a single stage process was adopted involving physical examination and interviews with alleged victims, social workers and parents. It is accepted that Dr. Woods was operating under substantial pressure. There was, granted, a substantial lack of resources. The Unit was subjected to a substantial pressure of work. But against this must be placed the very critical consequences of a finding of sexual assault, particularly within a family context. In some cases, in the opinion of the Committee, the telescoping of the procedure had profoundly unfortunate results. The staged process procedure, which was touched on by Dr. Baderman, was more explicitly set out by Dr. Baker, an acknowledged expert in the area of child sexual assault, who also gave evidence on behalf of Dr. Woods. The Standard of Proof: It was common case at the hearing that the onus upon the Registrar in relation to the allegations of professional misconduct was the criminal standard of proof, that is, beyond all reasonable doubt. The onus lay upon the Registrar to prove every relevant averment of fact not admitted by Dr, Woods and to establish beyond reasonable doubt that such facts as so proved or admitted constituted professional misconduct. Moreover, the onus rested on the Registrar to negative every reasonable hypothesis consistent with Dr. Woods’ innocence of the allegations against her. At the opening of the case it was stated on behalf of the Registrar that reliance was being placed upon the fifth of the five principles set out by Mr. Justice Keane as he then was in the case of O’Laoire v. The Medical Council, the High Court (1993) No. 582P (unreported 27th January 1995). These principles were:- "1. Conduct which is ‘infamous’ or ‘disgraceful’ in a professional respect is ‘professional misconduct’ within the meaning of Section 46(1) of the Act. (a) Conduct which would be ‘infamous’ or ‘disgraceful’ in any other person if done by a medical practitioner in relation to his profession that is with regard either to his patients or to his colleagues may be considered as ‘infamous or disgraceful’ conduct in a professional respect. (b) ‘Infamous or disgraceful’ conduct is conduct involving some degree of moral turpitude, fraud or dishonesty. (c) The fact that a person wrongly but honestly forms a particular opinion cannot of itself amount to infamous or disgraceful conduct in a professional sense. (d) Conduct which could not properly be characterised as ‘infamous or disgraceful’ and which does not involve any degree of moral turpitude, fraud or dishonesty, may still constitutes ‘professional misconduct’ if it is conduct connected with his profession in which the medical practitioner concerned has seriously fallen short by omission or commission of the standards of conduct expected among medical practitioners." In its consideration the Committee has had careful regard to the evidence adduced by the Registrar and by Dr. Woods as to the appropriateness of Dr. Woods’ conduct. It has also had regard to the relevant Guide to Ethical Conduct and Behaviour (Second Edition, 1984) which was that applicable at the time of the matters complained of. The principles in O’Laoire have been subsequently approved of by the High Court in a number of decisions and may now be accepted as settled. In considering each allegation the Committee had regard to the evidence adduced in relation to each child under the heading of each allegation. It considered the evidence having regard to the relevant standard of proof and applying the principles set out in O’Laoire v. The Medical Council as approved in subsequent legal authorities. For ease of reference the Committee deals with its findings in the context of each of the allegations as set out in the Notice of Inquiry. Allegation (a) states: ‘You failed to show and apply the standards of clinical judgment and competence required of a person in your position in relation to one or some or all of Cherie Eustace, Michelle Flynn, Nicola Smith, Hilda Flynn, Monica Flynn, Martina Flynn, Samuel Ralph, Matthew Ralph, John Ralph, Karen Ralph and Claire Ralph.’ In the case of Nicola Smith and Monica Flynn, the Committee concluded by a majority that the facts adduced by the Registrar were proved and that they constituted professional misconduct. In the remainder of the cases the Committee concluded that the Registrar had not proved his case beyond reasonable doubt. Again this decision was by a majority. NICOLA SMITH Mr. And Mrs. Smith were married in 1985. Their first child, Nicola, was born on the 7th December 1985. A second child, Carolyn, was born on the 27th October 1987. Whilst she was pregnant with Carolyn, Mr. Smith assaulted his wife. This led to Mrs. Smith bringing an assault case against her husband, which was heard on the 21st March 1988. When the matter came on before the court Mr. Smith was placed on probation for assault. During the period after the assault but prior to the court hearing, Mrs. Smith brought her eldest child, Nicola, to Crumlin Hospital on the 15th February 1988. She spoke to the head social worker, Doreen McNamara. On the 4th March 1988 Nicola attended Dr. Patricia Crowley in Crumlin Hospital. She stated in evidence that she had a discussion with the mother and carried out a physical examination. Dr. Crowley concluded that neither the history nor the physical examination supported the diagnosis of child sexual abuse and a report was written by the head social worker, Doreen McNamara, dated the 16th March 1988, to be found in Book C3 at page 7. Mr. And Mrs. Smith separated on a permanent basis in October of 1988. They have remained separate thereafter. Family law proceedings took place. Access was always by court order and mainly supervised. There was conflicting evidence regarding the extent of matrimonial violence. On Wednesday, the 21st June 1989, following access by Mr. Smith the previous weekend, Mrs. Smith brought her daughter to Temple Street Casualty for a physical examination. Mrs. Smith suspected that an episode of child sexual abuse may have taken place. Following that visit, on the 23rd June 1989, contact was made with the duty social worker, Bernard Morrin (Transcript 12, Questions 12 and 13). A referral was made to St. Clare’s Unit in Temple Street and certain advice was given about putting access by Mr. Smith on hold whilst the matter was being worked out and looked into. Mrs. Smith stated in evidence that Nicola had a vaginal discharge at the time and she was referred back to her GP, Dr. Hanlon. An interview was held with the mother in St. Clare’s Unit on the 12th July 1989 and the interview protocol was filled out. On the same day, an interview with Nicola was carried out by Kay Keary of St. Clare’s Unit, Temple Street, while another member of the team was present on the far side of a two-way mirror. On the 13th July 1989, the day following the interview, Nicola was brought back to Temple Street Hospital for a physical examination. This was carried out by Dr. Peter Keenan, a Paediatric A & E Consultant. Dr. Keenan did not find any physical evidence of vaginal discharge or abnormality on physical examination. He also stated in addition that there was no visible vaginal discharge and that such findings are not uncommon in small girls. (See Transcript 16, Question 29). An appointment was given for a second interview on the 14th August 1989. However, Mrs. Smith was dissatisfied following the initial interview, the physical examination carried out by Temple Street and the lack of confirmation of sexual abuse. She stated she believed that she was not getting anywhere and did not feel secure. She therefore made contact with Dr. Woods (See evidence of Mrs. Smith, Transcript 19, Questions 123 and 128). It is important to note that this contact was made at a time when the process involving St. Clare’s and Temple Street Hospital was incomplete. (See evidence of Ms. Keary, Transcript 15, Question 26). It was Mrs. Smith’s general practitioner who suggested she contact Dr. Woods. Contact was made with Dr. Woods by telephone