Dr Kate Ward, a consultant paediatrician at Airedale General Hospital in Keighley, reviewed the physical evidence about whether the children at Shieldfield nursery had been the subject of sexual or physical abuse.
'Paediatricians are skilled at speaking to children and it is not uncommon for children to disclose sexual abuse during physical examination,' Dr Ward said on Friday, noting it was most important for the examiner to listen to the child.
'Many of the children disclosed to Dr San Lazaro and her colleagues the nature of the abuse and indicated the identity of the alleged perpetrators,' she said.
'I am of the view that there is significant evidence that children who had attended Shielfield nursery were the subject of abuse by Christopher Lillie and Dawn Reed.'
Dr Ward, who has been a paediatrician for 25 years and been involved in child abuse and susupected abuse work for all that time, was giving evidence on behalf of Newcastle City Council and the four-member team it commissioned to investigate complaints about Shieldfield.
The council and team are being sued by Mr Lillie and Ms Reed over the team's 1988 report which concluded the workers had sexually, physically and emotionally abused children from Shieldfield.
Four years earlier, they were acquitted of indecently assualting children from the nursery.
Dr Ward said she found no evidence that Dr Lazaro erroneously interpreted disclosures by the children.
'There were a number of common themes in the children's disclosures,' she said. 'They made specific reference to Chris and Dawn and they spoke of being taken away from the nursery to another place including Chris's flat, the library or a 'hospital'.
'Children spoke of anal and genital abuse.'
Dr Ward said in some of the children physical findings were found which supported the disclosure made by the child.
For example, one child who made a disclosure of genital abuse was found to have a complete tear in the hymen and scarring.
Dr Ward said for most of the time Dr San Lazaro was working in isolation and this may have increased the levels of stress.
'That she was deeply involved with the families and was able to identify the extreme distress suffered by parents is indicted in her letters to the Criminal Injuries Compensation Board when there was a tendency to over-emphasise the consequences of abuse,' she said.
'Nevertheless this does not diminish in any way the significance or relevance of her clinical findings or summaries and in most cases I did find that Dr Lazaro's conclusions at the end of the examination were well reasoned and not overstated.'
Dr San Lazaro, the consultant paediatrician at Newcastle's Royal Victoria Infirmary, who examined children from the nursery, said at the libel case last Monday that she found evidence of intrusive damage to a number of them, which was entirely consisent with sexual abuse.
The doctor, who also is a senior lecturer in Paediatric Forensic Medicine at Newcastle University, has practiced in paediatrics for about 30 years, specialising in the area of child abuse and neglect for about 22 years.
Dr San Lazaro said she found evidence of physical trauma in a significant number of Shieldfield children, many of whom 'disclosed to me the nature of the abuse and indicated to me the identity of the alleged perpetrators of that abuse'.
'The theme common to the children was the nursery and activities associated with the nursery,' she said. 'Further, two names kept coming up and those were 'Chris' and 'Dawn'.'
Dr San Lazaro was giving evidence on behalf of Newcastle City Council and the four-member team it commissioned to investigate complaints about Shieldfield.
Dr San Lazaro said that nearly 10 years have passed since she carried out her examinations on Shieldfield children.
'If I reviewed the records now, I might reach a different conclusion in one or two of the cases,' she said.
'I had no reason, however, to doubt what I was told by the children, or their carers, was anything other than the truth. Any disclosures made to me appeared to be spontaneous.
'There was nothing in what the children or their carers told me which led me to believe they were lying or making up stories.'
Dr San Lazaro said although it was possible that mass family abuse was taking place, she believed this was very unlikely particularly as there was no other evidence to suggest that was the case.
She also referred to the how her task had been 'extremely demanding' and said the inquiry became emotionaly taxing.
'I am on record ... as saying that this was a particularly bad case of multiple abuse, and that I found it distressing,' she said.
'I would like to make it clear that I see it as a matter of professionalism not to deny my own emotional response nor that of others, but equally not to allow it to cloud or colour my professional judgment.'
