Archived Transcript for 18 Febuary 2002: Pages 1 to 50


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1 Monday, February 18th 2002

2 (10.00 am)

3 THE CHAIRMAN: Good morning ladies and gentlemen. After

4 55 days of taking oral evidence from witnesses we have

5 now reached the stage of hearing final submissions in

6 Phase I of this Inquiry. As you know, each of the

7 interested parties has had the opportunity to present

8 the Inquiry with written submissions, some have done so

9 in considerable detail. I am very grateful to each of

10 them for the thought that they have given to these

11 written submissions and I assure you that each of them

12 will be very carefully considered.

13 The interested parties were not obliged to produce

14 written submissions but if they are not with us this

15 morning I will only receive them after an application

16 has been made when I have considered the reason for the

17 delay.

18 Today and tomorrow we are going to hear the final

19 oral submissions. These submissions will be time

20 limited and I am grateful to my colleague, who will be

21 sitting in the witness position shortly, because she

22 will take careful note of the time and if necessary she

23 will help me to alert speakers as they approach the

24 final few minutes of their presentation. But I hope

25 that will not be necessary. I hope that I can rely upon

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1 advocates to adhere to the timetable.

2 I should indicate that I have agreed to hear oral

3 submissions from one party, that is the London Borough

4 of Enfield, on Wednesday 27th February because of

5 personal difficulties in which their advocate finds

6 himself. These submissions will be made in public and

7 will be subject to the same time restraints as every

8 other party.

9 Now, ladies and gentlemen, if I could as ever ask

10 you to make sure that mobile phones are off, we will

11 begin and we begin with Mr Herbert making the first

12 submission. Mr Herbert, as you know, you have

13 15 minutes.

14 MR HERBERT: Good morning.

15 THE CHAIRMAN: Just making sure that the communication

16 between me and the time keeper was working.

17 Closing submissions by MR HERBERT

18 MR HERBERT: Thank you. You will have the written

19 submissions already of Ms Baptiste so I do not seek to

20 repeat any of the matters that are in there. If I can

21 make some general points. The context in which

22 Ms Baptiste's involvement is to be seen is that she

23 starts from a point of view where she deeply regrets

24 obviously any contribution that she has made to

25 Victoria's death. In respect to those matters, that is

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1 set out in her statement and in the oral evidence that

2 you heard.

3 In terms of the context in which it is to be seen,

4 there are several main themes which we would say are set

5 out in Counsel to the Inquiry's submissions already and

6 we support those in the sense they put her role in the

7 context. She was involved for a limited period of time

8 effectively between 31st July and towards the end

9 of October 1999, and therefore her power to alter the

10 direction and the course of events is limited to that

11 time period.

12 The points that are raised about her responsibility

13 are that she would only be as good as the information

14 that would be sent from both the Central Middlesex and

15 more importantly the North Middlesex Hospital to social

16 services. Any supervision or failure to supervise

17 properly, any criticisms must be seen, we would say, in

18 the light of the information that both she and

19 Lisa Arthurworrey received at that time. You will be

20 aware that there were key pieces of information which

21 were missing as between the hospital records and social

22 services, and that was a matter which came into a number

23 of different categories which you have set out before

24 you in terms of the evidence.

25 Generally, much of the nursing evidence, which would

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1 have highlighted any team leader to the concerns about

2 Victoria's general care and treatment, were not

3 communicated. Much evidence that you have heard is

4 people's hindsight, 20/20 vision about what may have

5 been the case and what would have been highlighted as

6 concerns. Very little of that found its way into the

7 medical notes.

8 It was accepted by Dr Reynders that there was

9 a serious deficiency in the management of Victoria's

10 case before she left hospital. That was a failure in

11 a sense which was bound to carry on into the work that

12 Ms Baptiste would have done. The discharge from the

13 hospital, from North Middlesex Hospital on any view was

14 probably improper. The concerns that Dr Rossiter later

15 said that she had were not properly communicated or set

16 down into writing at that time. If they had been, then

17 it is likely that another course of events would have

18 been adopted.

19 As far as Ms Baptiste was concerned, there is

20 nothing to indicate that she was available to have

21 chaired the strategy meeting on 28th July, and the case

22 was allocated on 31st July as soon as she was aware of

23 it, and therefore, in terms of her involvement, it was

24 limited by the time that she was at work physically.

25 As far as the way in which she asked for matters to

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1 be looked at then, you will recall before the discharge

2 there was evidence that the Child Protection Team had

3 already spoken to Kouao and Manning and had been

4 satisfied that there were no child protection concerns

5 to further vet in detail at that time. On a medical

6 basis the hospital were quite clear in saying medically

7 Victoria was well enough to go home and in fact had

8 expressed a view that she wanted to go home.

9 Those three main ingredients would have led in our

10 submission any team leader, no matter how diligent and

11 how well able to supervise what was happening at that

12 time, and under the pressure of the workload that you

13 are aware that was currently in vogue in Haringey at

14 that time, it is quite likely that mistakes would have

15 carried through, and what I would ask you, Chair, to

16 look at is this was one of those tragic cases where

17 there is no one individual who can be held directly

18 responsible for Victoria's death apart from those two

19 individuals who face that criminal conviction. But it

20 is one where mistakes are layered one on top of another.

21 It is quite clear that Ms Baptiste had a layering of

22 mistakes but it certainly came on top of other more

23 fundamental mistakes that were made further down the

24 line, and each mistake, each failure adds cumulatively

25 to the next, and in terms of the general observations

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1 that we would seek to make, it is not to excuse but it

2 is certainly to explain any errors of judgment that may

3 have been made by Ms Baptiste during her time, her three

4 months' involvement.

5 We have talked about opportunities to change the

6 course. The opportunities probably diminish and the

7 opportunities may well have been at their height before

8 the point of discharge. Once Victoria goes back into

9 the community it is always more difficult because she

10 was certainly safe while she was in that hospital

11 placement.

12 As far as the supervision goes thereafter, it is

13 again the fact that, and it was accepted by Ms Baptiste

14 in evidence, that she did not read every single piece of

15 the case file. That is clearly evident. She

16 acknowledged that quite openly, and in terms of the

17 failures, if I can put that, they can be summarised as

18 these in a sense from her evidence: her failure in part

19 to read Victoria's case file, certainly properly before

20 the 20th September 1999. A partial failure to discuss

21 each and every item, and I mean each and every item,

22 with Lisa Arthurworrey, so that she would have checked

23 the full 18 items discussed in the strategy meeting

24 of July 1999. It is quite evident that she did go

25 through some of those issues but not all of them. And

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1 the failure to record some of the decisions of the

2 supervision sessions.