and an appointment was set up for the 1st August 1989. It is important to point out that in the context of the other cases this took place at a chronological late period and obviously at a time when the multi-disciplinary Units in Temple Street and Crumlin had already been set up. It is also to be noted that at the relevant time Nicola Smith was aged 3 ½. It will be recollected that the entire incident took place in the context of matrimonial proceedings where, clearly, it would be prudent for a medical practitioner to proceed carefully. On the 1st August 1989, Mrs. Smith brought Nicola to Dr. Woods’ private residence. No one else was present. Dr. Woods obtained a history from the mother, in the absence of the child. She then interviewed the child separately. The notes taken by Dr. Woods have been copied from the original card. They appear in Book C1, pages 9 to 11. It will be noted that on the 10th July 1989 the question of access had come before the court. The terms of access had been altered so that it was to be supervised by Mrs. Smith in her parents’ house. This is noted in Dr. Woods’ notes. She also stated that the child was being seen in Temple Street in relation to the allegation of sexual abuse and that the first interview had taken place on Wednesday the 12th July 1989. She also stated that a second interview was due for the 14th August 1989. Dr. Woods was also informed of the visit to Temple Street Hospital. (See the bottom of page 10 of the notes). Mrs. Smith confirmed that the history given would have included the fact that since July 1989 access by Mr. Smith was supervised in her parents’ house (Transcript 19, Question 170). She also confirmed that she would have given a full history in relation to Temple Street Hospital and also referred to the Crumlin visit. Following the first interview, and before Mrs. Smith has left, she was informed by Dr. Woods of the results of her investigations. These were that Nicola had been sexually assaulted and that it was believed to have been done by her father. After this consultation and prior to the return visit on the 10th August 1989, Mrs. Smith called Temple Street Hospital and informed them that Dr. Woods had obtained the information and that her husband would never see the child again but that she had been advised to keep the appointment for August 14th. Mrs. Smith deals with her contact with Temple Street Hospital in her evidence at Transcript 19, Question 148 to 153. The Solicitor acting for Mrs. Smith, also called Temple Street Hospital on the 8th August 1989. Dr. Woods had informed Mrs. Smith that she would contact Mrs. Smith’s Solicitor and Mrs. Smith also stated that she knew that court proceedings were coming up and that her solicitor would have to have the reports. It was clearly established by the evidence that on the 12th and 13th July 1989 Temple Street could not confirm the allegation of sexual abuse. (See also the history given by Mrs. Smith to a consultant psychiatrist, Dr. Gerry Byrne, on pages 20-23 of Book C1). Dr. Woods saw Nicola for a second time on the 10th August 1989 and there is a brief note of that in typed form on the bottom of page 11 of Book C1. Thereafter she prepared a report of the 14th August 1989, which was sent to Mrs. Smith’s Solicitors and also to Temple Street Hospital. Nicola was again seen in Temple Street on the 14th August 1989. There are notes of that interview in C2, paged 33 to 36. Mr. Smith was interviewed on the 21st August 1989 and the notes of that interview are contained at paged 9 – 42 of Book C. A report was prepared by St. Clare’s Unit in Temple Street dated the 24th August 1989 (Book C2, pages 56 to 63). Kay Keary signed this. This concluded: - "On the balance of probabilities, it is not possible to confirm that Nicola has been sexually abused" (See evidence, Transcript 15, Questions 127 onwards.) In making her findings, Dr. Woods neither contacted Crumlin nor Temple Street. She did not obtain any history or information prior to giving her oral confirmation of sexual abuse. This was validated in respect of the husband on the date of the initial examination on the 1st August 1989. Thereafter there is no evidence that Dr. Woods made any attempt, either before writing her report or before giving evidence in court, of making contact or attempting to make contact with Crumlin Hospital or Temple Street. She prepared a report of the 14th August 1989 on Rotunda Hospital notepaper. This was headed ‘Sexual Assault Treatment Unit’. It was stated that the purpose of the contact was to perform an ‘investigative interview’. Dr. Woods subsequently gave evidence in one of the District Court hearings confirming her opinion that Nicola had been sexually abused by her father. (See Transcript 14, Questions 42 onwards, evidence of Mr. Smith and also the evidence of Pamela Madigan, Solicitor for Mr. Smith, Transcript 16, Questions 160 onwards). This court case took place on the 27th February 1990 six months after Dr. Woods interviews with Nicola Smith. On the evidence, Dr. Woods stated in court that she formed her view following the first visit on the 1st August 1989. There appears to be little indication of any additional information being obtained on the second visit. The child was not actually treated by SATU in the Rotunda Hospital. Clearly the report might be used for forensic purposes, i.e. it was to be used in court proceedings or had that potential. There were inconsistencies in Dr. Woods’s evidence as to whether she was asked to carry out a physical examination or an investigative interview. The majority of the Committee does not accept that the purpose of the meeting was for physical examination only. This is not reconcilable with the interviews which were carried out by Dr. Woods on Mrs. Smith and on Nicola. It would be difficult to reconcile such testimony with the fact that clearly physical examination on the 12th and 13th July previously. There were apparent inconsistencies in what the Committee heard was Dr. Woods’ evidence in the District Court as to whether the meeting was for the purposes of the physical examination or performing an investigative interview. In either instance, it is the view of the majority of the Committee that detailed enquiries should have been carried out with Temple Street and with Crumlin Hospitals. It is also to be noted that Dr. Woods clearly committed herself to writing in relation to what she stated she found in the knowledge that Nicola was the subject matter of investigations and treatment in Temple Street and Crumlin Hospital. The Committee notes that Dr. Baderman who gave expert evidence on behalf of Dr. Woods stated: "It would be proper clinical practice to contact that hospital unless there were good reasons for not doing so." (See evidence of Dr. Baderman, Day 39, at questions 236 onwards). No such evidence of good reason was adduced in the view of the majority of the Committee The Committee notes that Dr. Woods orally discussed her findings on the 1st August 1989. She placed her findings in a report of the 14th August 1989 yet at no time did she discuss these findings with either the units in Temple Street or Crumlin Hospital even though at the time she was aware that Nicola was the subject matter of investigations in both hospitals. This, in the view of the majority of the Committee, is of particular importance in view of the risks which exist in this sensitive area of interviews in one institution affecting the contents of interviews in another location. It was suggested on behalf of Dr. Woods that she did not want to get involved in the case. Unfortunately, however, in the view of the majority of the Committee, this was not borne out by the evidence. The majority conclude that the clear purpose of the interview was that Dr. Woods would forward the report to Mrs. Smith’s Solicitors. The majority of the Committee conclude that it is difficult to reconcile a stated unwillingness to become involved in the case with the fact that Dr. Woods said that she would forward the report to Mrs. Smith’s