The following day, Dr San Lazaro, who concluded children from a Newcastle nursery had been sexually abused, denied that the integrity of her opinion was compromised by her becoming too close to the families.
Under cross-examination at a the hearing, Dr San Lazaro agreed she went to parents' support meetings and they were free to ring her whenever they wanted to talk over their anxieties.
Adrienne Page, QC for two former workers at Shieldfield nursery, submitted that Dr San Lazaro was also involved in arranging a phone connection for one of the mothers.
Miss Page asked if it was appropriate for a paediatrician - who has to bring objectivity and detachment to the task of deciding if there were signs of abuse - to become involved personally with a parent inthat way.
'If it eases the families' experience, I don't think it compromises my integrity,' Dr San Lazaro replied. She said it was usual for families to be helped - perhaps to buy shoes - using money from her unit's common fund.
But Miss Page suggested the doctor had to assume detachment from parents until she could rule out for certain that the source of any trauma was not the parents themselves or the family.
Miss Page suggested the paediatrician became 'too close to the parents' at a time when her role was to provide evidence as to whether or not the children had been abused.
But Dr San Lazaro said she was no different than a paediatrician working with children with cystic fibrosis, who go to support groups, run fund-raising marathons and became involved in assisting families.
'I don't think this particular case generated in me any different response than I continue to give all my patients,' she said.
Miss Page suggested it was not in the interests of a child that an investigating paediatrician should be anything less than 'objective, rigorous and scrupulous'.
'Yes, but I think being empathetic and supportive ... should not compromise your ability to find a scar or tear, it's not going to materialise because you are a kindly person,' she said. 'They are going to be there.'
But Miss Page argued that Dr San Lazaro had not been open to the possibility that the source of the abuse - if the children had been abused - could be anything other than Shieldfied.
'You put forward the assumption, before anyone else in this case, that this was a case of multiple abuse,' the barrister continued, suggesting she also had assumed Shieldfield was the source.
'These children were saying Shieldfield was the source,' replied Dr San Lazaro.
The QC referred to concerns about 'wholesale screening' of children, including the potential that the medical examination can have a contaminating effect on the child.
The unusual 'focus on the genital area' and heightened awareness could trigger sexualized behaviour in the child, she said.
But Dr San Lazaro said a full medical examination was carried out and it was not unusual for the genital area to be a focus when children are being bathed, towelled or creamed.
She added it had never occurred to her that an examination could be the trigger for sexualized behaviour.
On Wednesday, Dr San Lazaro said she could not explain why she changed findings which then provided more emphatic evidence to support a child-rape allegation made against a nursery worker.
Under cross-examination at the hearing, she said: 'I cannot explain it; it was a long time ago. But I know I am not a dishonourable person'.
She agreed with Adrienne Page, QC for two former nursery workers, that what she described in her police statement was 'unequivocally more serious damage' to a child then she earlier described in her medical report.
'I cannot even imagine altering physical signs to provide for more emphatic evidence for an allegation,' Dr San Lazaro said. 'I have never done it and I deny having done that in this case, but I cannot explain it.'
Mr justice Eady, who is hearing the case without a jury, asked whether she may have written the 1993 police report in a hurry, from memory.
'My Lord, what I do not understand, I just do not understand, this is causing me a lot of grief,' she said, adding that she may have done it from memory because it was 'being done on the hoof'.
Miss Page asked Dr San Lazaro about one of those children - a little girl Mr Lillie had been charged with raping.
The paediatrician wrote a report after examining her on 8 October 1993. She told Miss Page she believed that report was compatible with a prosecution case that the child had been raped by Mr Lillie.
Dr San Lazaro wrote a police statement weeks later around the time Mr Lillie and Miss Reed were applying for bail. She agreed the police statement describes 'unequivocally more serious damage' to the child than in her original medical report.