3 Those in summary are in a sense the main aspects of

4 what she may have failed to do at different points, but

5 in my submission on her behalf, that has to be put in

6 the context of the information that was received. It

7 was always less than complete, and if there is one

8 thread that goes throughout her involvement, there was

9 no point at which that file between the July, when she

10 had the charge of supervising Miss Arthurworrey, to the

11 end of her involvement at the end of October, was ever

12 complete. It was never a complete file.

13 The responsibility for that lies with several

14 individuals but it is quite clear at the beginning

15 of August it is apparent that many individuals, those

16 key individuals responsible were saying the situation

17 was satisfactory, there are sufficient safeguards in

18 place, and therefore the discharge that she confirmed

19 for Victoria to return home was one that was done on an

20 informed basis. It was done on the information from the

21 Child Protection Team, from the hospital and from

22 Lisa Arthurworrey's assessment. It was not done on the

23 basis of no information whatsoever.

24 Subsequently, as far as the information that flowed

25 through to that file, you will know, and I do not seek

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1 to go into any detail, but there are several key pieces

2 of information which were not clarified or never reached

3 the file. The serious concerns by Dr Rossiter in the

4 letter to Petra Kitchman of 13th August were not seen

5 for a considerable period, if at all, by

6 Carole Baptiste. The discharge summary found its way

7 through on 2nd September and there was finally another

8 letter on 19th October. There was in a sense

9 information going in two directions. It was going to

10 Petra Kitchman but it was not all coming to the social

11 work team and Lisa Arthurworrey, and when it did, it was

12 quite clear there was a serious misunderstanding because

13 the correspondence from Petra Kitchman back to

14 Dr Rossiter clearly highlighted the fact that the social

15 services at least appeared to have got the case back to

16 front, specifically in terms of the injuries.

17 That was a misapprehension that several people

18 worked under and in a sense it may well have been that

19 Dr Rossiter would have been in the best position to have

20 understood how the information could have been

21 misunderstood in so clearly a dangerous way.

22 It is not surprising in our submission therefore

23 that the team leader in effect suffered the same

24 misapprehension about the information, and rather than

25 simply confirm the fact that this case was to be treated

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1 as something which was just simply about accommodation

2 and support, it was to be something that was directed by

3 a failure to properly understand the seriousness of the

4 medical injuries that were already apparent on Victoria.

5 There is nothing more difficult to deal with, not

6 only than conflicting medical evidence but evidence

7 which on the face of it to any reader could be

8 interpreted as that these are not anything other than

9 accidental injuries. That is a path which in my

10 submission clearly would have led social services down

11 one particular pathway and one knows from practice how

12 difficult it is, once a case has been set along one

13 track, how difficult it is without other medical

14 evidence or clear evidence of admissions or from another

15 serious source for that case to be brought back off the

16 track of non-accidental injury to a track of accidental

17 injury or vice versa.

18 If, say, for instance there had been a clear

19 diagnosis of non-accidental injury, it would have been

20 extremely difficult for this case to have been dealt

21 with in any other way than by way of a full case

22 conference and full care proceedings.

23 The highlights that I have mentioned of the possible

24 failures to supervise recognised by Ms Baptiste are to

25 be set in context. I have dealt at some length with the

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1 lack of information but there are also the inherent

2 difficulties that she told you about. There was by way

3 of explanation difficulty to supervise

4 Miss Arthurworrey. Part of that responsibility is

5 obviously Ms Baptiste's but part was the dispute and the

6 dynamism of that team in relation to the incidents of

7 bullying and the complaint. People took sides, and

8 effectively there is an issue between Miss Arthurworrey

9 and Ms Baptiste that you would have to resolve about the

10 ease with which Miss Arthurworrey allowed herself or was

11 willing to be supervised in any event. That is

12 something that was quite clearly a difficult office

13 dynamic at the time and compounded the issues that

14 I have said.

15 As I come to the closing of what I have to say,

16 there was also the issue that Miss Arthurworrey was not

17 a novice or a social worker that was just beginning. It

18 was understandable and acceptable that Ms Baptiste would

19 have recognised her capability to manage that case.

20 Ms Baptiste herself was not properly managed and at that

21 particular time she was under enormous strain because of

22 the insistence of Haringey in making managers apply for

23 their own jobs in the face of a heavy case load at that

24 material time. All that diversion undermined her

25 ability.

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1 Finally, there is the deliberate manipulation of

2 information that was clearly in evidence at any occasion

3 where Kouao and Manning met Lisa Arthurworrey and

4 anybody else who had involvement with them. They were

5 two individuals who deliberately sought to mislead

6 health care professionals and that was something that

7 Ms Baptiste would also labour under.

8 Finally her mental health. You will know, and I do

9 not seek to reiterate the points that were made last

10 time, this team leader was unwell. It is highly likely

11 that she was suffering from depression and was not

12 operating to her full capacity. She must be judged even

13 in the absence of the general practitioner's notes as

14 a person who was seriously unwell. Being seriously

15 unwell in a job that does not demand the highest

16 standards of judgment is difficult enough, but all of us

17 in this room will know that it is extremely difficult to

18 judge a fellow professional or anybody indeed when they

19 are suffering from mental illness.

20 If she was in the early stages, in all probability

21 she had little or no insight. Those around her would

22 not have picked up the signs, they were not trained to

23 do so, but one thing that is glaringly obvious in her

24 evidence before you, she is somebody who has not escaped

25 the consequences of that period where she clearly had

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1 a breakdown by the February of the following year. That

2 was only in part to do with this particular case,

3 because the tragic event of Victoria's death had not

4 become fully apparent by then. At that particular time

5 I would ask you, in spite of the medical notes, to take

6 full cognisance of the fact that this person herself was

7 mentally ill and unwell at the time and therefore all of

8 her failings such as they are must be seen, I would ask

9 you, in that light.

10 THE CHAIRMAN: Thank very much indeed Mr Herbert. I am

11 grateful to you. Now, ladies and gentlemen,

12 Mr Wilkinson, Rose Kozinos. Mr Wilkinson you also have

13 fifteen minutes.

14 Closing submissions by MR WILKINSON

15 MR WILKINSON: Thank you. Sir, in the time which I have

16 available I do not propose to run through the detailed

17 response to the potential criticisms which my client

18 Miss Kozinos has received and I propose to limit myself

19 to just a few general remarks during these closing

20 submissions.

21 Sir, Miss Kozinos accepted in her evidence that she

22 was part of an organisation which failed Victoria. As

23 one part of that organisation and as someone who had

24 dealings with Victoria's case on more than one occasion,

25 Miss Kozinos accepts some responsibility for those

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1 failings. This Inquiry has demonstrated for all to see

2 that in the North Tottenham office where she worked

3 there were many significant respects in which the theory

4 and practice of child protection had long since parted

5 company. It is clear looking back now with the benefit

6 of hindsight that there were numerous occasions when

7 those with responsibility for Victoria's case could and

8 indeed should have handled it differently.