Solicitor. The majority of the Committee conclude that it was unwise and inappropriate for Dr. Woods to have involved herself in this case when she knew that Nicola Smith was being investigated on multi-disciplinary basis elsewhere. This is reinforced by the possibility which may have existed that Dr. Woods might be deceived or misled. Accordingly, the Committee, by a majority, concludes that Dr. Woods failed to show and apply the standards of clinical judgment and competence required of a person in her position in relation to Nicola Smith and that such facts constitute professional misconduct. MONICA FLYNN: Background Facts: Patrick Flynn married Maria Flynn in 1976. They had a number of children. These were Hilda, born on the 16th July 1977, a son who was born in January 1979 and died aged 3 weeks, Monica, born on the 31st December 1979, Martina born on the 26th February 1981 and Ciara born on the 23rd November 1985. The relationship between the parents was not good. Mrs. Flynn had great difficulty in coping. There was some evidence that Monica was hyperactive. There was also evidence that she suffered from significant intellectual impairment. On occasion she took her clothes off and used to wander out on the road. Sometimes she left the house and her bed at night. The South Eastern Health Board had contact with the Flynn Family from April 1983. A number of reports were obtained relating to Monica. See Book E1, pages 1-15. It is evident she suffered from a degree of mental handicap. It is not possible to be certain or identify the level of that handicap but it was probably in the region of high severe to low moderate. She also had attention deficit syndrome associated with severe behaviour disorder. From the middle of 1984 Mrs. Flynn sought assistance from the Health Board due to her inability to cope. In late August of 1984 she contacted the public health nurse responsible for the service to mentally handicapped children in the local area asking for Monica to be taken away as she could no longer cope. By the autumn of 1984 Monica was attending Cashel Day Care Centre during weekdays. She was thereafter placed in a residential group home in Fethard, Co. Tipperary. She had a tendency to take off her pants and clothes and urinate in any location. Caroline Smith who worked in the Centre stated that there was evidence of sexualised behaviour (Day 22, Questions 202). This included putting lollipop sticks, cereal bowls and other objects including knives up her vagina. Ms. Smith also stated that there was evidence of ‘her masturbating at night’. From February of 1985 up to October of 1986 Monica remained resident in the group home in Fethard. She occasionally went home on weekends. Access was not regular. By the end of 1985 visits of the Flynn Family to Fethard were very rare. At that time Mrs. Flynn was pregnant again and she gave birth to her fourth daughter, Ciara, on the 23rd November 1985. The question of whether Monica had been sexually abused prior to coming into care was raised at a Health Board review on the 31st October 1985 (Book E1, page 24) prior to Dr. Woods’ involvement. Martina Flynn, the third daughter, was also reviewed by the Health Board during 1986 relating to her backward development. By February of 1986 she had the mental age of three years and nine months and a biological age of four years and ten months. She was reviewed on a number of occasions to see whether she had reached the stage where a transfer to a mainstream primary school might be appropriate. Throughout the year of 1986 there was concern as to whether Monica Flynn had been sexually abused. Contact was first made between the home at Fethard and SATU on the initiative of Caroline Smith and without the involvement of the parents. The first visit was made to SATU with Monica on the 23rd October 1986 although there may have been some previous contact. Monica was assessed by Dr. Woods on the 23rd October 1986. No videotape of this interview has been produced. It appears that anatomically correct dolls were used and a physical examination was carried out. Dr. Woods’ report was issued thereafter. Although it does not positively identify Mr. Flynn as the perpetrator, it points strongly towards him. Dr. Woods recommended that it should be assumed until proved otherwise that Monica had been abused by a family member. A further recommendation was that ‘it may be that the children should not have any more contact with their father’. In a further report of the 12th February 1987, on Hilda Flynn and Martina Flynn, Dr. Woods stated ‘it was apparent from an examination of Monica Flynn that she had been sexually abused. It was difficult to think of any other person who could have been in contact with her other than her father’. Following her first report on Monica, Mr. Peter Kieran of the South Eastern Health Board wrote to Dr. Woods on the 22nd December 1986. (Book E1, page 45). He stated that the Board was anxious that it was not going to be able to identify the person who abused Monica. He said that the Board was not really in a position of being able to state categorically it was any named person. He raised two particular issues. Firstly, he mentioned that Monica was moderately mentally handicapped with many autistic type features. He asked whether there could be any doubt under those circumstances about the origins of her behaviour in inserting objects into her vagina, that is, having discovered it she might have developed a fixation. Secondly, he asked whether Dr. Woods could arrange to see Hilda and Martina Flynn and whether she would wish to interview the mother at the same time. In a phone call which subsequently took place with Mr. Kieran, Dr. Woods informed him that the findings were so unusual that despite her difficulties in communication and with the limitation therefore of the interview part of the assessment she believed the assessment was valid and could be relied on. Thereafter, on the 20th March 1987, the Health Board applied ex parte for a place of safety order relating to Monica and her two sisters, Hilda and Martina. An application was made for a fit person’s order by the District Court on the 7th September 1987 at which Dr. Woods gave evidence. Her evidence was summarised in an agreed form in Book E3, page 22. Dr. Woods went through the details of her reports. She stated that all the indicators pointed to the father as being the perpetrator as he was the only person who could have been in regular contact with the children. In a meeting which took place in or about Easter of 1987 Dr. Woods repeated her view that the three children had been abused. Hilda and Martina remained in care until Easter of 1989 when they were returned to their parents. In the case of Monica, however, the evidence demonstrated, in the view of the majority of the Committee, that Dr. Woods had failed to address the following issues: - (a) The possibility that Monica’s behaviour was related to her mental handicap and that the physical findings were the result of behaviour that followed from that handicap; (b) The possibility that Monica had been abused by someone other than her father and/or that in particular she had been abused while in care; (c) The possibility that if abuse had occurred at all it had been perpetrated by someone other than their father. In the view of the majority of the Committee the failure of Dr. Woods to obtain expert advice on autism was a substantial failing below the standards that are to be expected of a medical practitioner. Further, in the view of the majority even having regard to the knowledge which Dr. Woods had of autism in 1986 a reference ought to have been made in her report of the 29th October 1986 to Monica’s mental handicap as a possible explanation of the matters observed and reported on by her, in view of the importance of such reports and the near conclusive treatment of these reports by the Health Boards. At Day 37, Question 235, Dr. Woods stated that this was the first and only occasion on which she was involved with