Miss Page suggested the wording was changed quite deliberately to make the police statement fit with the rape allegation the child was supposed to have made that day.
'I suggest ... you have said nothing to explain, any innocent explanation, for a professional person of your experience and your standing engaged in the very serious task of providing evidence for a criminal prosecution on a very serious criminal offence,' Miss Page put to the witness.
But Dr San Lazaro replied the original medical report would have been sufficient evidence for an allegation of rape had it been made at that time.
'In which case, there is no reason to have changed the wording in your police witness statement and, in fact, the more pressure time-wise you might have been under, the more likely that you would have simply reproduced what you said in your original report,' Miss Page put to her.
Dr San Lazaro replied that that seemed logical and she could not explain why she changed her findings.
Earlier Miss Page asked Dr San Lazaro if she was a 'warrior in the fight against child abuse', as she was described in another court case.
She replied she would not describe herself that way, but as a 'fairly senior professional who has academic expertise'.
Miss Page suggested that, on the face of her Shieldfield medical reports, the doctor displayed 'an almost morbid eagerness to find signs and symptoms of serious sexual abuse'.
'I put it to you that there were signs and symptoms and that ... I did, I hope, exhibit balance,' she replied. 'I did downgrade signs after considering them, removed them, re-considered their probative value. I do believe that I did my best.'
The following day, Dr San Lazaro admitted her records contained inconsistencies as well as careless, imprecise and inadequate reporting.
At one stage, she told the hearing that she was 'embarrassed to see errors of this nature' in her report on one child.
Adrienne Page referred the witness to a report where Dr San Lazaro indicated the child had told her that Chris had hurt her.
But this was not written in the paediatrician's notes and Dr San Lazaro admitted it would have been good practice to have done so.
'This is either another example in a catalogue, at best, of appalling sloppiness in your records, or it is a mischievous embroidery of what a child said to you - help us out,' Miss Page put to the doctor.
'If a child had said nothing to me to indicate ... I certainly would have not made a record indicating a child made an allegation to me if that was not so,' Dr San Lazaro replied.
'This is another case of inconsistent records emenating from your consulting rooms,' Miss Page suggested.
'I don't deny that these records are less than adequate in areas,' Dr San Lazaro replied.
Referring to the criminal charges brought against the two nursery workers of which they were acquitted, Mr justice Eady put to the witness: 'You did realise that someone could get a sentence of life imprisonment?'
Dr San Lazaro replied that she would not have made a Criminal Justice Act statement about a matter of which she was not sure.
Miss Page, taking Dr San Lazaro through her examinations, records, medical reports and police reports on various children, referred to one case in which the decriptions of 'damage' to a child were not compatible in her medical and police reports.
'There are inconsistences between these two reports. I imagine 10 years ago we were less sophisticated about how we recorded things,' Dr San Lazaro said.
She said there was a lot of language she used in her reports then which she would never use now, including expressions like 'gross'' or 'severe'.
Referring to another child's case, Miss Page said Dr San Lazaro's report implied that the girl had clearly described trauma she had suffered, where on the face of it this disclosure was not recorded in consultation notes.
'Do you agree that in November 1993, when a child was suspected of being the subject of abuse, it was very important that you - a professional person independent of the parents - should record any child's statement of the abuse,' Miss Page asked, to which the doctor agreed.
'If you don't it is lost and gone for ever,' Miss Page said.
'Unless I make a report pretty quickly about it, and specific,' she replied. 'This report is not specific.'
She later agreed that terminology in that report was sometimes imprecise and that various terms were used 'rather confusingly', adding that 'I know the terms used at the time could have been more precise'.
Miss Page asked if Dr San Lazaro had actually known what she was looking at when she looked at these children.
'Before I started doing child abuse work, I conducted literally hundreds of genital exminations on normal children,' she replied. 'I think I was as trained as much as I could possibly be for the work I was doing.
She said there had been no independent review to measure her skills and compentence at the time she was doing the reports.
The hearing is continiung.
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