9 Miss Kozinos does not seek to persuade this Inquiry

10 against that inevitable conclusion. The work of this

11 Inquiry would not be complete unless it sought out and

12 identified those failings. By doing so, however, the

13 Inquiry we submit will do no more than establish the

14 effects rather than the cause of the most fundamental

15 failings which afflicted the North Tottenham office.

16 Undoubtedly, sir, you will find that there were some

17 extreme instances where the action or inaction of

18 certain individuals may be such as to justify personal

19 criticism. Thus one thinks for example of disruption

20 caused by individuals who simply failed to attend work

21 to do their job. But for the majority we submit it

22 would be unfair to single out for criticism those who

23 simply got on with their job, performing their work in

24 the way which they had been taught, or, when training

25 was not available, at least in the way which they

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1 observed the job being done by more senior colleagues.

2 Many of the errant practices which this Inquiry has

3 highlighted were long-established. In many cases those

4 practices have been condoned or even devised by senior

5 management in the office. At the very least, the

6 interest of fairness demands that any personal criticism

7 directed at Miss Kozinos or indeed at her colleagues

8 should be put into the appropriate context. It should

9 be based on the full and proper understanding of the

10 working environment which this Inquiry has now lain

11 bare. Those factors must include the following:

12 The workload that was imposed upon members of staff

13 in the Investigation and Assessment Team. The quality

14 as well as the quantity of the staff available to do

15 that work. The disruption caused by the restructuring

16 exercise which you have heard about, as well as the

17 effect which that had upon staff morale and workload.

18 The inadequacy of the training provided. The inadequacy

19 of the resources and materials available to members of

20 staff. The practices and customs which had been allowed

21 to develop in the department over many years which

22 diverged as we have seen from the procedures laid down

23 and the need reasonably to place a degree of trust in

24 the work of apparently competent colleagues in

25 a department which could only ever operate through

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1 partnership and team work.

2 Sir, whatever shortcomings may have been exposed

3 I would urge the Inquiry to accept that Miss Kozinos was

4 a diligent, committed and hard working social worker.

5 There are numerous examples of this but perhaps most

6 striking is the fact that her involvement with

7 Victoria's case only ever arose through her willingness

8 to assist colleagues both junior and senior to herself.

9 Indeed, if a department's procedures had all been

10 followed strictly then Miss Kozinos would not have been

11 called upon to deal with Victoria's case at all.

12 As the Inquiry moves into Phase II it will of course

13 be looking forward at ways in which a recurrence of

14 these tragic events can be avoided. It goes without

15 saying that the importance of this work cannot be

16 underestimated.

17 Miss Kozinos gave evidence to you, sir, about the

18 circumstances of her resignation from the London Borough

19 of Haringey in the summer of last year. Her evidence

20 strongly suggested that despite whatever public

21 utterances have been made to the contrary, few if any

22 lessons have yet been learned. Many of the problems

23 which face the department in 1999 were just as evident

24 in the summer of 2001 when she left. It is apparent

25 that much remains to be done. Thank you.

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1 THE CHAIRMAN: Thank very much indeed Mr Wilkinson.

2 Ms Reindorf you also have 15 minutes.

3 Closing submissions by MS REINDORF

4 MS REINDORF: Thank you sir. Sir, the written submissions

5 that we have submitted on behalf of Angella Mairs deal

6 in detail with a number of issues which have arisen in

7 the course of the evidence to the Inquiry.

8 Today, given the shortness of time, I intend to

9 concentrate on three themes in particular.

10 Firstly, Angella Mairs's competence as a manager in

11 the context of her working environment. We say that

12 mistakes were made by Ms Mairs which she accepted in

13 evidence and I would echo Mr Herbert's statement that

14 his client as well as my client regret deeply any impact

15 which actions had on Victoria's case, but we say that

16 Ms Mairs was a good manager, following normal custom and

17 practice, and was trusted by her employers.

18 Secondly, I will deal with the question of whether

19 Lisa Arthurworrey told Angella Mairs about the sex abuse

20 allegations in the supervision of the 15th November

21 1999. We have say that she did not and that that is an

22 implausible allegation. It is necessary for the Inquiry

23 to look very carefully at the allegations and the

24 evidence.

25 Thirdly, I will discuss the question of whether

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1 Angella Mairs removed the final contact sheet from

2 Victoria's file on 28th February 2000. Again we say no,

3 that is another implausible allegation.

4 As to Ms Mairs's competence as manager, firstly

5 a number of witnesses have given you very positive

6 evidence about Angella Mairs's management style and

7 effectiveness. Dave Duncan said that Haringey have

8 called on Angella to pull it out of a tight spot because

9 she is clear, because she sets up safe systems and

10 strong systems. Barry Almedia said Angella had many

11 excellent qualities and was a very hardworking and loyal

12 manager in Haringey. Rose Kozinos said that she was

13 approachable, frequently praised, and that she had never

14 known her to be criticised. We have set out in our

15 written submissions evidence from Valerie Robertson,

16 Philip Peatfield and Carole Baptiste who all praised

17 Ms Mairs's ability, and in the light of all of that

18 evidence we would ask the Inquiry to find that she was

19 a highly regarded team leader who was trusted as a safe

20 pair of hands in Haringey, and that that is also

21 demonstrated by Haringey's decision after Victoria's

22 death to transfer Angella Mairs to the Hornsey office as

23 effectively a trouble shooter where she sorted out

24 a situation which was described by Dave Duncan as

25 desperately critical and very worrying, and

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1 Angella Mairs was very effective in pulling that system

2 into place.

3 It is also important to remember, we say, that

4 during the period of Carole Baptiste's absence from the

5 North Tottenham office the number of social workers for

6 whom Ms Mairs had responsibility virtually doubled. She

7 had 10 or 11 and that number went up to about 20, and

8 Ms Mairs's managers knew about that increase in her

9 responsibility, and we ask you to find that they were

10 content to allow that to happen.

11 Rose Kozinos supported Ms Mairs's evidence that

12 management, Dave Duncan and Carol Wilson knew about the

13 impact of the increase in responsibility and that that

14 impact was that team leaders were not able to read case

15 files properly or follow case recording policy properly.

16 Angella Mairs was open and very honest in her evidence

17 that that happened and that the reason for it in part at

18 least was her heavy workload.

19 In summary, under that heading we say Angella Mairs

20 was working within the parameters of normal working

21 practice at Haringey and she was considered to be a very

22 competent and reliable worker and that she was being

23 clear about the mistakes that she made.