investigating a child suspected to be autistic. Her knowledge of autism was gained by her involvement with a friend who had an autistic child. Day 31, Question 412 she stated however that she was aware that autistic children could engage in self-stimulatory behaviour, that such children could damage themselves and this could be part of repetitive behaviour. Dr. Woods also believed that the sexualised behaviour observed in Monica was more closely associated with Monica’s family than other circumstances. It was the view of the Committee that in view of the limited nature of Dr. Woods investigations, her conclusions were inappropriate and too bold. It was inappropriate for her to omit in her report of the 29th October 1986 the possibility of a connection between Monica’s mental handicap and the matters reported. This is in contrast to the possibility that occurred to the social worker, Mr. Peter Kieran. In making its findings the majority of the Committee had regard also to the statement in the report of the 29th October 1986 that Monica had been ‘abused by a family member unless proved otherwise’ and also her recommendations that there should not be any further contact with her father. This is borne out by Dr. Woods’ statement in the report of the 12th February 1987 on Hilda and Martina where she stated ‘it was apparent from an examination of Monica Flynn that she had been sexually abused. It was difficult to think of any other person who could have been in contact with her other than her father’. During her reports Dr. Woods does not appear to have had regard to the possibility that another male person may have had access to Monica in the family home. Nor does she appear to have had regard to the possibility that such person might have had access to Monica while in residential care. In the view of the majority of the Committee, Dr. Woods paid insufficient regard to the fact that Monica had been in care for a year and a half and did not know, and did not investigate, the extent of access which Monica’s father had to the child during the relevant period. While accepting that the phenomenon of sexual abuse in residential care was less understood in 1986 than it is now, the majority of the Committee found it impossible to understand that Dr. Woods failed to have regard to the other possibilities as outlined above and that her conclusions appear to be directed almost entirely towards the view that Monica’s father was the abuser. This is more clearly demonstrated in relation to the reports furnished relating to Monica’s sisters, Hilda and Martina (particularly that of the 10th March 1987) where Dr. Woods states that ‘all the indicators point to their father as being the perpetrator’. The Committee had the advantage of hearing evidence from Dr. Paul McQuaid on the behaviour of autistic children (Day 26, Questions 168 onwards). He stated that the prevalence of self-stimulatory and destructive behaviour in autistic children may not have been something of which ordinary general practitioners were aware at the time. However, the majority of the Committee has regard to the fact that Dr. Woods gave evidence that she was aware of such conduct and therefore the majority of the committee conclude that she cannot rely upon a general lack of awareness in parts of the medical community in view of her specific knowledge of this matter. The majority of the Committee has had regard to the fact that the disregarding of autism took place in circumstances where there was no urgency and where Monica had been institutionalised for a very considerable period of time. Dr. Woods could and should, therefore, have consulted with an expert in autism or, alternatively, ought to have asked herself the question whether Monica’s symptoms were related to her autism. Equally, while there is evidence that Dr. Woods received a brief history from Caroline Smith, a social worker, and also from Peter Kieran and Lisa Cristiansson, all social workers with the South Eastern Health Board, there is no indication that Dr. Woods took steps to obtain a full history from other persons including Mr. Flynn prior to reaching her conclusion. While Mrs. Flynn was present in SATU on both the 4th February and 20th February 1987 when interviews took place, Dr. Woods concedes that she did not speak to her on either occasion. Nor did she interview Mrs. Flynn prior to producing her report on Monica on the 29th October 1986. In view of the fact that the Flynn family were in contact and being interviewed by SATU over the period October 1986 to February 1987 it is the view of the majority of the Committee that there was ample opportunity to interview Mrs. Flynn, Mr. Flynn and to fully interview other professionals and childcare workers involved in the care of the children. The majority of the Committee had difficulty with Dr. Woods’s statement (Day 37, Question 415) that she had deliberately not interviewed Mrs. Flynn because she would prefer that the mother be interviewed by a different member of the team. This was difficult to reconcile with the fact that clearly the SATU assessment was not multi-disciplinary in nature, that Dr. Woods herself carried out all the interviews in the cases before the Committee and also that such assertion was at variance from Dr. Woods’ behaviour in other cases such as that of Cherie Eustace, Nicola Smith and Michelle Flynn. In conclusion, the majority of the Committee take the view that in her conduct Dr. Woods failed to show and apply the standards of clinical judgment required of a person in her position in relation to Monica Flynn. As stated in relation to the remainder of the children, the subject matter of allegation (a), the Committee concluded by a majority that the Registrar had not proved his case. Allegation (b) states: ‘You advised the Eastern and South Eastern Health Boards and other parties that one or some or all of Cherie Eustace, Michelle Flynn, Nicola Smith, Hilda Flynn, Monica Flynn, Martina Flynn, Samuel Ralph, Matthew Ralph, John Ralph, Karen Ralph and Claire Ralph were or might have been sexually abused by a relative when you knew or ought to have known that there was insufficient foundation to or basis for such advice’. In the cases of Cherie Eustace, Nicola Smith, Hilda Flynn, Monica Flynn and Martina Flynn the majority of the Committee found the facts proved and that they constituted professional misconduct. In the remainder of the cases in this allegation the Committee concluded that the Registrar had not proved his case beyond reasonable doubt. Again, this decision was by a majority. CHERIE EUSTACE Background: Cherie Eustace was born on the 18th June 1981. Her parents were Bernadette Eustace and Eddie Hernon. On the 18th December 1985 Ms. Eustace, Cherie’s mother, noticed blood on the child’s pants. She was 4 ½ years old at the time. The mother was visiting London when this occurred and she took the child to a local GP who referred her to Queen Elizabeth’s Hospital for Children. On the occasion of this visit Cherie and her mother were staying with the child’s father, Eddie Hernon. Cherie was brought to the Queen Elizabeth Hospital for Children and the casualty notes are set out at page 108 of Book B1. She was examined in the morning and the details of such examination are set down in the notes. The notes also indicated that a later examination at 2 o’clock in the afternoon was carried out by the medical registrar. An entry in those notes reads: - "No explanation for injury: mother does not feel that there is a possibility of sexual abuse: probably the result of child’s own manipulations." The last line on the noted (page 108) was to the effect that Cherie was to be brought back for re-examination one week later. By that time Ms. Eustace had returned to Ireland with Cherie. Eddie Hernon remained in London where he was working. On her return to Ireland Cherie was brought to the local GP, Dr McNally, early in January of 1986. Dr. McNally gave evidence in relation to that examination. (Transcript 4, Question 123 onwards). His evidence was that he did a visual examination of the child and found no evidence whatsoever of any injury or damage or trauma. The visual examination was carried out with the mother and grandmother and the child was asked to widen the labia to the extent that Dr. McNally could see the introitus. Dr. McNally’s evidence was to the effect that there was nothing abnormal but due to agitation on the part of the mother, he referred Cherie to Dr. Bowman, a consultant in the Adelaide Hospital. Dr. Bowman examined Cherie on the 14th January 1986 and his report of the 16th January 1986 is contained in Book B1 at page 1. Dr. Bowman did not think there was any evidence of sexual abuse. For the remainder of 1986 Cherie continued to live in Dublin with her mother while the father, Eddie Hernon, continued to work and reside in London. There was little or no contact between the parents for most of 1986 as they fell out for a couple of months. This continued to be the case until September or October of 1986 when Ms. Eustace got in touch with Mr. Hernon. (Transcript 3, Question 857). Rumours had spread in London among the friends and family of Mr. Hernon and Ms. Eustace that the mother and child had returned home at Christmas 1985 due to alleged sexual assault by the father. (See evidence of Bernadette Eustace, Transcript 3, and Question 858 onwards). In October 1986, as a result, the mother sought to have it confirmed that the father had not assaulted the child. She sought to do this through her GP. Cherie was brought back to Dr. McNally who referred the mother to the Sexual Assault Treatment Unit by letter of the 22nd October 1986. (Transcript 4, Question 193). Following the referral, an appointment was made and the typed hospital notes indicate attendance by the mother on the 7th November 1986 (incorrectly stated as 1988). A second visit was on the 28th November 1986 and a third on an unidentified date in December which may have been the 5th of that month. There were apparently three visits – one by the mother and two where the child was examined prior to the report being written on the 9th December 1986. Details of what was taken down by Dr. Woods are set out in the SATU notes and the evidence from Ms. Eustace is to be found in Transcript 3, page 146 onwards. Ms. Eustace stated that she told Dr. Woods everything that happened in England and told her about going to the doctor and the hospital in England and about bringing Cherie back to he own GP and to Dr. Bowman. She indicated that she told Dr. Woods that Cherie was not in contact with her father at that time as of December 1986 as Mr. Hernon lived and worked in England. At transcript 33, Questions 391 onwards Dr. Woods stated that Bernadette Eustace was agitated and unable to engage in rational discussion. Ms. Eustace did not give such evidence nor was it suggested that Ms Eustace was in any way incapable of giving a proper or accurate history of the event. (Transcript 3, pages 173 onwards). Dr. Woods stated in the course of her evidence that she was dealing with an acute emergency situation (see Transcript 33, Question 400). It is the view of the majority of the Committee, however, that there was no evidence for this proposition. It was further contended that the report given was emergency in nature, written quickly, and that Dr. Woods would have preferred to have more opportunities with Cherie at a slower pace and with support from the mother. The final report was written on the 9th October 1986. The majority of the Committee do not accept that there was any indication that Dr. Woods would have preferred to have further reports or interviews. There are four separate versions of Dr. Woods' report of the 9th December 1986. These are the short form report appearing at page 7 of Book B1 received by the Medical Council from Dr. Woods' solicitor. This is the unsigned copy of the same report appearing at pages 9 and 10 which was the original signed report returned by Ms. Eustace's solicitor to SATU in or about November of 1988. The third report is at pages 11 and 12 of Book B1 and is a long form report minus the additional paragraph in the fourth report about Cherie being interviewed using play materials an anatomically correct dolls. This was obtained from the SATU file. The fourth report is to be found at pages 13 and 14 and is the most extensive. This was sent out on the 9th December 1986 to the Eastern Health Board and was obtained from that agency. This stated at paragraph 1 : - 'Cherie has been sexually abused by her father. This has involved digital vulval/vaginal contact'. The report states that this had occurred on lots of occasions. In the view of the majority of the Committee there was no evidence that Dr.Woods had made efforts to verify or evaluate the matter further in advance of preparing a definitive report which identified Cherie's father as the perpetrator of the alleged sexual abuse. Dr. McQuaid, who gave evidence on behalf of the Registrar, indicated that it would have been necessary, in order to write such a report, to have contacted others who would have had knowledge of what occurred in London in December 1985 and that the issue of 'lots of times' as a definition of what happened to the child, allegedly at the hands of her father, should have been more certainly evaluated and determined In her testimony, Dr. Woods indicated that in 1986 she was expressing herself more definitively than she would have done at a later time. Dr. Woods saw Cherie again on two occasions on the 16th December 1986 and on the 9th January 1987. Thereafter she apparently had no further involvement. However it is to be noted that the Eastern Health Board, who became involved in the case, apparently concluded and accepted that Dr. Woods’ views were definitive and did not themselves carry out further investigations on the factual background. Dr. Woods became again involved in the case in District Court proceedings which were taken on the 15th January 1989 where Mr. Hernon sought access. Again, during the course of the evidence, there was evidence, accepted by the majority of the Committee, that Dr. Woods’ clear finding was that the child had been sexually abused by her father. In the view of the majority of the Committee there is a lack of clarity in the explanations given for the variations which occur between the various reports. In preparing for the District court proceedings Dr. Woods provided the Solicitor acting for Ms. Eustace, Mr. Frank Murphy, with a copy of a report. This was returned to Dr. Woods in the latter part of 1987 and is the report to be found on pages 9 and 10 of Book B1. In cross-examination, it was suggested that Dr. Woods had, in the light of developments, altered her conclusion contained in the report at pages 13 and 14 from the view that ‘Cherie had been sexually abused by her father’ to ‘Cherie identified her father as having sexual contact’. It was suggested that in error the date of 9th December 1986 appeared in the new medical report at pages 9 and 10. It was accepted that the Eastern Health Board only had the report appearing at pages 13 and 14 of that Book. The background to the divergences between the reports is unclear. It is the view of the majority of the Committee that whatever the divergences, no full or proper explanation was given for them by Dr. Woods. Nor, in the view of the majority of the Committee, was there evidence that Dr. Woods had made it sufficiently clear to the District court that her view was more guarded or circumspect than that ‘Cherie had been sexually abused by her father’. More relevant to this allegation there was no evidence that at two Eastern Health Board Case Conferences which took place after the Court case that Dr. Woods had made clear that she altered her views or that she had sought to bring any alteration of her views to the attention of the Health Board or other agencies or to provide a copy of her altered report. It appears that Dr. Woods' was involved in two Case Conferences held on the 24th February 1989 and on the 12tthMay of that