24 Moving on to the question of the sex abuse

25 allegations, Lisa Arthurworrey of course says that she

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1 did say in the supervision on 15th November 1999 to

2 Angella Mairs that there had been sex abuse allegations

3 and Angella Mairs says that Lisa Arthurworrey did not

4 mention that. Counsel to the Inquiry in his submissions

5 at page 112, paragraph 11.25 picks up on this and

6 I would refer you to the evidence which is set out

7 there.

8 Sir, the context of the supervision of 15th November

9 was that Angella Mairs had not read the file before the

10 supervision. She was candid about that in evidence.

11 Secondly, it was the only supervision which

12 Angella Mairs had ever had with Lisa Arthurworrey and

13 was ever to have. It was a one-off. Thirdly, that

14 Carole Baptiste, whose file it was, had not properly

15 handed over her cases to Angella Mairs.

16 Sir, in that context Miss Arthurworrey admitted in

17 evidence that the way the supervision worked was that

18 she sat with the notes, with the file on her lap and

19 that Ms Mairs was taking notes as Miss Arthurworrey was

20 referring to the file. The notes of the strategy

21 meeting which contained the sex abuse allegations

22 actually do not mention sex abuse explicitly. All they

23 say is: "Client to give police a statement or one

24 withdrawing", that is at item 5.

25 It is also important to know that there are nine

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1 other matters referred to in the notes of the

2 5th November strategy meeting which do not appear in

3 Ms Mairs's notes and those are set out at paragraph 23

4 of our written closing submissions.

5 We say that it is entirely conceivable in those

6 circumstances that Miss Arthurworrey did not mention the

7 sex abuse allegation along with all those other nine

8 matters and by contrast it is entirely inconceivable

9 that Ms Mairs would have ignored any mention of sex

10 abuse in order just to close the file quickly.

11 The Inquiry is reminded of the endorsements of

12 Ms Mairs's management skills from her colleagues and in

13 particular that she was very experienced and was

14 regarded as being capable of ensuring safety.

15 We say that it is implausible that a manager of this

16 sort would allow an allegation of this sort to pass

17 unactioned. Counsel to the Inquiry poses this question

18 at page 117 of his submissions:

19 "Which account of the supervision is to be

20 preferred?"

21 We say that the Inquiry must decide that

22 Angella Mairs's account is the plausible and truthful

23 account.

24 Finally, the allegation of removing documents. Of

25 course, Lisa Arthurworrey alleges that Ms Mairs removed

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1 the final contact sheet from the file on the Monday

2 following Victoria's death. We say Ms Mairs had no

3 reason to do that and she did not do it. It had not

4 been her decision to close the file. It had been

5 Rose Kozinos and Lisa Arthurworrey's decision and the

6 documents contained no material that was likely to

7 incriminate Ms Mairs. Even Miss Arthurworrey's account

8 says the final contact sheet showed only Ms Mairs's

9 signature, Miss Kozinos's signature and details of the

10 closing letter which Miss Arthurworrey sent to Kouao and

11 also a message which Miss Arthurworrey had left to

12 Constable Jones to say that the department had closed

13 the file.

14 It is clear from the evidence then that there were

15 opportunities for other people to remove papers from

16 that file. Ms Mairs said that she did not handle the

17 file between the morning of the Friday 25th February

18 when the file was initially closed and the morning of

19 Monday 28th February. A new referral came in on the

20 Friday from North Middlesex Hospital and the file went

21 back up to Duty and Miss Arthurworrey dealt with that

22 referral. There was a strategy meeting and Victoria

23 died later that day. The last contact sheet could have

24 been removed at any time between then and the Monday

25 morning by anybody else.

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1 We also say that Miss Arthurworrey's account is

2 seriously undermined by her failure to report the

3 alleged incident to any of the following people:

4 Dawn Green, Ms Wilson, who had requested the file, the

5 Director of Social Services, her own union. All of

6 those people were people that she could have gone to, as

7 well as Mr Duncan of course. However, she did not

8 disclose it until September 2000, except to

9 Miss Robertson and John Myrie who were people who were

10 not in a position of authority over her. She would of

11 course have been at no risk of disciplinary sanction if

12 she had reported it.

13 We also say that her account is entirely implausible

14 because she says that Ms Mairs took this sheet off the

15 top of the file in front of Miss Arthurworrey and an

16 administrator who nobody knows who she is, and tore up

17 the sheet and said, "Let us get rid of this" and threw

18 it in the bin. We ask you to find that no sensible

19 person who had intentions to destroy incriminating

20 evidence would do so in front of a stranger and a member

21 of staff.

22 The true picture, we say, sir -- and this is

23 a matter that was put by Mr Garnham to several

24 witnesses -- is that a situation arose, was allowed to

25 arise in which Ms Mairs could be wrongly accused of

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1 taking that sheet off the file. There was not any real

2 effort to secure the file by those people who had

3 responsibility to secure it and nobody raised the issue

4 afterwards of where the final contact sheet was.

5 Dawn Green talked about the single agency meeting later

6 that day. Nobody asked Angella Mairs about the file

7 then. At no point did Ann Graham question even why the

8 file had been photocopied.

9 In conclusion on that point, Ms Mairs entirely

10 refutes any suggestion that she attempted to thwart the

11 proper investigation of Victoria's case and her tragic

12 death by removing documentation from her file, and the

13 Inquiry is invited to consider the evidence relating to

14 this very, very serious allegation with particular care.

15 Bearing in mind the inherent contradictions and

16 improbability in the account given by Lisa Arthurworrey,

17 we say that those must reveal that the allegation is

18 entirely without foundation.

19 Sir, I would like to sum up just by saying there has

20 been a very great deal of evidence and the witnesses'

21 accounts have been meticulously scrutinised. I hope

22 that Miss Lawson will forgive me for ending with her

23 words from her opening address on behalf of Haringey as

24 follows:

25 "When any case is placed under a microscope and

24



1 investigated, with hindsight it is almost inevitable

2 that some failings and errors in practice will be

3 identified. Any casework done under the sort of

4 pressure which is the norm in most social services

5 departments will contain areas of good or even excellent

6 practice and some which could have been done better.

7 That is the case here."

8 Sir, it only remains for me to reiterate Ms Mairs's

9 regret at the impact of any of her actions on this

10 tragic case. Those are my submissions, thank you.