year. (Minutes, Book B1, pages 102 to 104, and 117 to 118). There was no evidence that Dr. Woods informed the Case Conferences of any change of view in the course of the Minutes of the Meetings. This is confirmed by her answers on cross-examination (Day 34, Questions 229 and 230). In the view of the majority of the Committee there was no express indication of a change of viewpoint although Dr. Woods sought to explain it on the basis that the Health Board were aware of the fact that she had changed the way she expressed herself and that she was in ongoing touch with the Health Board. In the view of the majority of the Committee there was no evidence to indicate a clear and transparent alteration in viewpoint furnished to the Health Board, to the Court or to any other agency. Nor was there evidence that Dr. Woods provided the Health Board with an altered or amended shorter medical report or that she had drawn attention to the fact of the multiplicity of versions of the report. The evidence of having videotaped the interview is contained in the report sent to the Eastern Health Board but was omitted from the report ultimately retained on the SATU file. In the view of the majority of the Committee there was no satisfactory explanation for this. In the context of the allegation the majority of the Committee concluded that Dr. Woods failed to follow what she knew or ought to have known was the correct practice and protocol of obtaining a full and accurate history. She failed to ensure that her conclusions and findings as outlined in the report were consistent with the history. She failed to ensure that the facts upon which her findings were based fitted within a credible framework. She drew inferences which were stated as hard conclusions. She was excessively definitive in her report and failed to follow standard medical practice in relation to her differential diagnosis. NICOLA SMITH: The background facts regarding Nicola Smith have already been set out under allegation (a). In this context the issue, which the Committee had to examine, was whether Dr. Woods advised or reported to others that Nicola had or might have been abused by a relative when she knew that there was insufficient foundation to or basis for that advice. In this instance, as already found, Dr. Woods furnished reports to the Solicitors acting for Ms. Smith and to the Court itself. As indicated, the Committee concluded that Dr. Woods failed to show and apply the standard of clinical judgment and competence required of a practitioner in her position in relation to Nicola Smith and the facts in this instance constitute professional misconduct as found by a majority of the Committee. HILDA FLYNN The background facts of the Flynn Family have already been set out in relation to Monica Flynn in Allegation (a). Hilda was the eldest child born on the 16th July 1977. Dr. Woods interviewed Hilda Flynn with Marina on the 4th February 1987. The notes in relation to the assessment are to be found in hand written form in Book E1, page 26, and in typewritten form on page 28 in relation to Hilda and hand written form on page 38 and in typewritten form on page 41 in relation to Martina. This resulted in a report of the 12th February 1987 to be found in Book E2, page 20. Hilda and Martina were again seen on the 20th February 1987. The notes in relation to Hilda are to be found in hand-written form in Book E1, page 27, and in typewritten form on page 28. Those in relation to Martina are to be found in hand-written form on page 39 and in typewritten form on page 41. This resulted in a report dated the 10th March 1987 to be found in Book E1, page 22. As already found, this resulted in the Health Board initiating District Court proceedings for a place of safety order and thereafter fit persons orders. Dr. Woods, in the course of the evidence to the District Court, heard on the 7th September 1987, went through the details of her reports and summarised her evidence by stating that all the indicators pointed to the father being the perpetrator since he was the only person who could have been in regular contact with the children. She also reiterated this view relating to the three children in a ten-minute meeting in or about Easter of 1987. Hilda and Martina remained in care until Easter of 1989 when they were returned to their parents. In the context of Hilda Flynn, the majority of the Committee have concluded that Dr. Woods failed to address the possibility that (if she had been abused at all) the perpetrator had been someone other than her father. In relation to the report of the 12th February 1987 Dr. Woods stated: ‘This is a preliminary report as I will be seeing the children again but it is quite clear from the physical findings that they have been abused by somebody’. In a report of the 10th March 1987 she stated the following: "Both children have been sexually abused by someone and all the indicators point to their father as being the perpetrator". Read together, the majority of the Committee concludes that Dr. Woods made a positive diagnosis of sexual abuse and accused the father. The majority of the Committee conclude that both conclusions were expressed more certainly than they ought to have been on the facts available. The majority of the Committee also concluded that there is no differential diagnosis element in Dr. Woods’ findings. There was no indication that Dr. Woods had ever sought to know or had been informed whether other adult males might have had access to Hilda and/or Martina and whether she considered that possibility. The majority of the Committee conclude that the usage of ‘all the indicators’ clearly identify the father as being the perpetrator in circumstances where a more careful investigation of the history, background and a differential diagnosis would have resulted in a different finding. Prior to reaching her conclusion there was no evidence that Dr. Woods took a history from other persons. More particularly, there was no evidence that Dr. Woods took a history from Mr. Flynn or Mrs. Flynn. Following her interview with Hilda and Martina on the 20th February 1987 Dr. Woods does not appear to have been given any additional information. However, she considered herself in a position to reach the conclusion as set out above. In addition to the parents, the majority of the Committee take the view that there were other professionals and childcare workers involved in the care of Hilda and the other children who should have been thoroughly interviewed prior to reaching any such definitive conclusion. Moreover, in the view of the majority of the Committee there was ample time in the context of Dr. Woods’ contacts with the totality of the Flynn family for her to interview other relevant persons, including Mrs. Flynn and Mr. Flynn, and particularly having regard to the fact that Mrs. Flynn was actually in the Rotunda on the occasion of the first interview with Hilda and Martina on the 4th February 1987. The views of the majority of the Committee (being the same majority) regarding Dr. Woods’ failure to interview Mrs. Flynn when she was available and her explanation for that have already been dealt with. In the context of Dr. Woods’ conduct in other cases it is difficult to identify any other person who should have interviewed Mrs. Flynn, if not Dr. Woods herself. Indeed this conduct is at variance from her conduct in other cases such as that of Cherie Eustace, Michelle Flynn and Nicola Smith. Videotapes exist of the interviews conducted with Hilda and Martina Flynn on the 20th February 1987. It was the view of the Committee that these videotapes indicate that Dr. Woods carried out these interviews in an inappropriate manner, that she tended to lead and that the report was not a full, fair or accurate reflection of the interviews. The interview with Hilda was conducted with anatomically correct dolls. In the course of the interview Dr. Woods asked questions which are by any interpretation leading in nature. The majority of the Committee accept the Registrar’s contentions that questions such as ‘show me him touching you in places that upset you’; ‘take his hand and point. Show me him touching you in places that upset you. You remember you showed me before’; ‘Show me you hand and the places which he touched you, show me on the dolly’, ‘was his tongue inside his mouth or any other place’ are leading in nature. In the latter report Hilda is identified as doing upsetting things to the female doll child and these involve the same things as she had described before. In the previous report this consisted of (a) digital breast contact; (b) digital/vulval/vaginal contact on the outside; (c) making the girl masturbate the adult male’s penis and (d) oral/oral contact. The majority of the Committee do not accept that anything on the videotape showed Hilda identifying an adult male doing any of these things. In the course of her report material that might have been supportive of Mr. Flynn is omitted. Hilda’s statement that she wanted her father to live with her and her denial that she wanted any change in circumstances was excluded. The majority of the Committee found it difficult to find that there was anything in the course of the videotape relating to Hilda which would or properly could have resulted in a conclusion such as ‘all the indicators point to their father as being the perpetrator’. The majority of the Committee concludes therefore that Dr. Woods was guilty of professional misconduct regarding Hilda Flynn as set out in allegation (b). This arises from her reports to the health professionals and the Health Board. MONICA FLYNN The full details relating to Monica Flynn have already been set out. It is the view of the Committee that in the light of the facts found by the majority of that Dr. Woods was guilty of professional misconduct in relation to Monica Flynn as set out in allegation (b). This arises from her reports to the health professionals and the Health Board. MARTINA FLYNN: In relation to Martina Flynn, the background facts are as set out in relation to the interviews conducted with Hilda and Martina together. In relation to Martina, the majority of the Committee accept the Registrar’s case that Dr. Woods engaged in leading actions and asked leading questions in relation to Martina. She undressed the father doll and so identified him. She places the anatomically correct ‘Martina’ doll when it was put on top of the father so that there is contact between the respective genital areas. Her demeanour was such as to encourage Martina whenever the child gave an answer that was consistent with the final conclusion. Again, material helpful to Mr. Flynn that might be seen in the interview was omitted from the report. There was no reference to the denial that any games were played and indeed the report would tend to suggest entirely the opposite. There is no reference to the various innocent activities demonstrated by Martina. The majority of the Committee noted that Dr. Baker in giving evidence in relation to this interview on behalf of Dr. Woods entirely disagreed with the interpretation placed by Dr. Woods on the interview itself (see Day 40 and Day 41). He states at Day 40, page 81, that Martina is not answering questions about her and her father but is rather answering Dr. Woods’ questions about the dolls in front of her. In other words she is simply engaged in game with Dr. Woods that has no meaning or reality. In the course of her report Dr. Woods stated that ‘Daddy lies on his back. Martina lies on top Daddy’s penis is in contact with the vulva/vaginal area of Martina.’ Dr. Baker, in the view of the majority of the Committee, did not in any way appear to accept or agree with Dr. Wood interpretation of the video nor the interpretation set out in the Report. For the reason outlined, the majority conclude that the facts are proved in relation to allegation (b) relating Martina Flynn and that, as in the other instances, the facts as proved constitute professional misconduct. Allegation (c) states: You failed to show the standards of judgment and competence required of a person in your position in respect of the investigations and court hearings relating to one or some or all of Cherie Eustace, Michelle Flynn, Nicola Smith, Hilda Flynn, Monica Flynn, Martina Flynn, Samuel Ralph, Matthew Ralph, John Ralph, Karen Ralph and Claire Ralph. In the case of Nicola Smith and Monica Flynn, the Committee concluded by a majority that the facts adduced by the Registrar were proved and that they constituted professional misconduct. In the remainder of the cases under this allegation the Committee concluded that the Registrar had not proved his case beyond reasonable doubt. Again, this decision was by a majority. NICOLA SMITH: The background facts relating to Nicola Smith have already been set out. In the view of the majority of the Committee it is clear that any report furnished by Dr. Woods had or might have a forensic use, that is, may be used for court or legal purposes. For the reasons already outlined in the case of Nicola Smith, allegation (a), the Fitness to Practise Committee concludes that Dr. Woods was guilty of professional misconduct as defined in allegation (c). In particular the majority of the Committee conclude that the investigation and interview carried out by Dr. Woods was unduly limited. She failed to have regard to the fact that important interviews had been carried out in Temple Street and in Crumlin. In addition she failed to have regard to the fact that a physical examination had been carried out. Quite clearly, in the view of the majority of the Committee, it would have been appropriate and prudent for Dr. Woods to have contact with those who had dealt with Nicola Smith. The findings arrived at by Dr. Woods in relation to Nicola Smith were excessively bold and were stated in terms which did not allow for alternative conclusions. In short, it was the view of the majority of the Committee that she stated her differences as being concluded views and persisted in this during the course of the court hearing. It will be recollected that Dr. Woods’ involvement in this case took place after her involvement in disputed court cases. There was no evidence that Dr. Woods clearly indicated any alteration in her viewpoint or that she had arrived at a different manner of expressing her views despite the time, which elapsed between the original accusations and the court hearing which ultimately took place. It was the view of the Committee that a particular duty devolves upon a doctor in circumstances such as these And accurately report the evidence. It is equally the view of the majority of the Committee that there is an obligation on the doctor in giving evidence for court proceedings to ascertain, as far as possible, the background factual information particularly having regard to the serious consequences which might occur in the light of a finding of sexual abuse. For these reasons in the view of a majority of the Committee this allegation stands proved. MONICA FLYNN: The background circumstances relating to Monica Flynn have already been set out. It will be recollected that Monica, born on the 31st December 1979, suffered from a significant level of mental handicap, had attention deficit syndrome and had substantial behavioural disorders as previously outlined. As already set out the South Eastern Health board applied for place of safety orders and fit person orders in relation to Monica in addition to the other members of the Flynn Family. Three particular matters should have been addressed by Dr. Woods as part of that diagnosis in the view of the majority of the Committee. These were the possibility that her behaviour was linked with her mental handicap and that the physical findings were the result of behaviour that followed from that handicap, the possibility that Monica had been abused by someone other than her father and in particular that she may have been abused while in care and the possibility that Hilda and Monica had been abused by someone other than their father. In view of the fact that