11 THE CHAIRMAN: Thank you very much indeed Ms Reindorf. I am

12 very grateful to you. Now Miss Marsh on behalf of the

13 NSPCC. Miss Marsh you have 30 minutes.

14 Closing submissions by MISS MARSH

15 MISS MARSH: Thank you. Sir, I want to begin by personally

16 and for the NSPCC giving our apology to Victoria, Mr and

17 Mrs Climbie and the rest of their family. It is clear

18 that we had an opportunity to help Victoria. It is

19 profoundly to my regret that we did not act in a timely,

20 adequate and appropriate way and this opportunity was

21 lost. I know that an apology can never be enough but

22 I am very sorry.

23 I would like, sir, to make some comments about the

24 NSPCC, the Tottenham Child and Family Centres and then

25 the Inquiry and the issues that it has raised for us and

25



1 I shall conclude with some of the lessons that we have

2 learned.

3 The NSPCC is a charity which specialises in

4 protecting children. I have been the Director and Chief

5 Executive since September 2000. The determination to

6 prevent cruelty to children led to our foundation in

7 1884 and our role since then has progressively evolved

8 along with the wider changes in the care and protection

9 of children in the UK. It is our mission to end cruelty

10 to children with a vision of a society where all

11 children are loved, valued and able to fulfil their

12 potential. This Inquiry has made us all the more

13 committed to achieving this.

14 After generations of work focused almost entirely on

15 those children who have been abused, the NSPCC

16 recognised in the 1990s that we needed to broaden the

17 range of our work. Our services do still include the

18 provision of therapy for abused children and young

19 people and for those who are responsible for abuse, both

20 adults and young people. With the police and social

21 services we investigate complex and organised cases of

22 abuse, we also provide counselling and support in

23 schools, a 24 hour national child protection helpline

24 and training and consultancy in child protection.

25 One aspect of our work is the provision of family

26



1 support for those children and families in need and in

2 some cases at risk. Responding to local needs we have

3 worked with families in a wide range of communities

4 across England, Wales and Northern Ireland where there

5 are real difficulties and often significant deprivation

6 for children and their parents. Our intention is to

7 protect children by supporting parents and so help to

8 prevent children from being harmed or becoming at

9 serious risk.

10 As the Inquiry will be aware, the NSPCC established

11 a small family support service in Tottenham and in 1997

12 we agreed to manage a new larger service in partnership

13 with Haringey Social Services and the health authority.

14 Our contribution was the manager employed by the NSPCC

15 and access to our training and support. The two

16 premises and the rest of the staff were provided by the

17 other partners. This was an unusual partnership

18 arrangement for the NSPCC with all the staff seconded

19 from other services.

20 The overall aim of the centres was to improve family

21 life. The centres provided planned pieces of family

22 support work, it was not set up primarily to handle

23 cases raising child protection issues, and the agreed

24 procedure was that when any cases raised such issues,

25 they were to be considered in a specialist referral

27



1 panel first and then the centre was to be asked to do

2 specific pieces of support work on those particular

3 cases.

4 The centre as you will know closed in March 2000 on

5 completion of the three-year Service Level Agreement.

6 Following Victoria Climbie's death the NSPCC was

7 concerned that there should be a full and public

8 inquiry. We have been very determined to support this

9 Inquiry. The NSPCC's own involvement with Victoria's

10 case was only discovered as you know through a further

11 search on our database in January 2001 against the

12 address of Carl Manning when this became known to us.

13 We informed the Area Child Protection Committee about

14 our involvement and conducted our own management review.

15 We were not named by the Inquiry as one of the

16 original nine agencies that were involved with Victoria

17 but we actively volunteered the evidence we had to the

18 Inquiry to ensure that we could be included and all our

19 information considered.

20 We have sought to be open and honest with the

21 Inquiry throughout and conducted detailed investigation

22 with our witnesses, three of whom no longer work with

23 us. We are grateful for their cooperation and support

24 in this.

25 Can I state, sir, that at no time did the NSPCC

28



1 attempt to alter records nor to deceive the Inquiry in

2 any way. I profoundly regret the confusion we caused

3 with some of our documentation. The anonymisation of

4 the referral documents, which you recall was done in

5 good faith for the ACPC report, the two original

6 documents finally presented to the Inquiry together with

7 the Post-it still in place to anonymise the staff on the

8 report did demonstrate this. The management review and

9 the other documents we had released earlier did make

10 clear the identities of those involved but it is

11 unfortunate we wasted your time in establishing this.

12 Sir, it is entirely inexcuseable that in our

13 presentation of papers no one went back to the case file

14 of Victoria which had been secured to absolutely check

15 whether the originals were in place and not lost or

16 destroyed as we understood and reported to you.

17 I accept our responsibility for this serious error and

18 I apologise for it.

19 A further difficulty I know was caused by the format

20 of printouts of the referral records that our case

21 database system provides, with no dates provided on them

22 other than the date of the opening of the case, which

23 clearly remains the same as the record has progressed.

24 Sir, the issues for us. The core issue in our

25 involvement with Victoria focuses on our response to her

29



1 referral to us from Haringey Social Services. As the

2 Inquiry has heard, the original phone referral did not

3 give a complete accurate view of Victoria's situation.

4 It was not presented as being the child protection

5 concerns. We do fully accept that there were sufficient

6 points made that should have alerted us to the

7 possibility of further concerns and they should have

8 been pursued promptly.

9 The allocation of the original referral itself was

10 delayed for a week by the community event at the Centre

11 for Children and Families as part of the school holiday

12 activity programme that was going on at the time. This

13 delay should not have happened. Once the case had been

14 allocated we did not clarify the information provided or

15 indeed the expectations of social services. An

16 open-ended request from them to inform them if we had

17 contact with the family was not sufficient but the

18 centre accepted the case.

19 The record thereafter is inadequate and incomplete

20 with no evidence of immediate action despite the

21 recognition of the urgency in the original indication.

22 Regrettably the only evidence we have is the undated

23 note on the file made by the practice manager, that she

24 was told in a phone call with Haringey Social Services

25 that the family had moved away, with no date recorded or

30



1 recalled.

2 There are serious issues here about the inadequate

3 maintenance of records and the supervision and

4 monitoring of the progress of cases and referrals, which

5 we recognise and we accept are our fault in this case.

6 It should not have been possible for this referral to

7 have been left without any follow-up apparently for so

8 long.

9 In such circumstances it is a mistake to seek to

10 focus only on those carrying responsibility on the front

11 line and their immediate manager, and I do not. The

12 wider context of the problem with referrals is relevant.

13 The demands on the centre meant that delays in offering

14 a service to family were not unexpected. The breakdown

15 in the formal process for referrals allowed them to be

16 made and accepted from phone calls with no documentation

17 or follow-up with or from social services. The NSPCC

18 area manager was actively trying to address these

19 problems. This should have led to intensifying the

20 support for the centre manager as well as taking more

21 assertive action with our partners. It was not

22 acceptable or appropriate to leave the centre manager to

23 deal with this.