the information provided by Dr. Woods was intended not only for the Health board but also resulted in court proceedings in which Dr. Woods gave evidence, there was a clear duty on Dr. Woods to take the steps which have been outlined and which, unfortunately, she failed to do. It is the view of the majority of the Committee that there was a substantial opportunity available to Dr. Woods to interview Mr. Flynn, Mrs. Flynn, social workers and those involved in the care of Monica in the various institutions in which she resided. The majority of the Committee do not accept the explanation furnished by Dr. Woods for her failure to interview Mrs. Flynn prior to her report of the 29th October 1986 and/or at the time of the interviews which took place relating to Hilda and Martina in February 1987. During all this time, there was ample opportunity to interview Mr. And Mrs. Flynn and the various other professionals. For these reasons the Fitness to practise Committee consider that Dr. Woods was guilty of professional misconduct in relation to Monica Flynn in the context of allegation (c). Allegation (d) states: ‘You failed to act in the best interests of the aforementioned children’. In the case of Monica Flynn and Martina Flynn, the Committee concluded by a majority that the facts adduced by the Registrar were proved and that they constituted professional misconduct. In the remainder of the cases relating to this allegation, the Committee concluded that the Registrar had not proved his case beyond reasonable doubt. Again, this decision was by a majority. Monica Flynn: The background facts have already been very fully set out. In view of Monica’s unfortunate circumstances the majority of the Committee conclude that Dr. Woods failed to act in Monica’s best interest, particularly having regard to her condition, her background and Dr. Woods’ failure to ascertain relevant background facts and material. Martin Flynn: The full background facts have already been set out in relation to Martina Flynn. Having regard particularly to Dr. Woods’ conduct in the interviews and in drafting the report the majority of the Committee conclude that Dr. Woods failed to act in the best interest of Martina Flynn and thereby she is guilty of professional misconduct. Allegation (e) states: ‘You acted in a manner which was derogatory to the reputation of the medical profession’. In the case of Nicola Smith and Monica Flynn, the Committee concluded by a majority that the facts adduced by the Registrar were proved and that they constituted professional misconduct. In the remainder of the cases relating to this allegation, the Committee found that the Registrar had not proved his case beyond reasonable doubt. Again the decision was by a majority. MICHELLE FLYNN: The Committee had also to consider whether Dr. Woods was guilty of professional misconduct in the case of Michelle Flynn. The Committee recognised that this was a difficult and complex case. The Committee had particular regard to the standard of proof taken on by the Registrar in presenting the case. By a majority, it considered the case against Dr. Woods was not proven in regard to this child. For this reason, it is unnecessary to set out the factual background and detail. SAMUEL RALPH, MATTHEW RALPH, JOHN RALPH, KAREN RALPH AND CLAIRE RALPH: The Committee also had to consider whether Dr. Woods was guilty of professional misconduct in the above cases. The Committee considered the evidence here in great detail. It had particular regard to the evidence of Dr. Wozencroft, who was called as an expert witness by the Registrar. Having regard to that evidence and the other witnesses called on behalf of the Registrar, the Committee considered that Dr. Woods was entitled to be exonerated from a finding of professional misconduct in these cases. Again, it is unnecessary to recite the factual background and detail. RECOMMENDATIONS: It is the view of the majority of the Fitness to Practise Committee that Dr. Woods has been guilty of professional misconduct on the facts as proved in each of the above cases. It is recommended that Dr. Woods should be censured in accordance with Section 45 of the Medical Practitioners Act 1978. In addition, it is recommended that the following conditions be imposed on Dr. Woods’ registration: (1) That Dr. Woods undergo a period of relevant retraining prior to returning to any form of medical practice. (2) That Dr. Woods seek guidance from the relevant recognised training body in relation to the nature and extent of such retraining. (3) That Dr. Woods avails of regular, continuing professional development activities for at least as long as she remains in active practise. (4) That Dr. Woods follow the advice of the relevant recognised training body and its regional post-graduate educational supervisor as to the nature of such continuing professional development activities. (5) That Dr. Woods should only engage in the formal assessment of children who are suspected of suffering abuse (psychological, physical and/or sexual) as part of a recognised expert specialist multi-disciplinary team. (6) That Dr. Woods furnishes the Medical Council with evidence of compliance with 1, 2, 3, 4, and 5 when requested by the Council. (7) That Dr. Woods meets any expenses incurred in satisfying these conditions. As a matter of fairness to Dr. Woods, however, it must be recognised that she was a pioneer in the area in which she became involved. While in the view of the majority of the Committee there is evidence of professional misconduct, it is not such that would merit either suspension or erasure from the Register. It is accepted that Dr. Woods operated under substantial pressure and in circumstances where the resources available to her were meagre. It is accepted that at the relevant times she was endeavouring to act in what she considered was an appropriate manner. Unfortunately, this was not always so. The Committee has had regard to the fact that in the course of the operation of the Sexual Assault Treatment Unit in the Rotunda it dealt with hundreds of cases and that it did a substantial amount of good at a time when t here had been a historic reluctance to deal with the entire phenomenon of child sex abuse. However, in the view of the majority this does not excuse a substantial falling away from the fundamental precepts and standards which are to be expected of any medical practitioner. This applies a fortiori in circumstances where the consequence of a finding of child sex abuse can be so very serious. The Committee has not had to consider the conduct of other individuals. Nor has it had to consider the conduct of health boards or health board personnel. It has not had to consider whether any adequate safeguards were installed in order to ensure that findings of child sexual abuse were properly monitored, whether proper safeguards existed, whether there was proper reviewing of conclusions and whether the manner in which the health boards approached such conclusions in these cases or others was correct. Nor has the Committee had to consider within the terms of reference of this enquiry the conduct of any other medical practitioner or hospital particularly with regard to the supervision of the Sexual Assault Treatment Unit during the period of its existence. While the Committee accepts that in this difficult area hard decisions must sometimes be taken, with devastating consequences, this does not absolve the medical practitioner from ensuring that he or she acts in accordance with the accepted and prevalent standards of conduct set out and applicable to all medical practitioners. Web www.falseallegations.com www.barbforgovernor.com www.generationaldynamics.com Barbara C. Johnson, Esq. Law Office of Barbara C. Johnson, 6 Appletree Lane, Andover, MA 01810-4102 USA telephone: 978-474-0833 USA Country Code: 426801 © Copyright 1998-2008 Barbara C. Johnson. All rights reserved Web designed, written, and compiled by Barbara C. Johnson Ruler designed by G. 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