24 The NSPCC London Regional Director also made

25 attempts to get recognition of the need for change,

31



1 particularly with reference to referrals, but this was

2 clearly not robust enough; and there was no intervention

3 from NSPCC senior management, as it is now evident that

4 there should have been. The concerns that were

5 recognised at the time about the centre should have been

6 shared at the most senior level between the NSPCC and

7 our partners.

8 Sir, we have taken the issues raised by this tragic

9 case for all the agencies involved very seriously. This

10 has been during a year when we had already begun the

11 process of restructuring our management arrangements and

12 reviewing all our services to children, young people and

13 their families. At every stage crucial lessons that

14 have come out of our review of Victoria's case have been

15 acted on as part of our wider review.

16 There are certain key lessons that I would like to

17 share with you now sir. Over the year we have aligned

18 all our service provision to our new full stop national

19 strategy and our standards, focusing the work at each of

20 our centres and projects and ensuring that they are

21 fully supported. We have established consistent

22 responsibilities across all our services, reducing the

23 layers of management and ensuring coherent

24 communications systems and processes. We no longer have

25 centres with such a broad remit or a majority of staff

32



1 on secondment and split site locations as at the

2 Tottenham Child and Family Centres.

3 We have clarified line management responsibility and

4 established clear accountability. The role of practice

5 manager, which had responsibility for both supervision

6 and direct casework, has been removed from our

7 structure. This role had the potential for confusion of

8 accountability and the monitoring of them.

9 We have examined our approach to local partnerships

10 and the service level agreements we negotiate for them.

11 We now emphasise the importance of being able to

12 challenge any issues of poor practice and make it quite

13 clear that we expect our partners to do the same towards

14 us. We accept that such challenges may put the

15 continuation of partnerships at risk. There must be no

16 delay in acting on any potentially unsafe practice.

17 The NSPCC is responsible as an independent agency

18 for its contribution to partnerships. Our independence

19 can give us the capacity to act firmly in the interests

20 of children. Where agreed systems and management

21 arrangements are not functioning properly we have now

22 clarified absolutely the need to challenge appropriately

23 at all levels.

24 Our database and case records are in the process of

25 being replaced by a new system to be fully live in

33



1 six months as part of our planned development of

2 information systems. I am sure you will agree this case

3 has demonstrated very clearly our urgent need for this

4 upgrade. In our new arrangement we are ensuring there

5 is a tight procedure for induction which gives better

6 support for staff joining the NSPCC in adapting to

7 a change in culture. This includes child protection

8 training for all family support workers and this must be

9 secured as part of any partnership arrangements as

10 a requirement for compliance.

11 The process for supervision, case reviews,

12 monitoring and management scrutiny have all been

13 reinforced. This includes precise attention to the

14 detail of records. NSPCC standards make it clear that

15 any evidence of concerns about practice must be acted on

16 promptly and following our reorganisation we have

17 confirmed our existing regular audits against our

18 principles and standards and we are reviewing our whole

19 quality assurance processes. Our inspection unit

20 continues to regularly inspect our front line services.

21 Finally, we have strengthened our case review

22 process for ACPC chapter 8 reviews and any external

23 inquiries. This now clearly emphasises the importance

24 of independent review and we are developing best

25 practice standards for this area of work.

34



1 The NSPCC recognises the crucial interrelationship

2 between the formal child protection system and services

3 providing family support. We have learned once more

4 from Victoria's case the importance of effective

5 interagency communication, a lesson we should never have

6 to learn again. It is my responsibility, together with

7 the leadership and management of all the other agencies

8 responsible for child protection, to ensure this. We

9 need to work effectively together to ensure that we can

10 support everyone in taking responsibility for the

11 protection of children.

12 As I have said, sir, I am very sorry that we let

13 Victoria down. I greatly regret the mistakes we made

14 and I know that everyone at the NSPCC shares with me my

15 absolute determination to learn from them. Thank you.

16 THE CHAIRMAN: Thank very much indeed Miss Marsh. I am

17 grateful to you. Now Ms Mayer on behalf of Ealing.

18 Good morning Ms Mayer. You have 30 minutes.

19 Closing submissions by MS MAYER

20 MS MAYER: Sir, although we have not attended

21 Hannnibal House daily we have followed the evidence

22 closely and between my solicitor, Ms Finlay, Director of

23 Children's Services and myself, read the majority of the

24 evidence of the Inquiry. I have also re-read the

25 opening speech of Mr Garnham and re-read the list of

35



1 potential criticisms submitted to the London Borough of

2 Ealing's witnesses.

3 Of the 13 alleged opportunities referred to by

4 Mr Garnham in his opening, opportunities to intervene in

5 a way which would have -- could have altered Victoria's

6 fate, the London Borough of Ealing is alleged to have

7 missed the first. In my final address I do not seek to

8 minimise the errors of the London Borough of Ealing.

9 Having re-read my own opening, it is clear that we

10 recognised even before the oral evidence commenced that

11 we failed to address Victoria's needs as an individual

12 and instead treated her as a part of Marie-Therese

13 Kouao's homelessness case. What her individual needs

14 were at the time, distinct and separate from those of

15 her so-called mother, and what statutory powers we had

16 to address those, you may have to decide. We clearly

17 took the view, based upon received impressions, that her

18 primary need was a place to live and food to eat until

19 Kouao's status in this country became clearer.

20 The purpose of that which I am about to say is not

21 to try and shirk our responsibility. We are aware that

22 the implications of Victoria's case are wide and lessons

23 will be learned from past errors through the

24 recommendations you make.

25 By the same token, it became clear in my submission

36



1 in the course of the evidence over the past 55 days that

2 so long as people like Marie-Therese Kouao are in our

3 midst conniving, manipulative and ultimately evil, there

4 will be continuing human tragedies. I say this not in

5 order to excuse the errors such as you may find in the

6 way the London Borough of Ealing conducted Victoria's

7 case. I say it not so as to suggest that because there

8 is such evil we should shy away from trying to eradicate

9 it by improving our systems. I say it because what

10 constructive criticisms you may make at the end of this

11 Inquiry, what measures you propose and what changes will

12 take place will have to take into account the

13 Marie-Therese Kouaos of this world, the fact that

14 children are silenced, the fact that social workers

15 cannot act as private detectives, that we have human

16 rights legislation, human rights convention and that we

17 have to balance finely our suspicions about particular

18 individuals as against the rights of an individual to

19 freedom and privacy.

20 We at the London Borough of Ealing have often

21 thought whether things might have been different had we

22 properly interviewed Victoria with the assistance of an

23 interpreter and asked her as to how she came to be here

24 and where she came from, how she felt in Nicoll Road,

25 how was her so-called mother treating her. Please bear

37



1 in mind that she could not have been seen on her own,

2 not without real child protection issues being evident.

3 On 24th July 1999 Victoria was admitted to North

4 Middlesex Hospital. It was her second admission to

5 hospital in London within two weeks. By this time, sir,

6 according to Carl Manning's evidence, he had started

7 hitting her and indeed according to him she was being

8 hit by Kouao. She had belt buckle marks on her, she was

9 incontinent of urine, she had burns on her head, she had

10 not been to school for months, and yet this child said

11 nothing. Her tormentors were not there. She was

12 temporarily protected, and liked. She was described as

13 very bright and lively and as a child who loved to talk.

14 She had a special French speaking nurse assigned to her

15 and yet she could not even bring herself to say that

16 Kouao was not her mother, let alone that she was subject

17 to abuse.

18 The question we ask ourselves is, knowing what we

19 now know about Victoria and Kouao, would an interview

20 with Victoria have made any of the social workers back

21 in April, May or June 1999 any the wiser about the truth

22 of Victoria's predicament? Sir if you wish to devise

23 protection for children like Victoria Climbie, bear in

24 mind the real tools of life in a busy London borough

25 such as the London Borough of Ealing.

38



1 You may remember the number of children related

2 referrals from my opening speech: 5,406 between April

3 1999 and March 2000; 6,131 between April 2000 and March

4 2001, and between April of last year to the end

5 of January this year in the period of the past 10 months

6 another 5,200. Of them many were asylum seekers or

7 some, like Marie-Therese Kouao, travellers under the

8 Treaty of Rome: people without documented history,

9 without language spoken or understood by the social

10 workers, without defined immigration status.

11 As you have heard from Julie Winter, the housing

12 officer who gave evidence, had Marie-Therese Kouao come

13 from Manchester, enquiries would have been easier to

14 make, cross references would have been possible.

15 Schools would have been contacted. Victoria not

16 attending school in Ealing would in due course have

17 raised questions.

18 The reality is that in respect of people who arrive

19 from abroad, schooling for their children, perhaps

20 wrongly, is not at the forefront of social workers'

21 immediate concerns. The children more often than not do

22 not speak English. They are sorting out their practical

23 accommodations. Accommodation, whether, where becomes

24 a priority rather than registering a child at one school

25 from which they might need to move on.

39



1 Matters of education and health are of course

2 a matter for those with parental responsibility for

3 a child and not for the local authority to organise

4 except in specific circumstances such as when a child is

5 the subject of a care order in favour of that authority.

6 Unless there is an immediate need for medical treatment,

7 the need to monitor registration with a GP is not

8 a priority, since finding accommodation often means

9 changing from one health practice to another. Perhaps

10 sir this is wrong. Perhaps this should be changed. If

11 so, the question is how.

12 The other important aspect of this particular case

13 was that Marie-Therese Kouao knew how to use the system

14 in the UK. She must have come here with a degree of

15 knowledge as to how to obtain help from the authorities.

16 It is quite possible, indeed it is likely, that the only

17 reason she brought Victoria over from the Ivory Coast

18 was so as to obtain financial assistance by way of

19 statutory benefits both in France and here. She most

20 probably knew, even if she was not intimately familiar

21 with the provisions of Section 17 of the Children Act,

22 that her chances of obtaining state assistance were much

23 better if she had a child with her.

24 The chronology of her brief time in Ealing

25 demonstrates that Kouao knew where to turn within

40



1 a couple of days of her arrival in Ealing. She arrived

2 in the UK on 24th April 1999, having reserved while

3 still in France seven days at a bed and breakfast place

4 in 23 Ford Road, Acton. On 26th April she went to the

5 homeless office in Acton and filled in the relevant

6 forms with the assistance of Julie Winter. She was told

7 that she failed the habitual residence test. She was

8 also told that an appointment was made for her on the

9 30th at the social services offices.

10 Kouao would not wait until the 30th. She returned

11 to social services offices on the 27th and the 28th and

12 indeed by the 28th the accommodation in Nicoll Road was

13 organised. It took in all four days to organise for

14 a woman who has not, as far as we know, visited London

15 before.

16 Furthermore, when the London Borough of Ealing

17 informed her that her allowance would end she went to

18 see solicitors. Quite a step I suggest for a newcomer

19 to this country. Within days the London Borough of

20 Ealing were threatened with a judicial review. This,

21 you will recall, was before the case of Queen on the

22 application of A and the London Borough of Lambeth,

23 which was decided at first instance by

24 Mr Justice Scott-Baker and later by the Court of Appeal.

25 No local authority wants to be judicially reviewed

41



1 and furthermore no local authority wants to spend money

2 on litigation when they have so many other deserving

3 causes. Thus we gave in to Marie-Therese Kouao, perhaps

4 unwisely, for another period of four weeks.

5 You asked our Director of Social Services

6 Norman Tutt, when he gave his evidence recently, what

7 would have happened if Marie-Therese Kouao and Victoria

8 walked into Ealing Social Services now. The answer was

9 that nowadays all homeless families with children are

10 referred to the new joint Housing and Social Services

11 team where the needs of children under Section 17 of the

12 Children Act are identified. Accommodation needs form

13 just one facet of the assessment. Children are not

14 however interviewed separately from parents and there is

15 no provision to do so.

16 In July 1999 we offered Marie-Therese Kouao a ticket

17 to return to France, since we took the view that the

18 needs of Victoria and Kouao would best be met in

19 a country where employment and financial security for

20 them were available. We await your conclusion on this

21 move on our part. As Mr Tutt correctly said, we had no

22 powers to escort her to the plane, but was our

23 assessment that erroneous? Did it not appear from the

24 information we heard that Victoria would have been

25 better off in France?

42



1 How are we to deal with similar predicaments in

2 future? These are not rhetorical questions. These are

3 matters which social workers in the London Borough of

4 Ealing have to consider on a daily basis. We are all

5 thankful for the fact that most people are not like

6 Marie-Therese Kouao but no doubt you will have your eye

7 on reality when you make recommendations for the future.

8 Sir, another issue which arose in the course of the

9 oral evidence in particular was inter-borough

10 communication in respect of mobility of children and

11 their families due to dearth of accommodation in London,

12 so that when Victoria and Kouao went to live in

13 Nicoll Road in the London Borough of Brent, they

14 remained the statutory responsibility of the London

15 Borough of Ealing. Brent were not notified, there was

16 neither a statutory provision requiring notification nor

17 was there a system in place to deal with this. As

18 Mr Tutt said, notified for what purpose? What do you do

19 with the information? Where do you keep it? What

20 happens when the family leaves and goes to a third local

21 authority?

22 Brent did of course notify Ealing of Victoria's

23 admission to the Central Middlesex Hospital in mid-July

24 after the case has been closed to Ealing for one week.

25 They were dealing with a child protection matter and

43



1 quite properly approached us for further information.

2 The next day, on 15th July, they notified the Ealing

3 social worker that the matter was no longer one of child

4 protection and that Victoria had been returned to the

5 care of Kouao. In fact, the social worker was told the

6 suspected non-accidental injury were marks of scabies.

7 She had no reason to disbelieve this medical diagnosis.

8 You have heard from Eddie Armstrong, then employed

9 by Brent, that he referred Victoria's case to Ealing

10 following her discharge from hospital. It is my

11 submission that on the preponderance of the evidence

12 before you, you are compelled to come to the conclusion

13 that Eddie Armstrong was not truthful when he told you

14 about the way he dealt with Victoria's case when she was

15 discharged from hospital. There is no record of any

16 communication with Godfrey Victor or John Skinner about

17 this case. Indeed it would be extraordinary if

18 Mr Armstrong rang the Assistant Director of Social

19 Services to rerefer a case to Ealing.

20 There is no record on either Ealing files or indeed

21 in Brent files about the case being transferred back to

22 Ealing and no record either of information about the

23 admission to Central Middlesex Hospital being faxed to

24 Ealing. Mr Armstrong said that parts of the file of

25 Brent must have been removed. He did not explain how

44



1 and by whom. He could not explain why all this

2 information was missing from the Ealing files too. The

3 fact is that the case was never transferred back to

4 Ealing.

5 Is there a better way to communicate between local

6 authorities in instances such as this? Is there no

7 statistic -- there is no statutory provision dealing

8 with this. It should be borne in mind that the child

9 protection investigation in Brent indicated rightly or

10 wrongly no child protection concerns. Should any of

11 this have been communicated to Ealing considering they

12 closed their case on 7th July 1999?

13 Sir, finally, a microscopic examination has been

14 conducted by this Inquiry for all aspects of structure,

15 methods of work, file keeping and tracking,

16 interpersonal relationships and life generally in the

17 departments of social services in the London Borough of

18 Ealing between April and July 1999.

19 I said in my opening, and therefore reiterate just

20 briefly, that London Borough of Ealing had undergone

21 a major reorganisation in December 1998. The service is

22 constantly improving. Changes are being implemented as

23 I speak. You heard about those from Norman Tutt when he

24 gave his oral evidence on 23rd January this year and

25 I shall not reiterate them. What he said to you was

45



1 that changes and improvement are a process and do not

2 happen overnight.

3 Lessons have been learned from the tragic death of

4 Victoria Climbie and those who worked at the department

5 will never forget the events concerning the case. For

6 those who have been employed after July 1999 there is

7 continuing vigilance of the London Borough of Ealing,

8 continued awareness of improving the service within the

9 limitations which exist, bearing in mind that no system

10 is infallible and human error cannot be totally

11 eradicated.

12 I end by reminding you of the words of Norman Tutt

13 on 23rd January this year, which is on page 44 of the

14 transcript:

15 "We have not reached the end yet. I mean I and my

16 staff are very actively pursuing higher standards all

17 the time. There is no perfection in social services.

18 You can always do something better."

19 Thank you sir.

20 THE CHAIRMAN: Thank you, I am very grateful to you

21 Ms Mayer. Mr Mason, ladies and gentlemen, I think that

22 this would be a convenient time to have a break before

23 we move on. We will break until 20 past 11.

24 (11.05 am)

25 (A short break)

46



1 (11.20 am)

2 THE CHAIRMAN: Thank you very much indeed. Now Mr Mason.

3 Closing submissions by MR MASON

4 MR MASON: Thank you sir. I would like to start this

5 closing statement by making a couple of points on behalf

6 of all the NHS bodies that I represent at this Inquiry.

7 The NHS as a whole, as well as the North West London

8 Hospitals NHS Trust, North Middlesex University

9 Hospitals NHS Trust, Brent and Harrow Health Authority,

10 Barnet, Enfield and Haringey Health Authority and

11 Haringey Primary Care Trust, together with all the

12 current and former NHS employees who gave evidence to

13 the Inquiry, have accepted the importance of this

14 Inquiry. We believe that we have owed a duty both to

15 you and to Mr and Mrs Climbie to do everything that we

16 can to help the Inquiry fulfil its terms of reference.

17 The report of the Commission of Inquiry into the

18 circumstances surrounding the death of Kimberley Carlile

19 states:

20 "Everyone who came before us accepted the overriding

21 interest of the Inquiry - to promote in every possible

22 way the optimum methods in child protection. We think

23 their unstinting efforts overall to relegate personal

24 interests to a secondary place has helped us to make

25 recommendations which we hope will keep the incidence of

47



1 death and serious harm to children from abuse by their

2 parents to an irreducible minimum."

3 I hope, sir, that you and your assessors reach the

4 same conclusion about our approach to this Inquiry,

5 because that has been our intention. Sadly the hope

6 expressed from the end of my quote remains unfulfilled.

7 The goal of minimising the incidence of death and

8 serious harm to children from abuse has not yet been

9 achieved, 15 years after Kimberley Carlile's death.

10 The second point that I would like to make at this

11 stage on behalf of the NHS relates to resources. NHS

12 bodies like other public authorities represented here

13 have to balance their resources to meet sometimes

14 competing demands on their services. That means that

15 they are not always able to do everything that they

16 would like to be able to do. The NHS accepts that this

17 is not a valid excuse for providing a sub-standard or

18 unsafe service. However, sir, you may feel that there

19 are occasions when overwork or lack of support may

20 excuse the conduct of an individual, even if not the

21 organisation as a whole.

22 I would now turn to the involvement of Central

23 Middlesex Hospital in Victoria's care from the 14th to

24 15th July 1999. There are a number of different stages

25 in Victoria's care that I want to address as follows.

48



1 1, the initial attendance in the A&E department on

2 14th July. 2, the Paediatric Department involvement the

3 same afternoon. 3, Dr Schwartz and her ward round. 4,

4 discharge and follow-up.

5 THE CHAIRMAN: Could you go a touch slower.

6 MR MASON: 1, attendance in the A&E department. The Inquiry

7 has heard evidence from a number of A&E staff. Amongst

8 the witnesses giving evidence was Dr Rhys Beynon, then

9 senior house officer in the department. He may not have

10 been able to recall seeing the A&E department child

11 protection policy. However, he did remember having

12 received training from Dr Schwartz. As Dr Schwartz said

13 in her oral evidence, Dr Beynon did everything required

14 of him in the protocol which is after all what matters

15 at the end of the day.

16 One issue that has been raised in respect of this

17 attendance is that the attendant A&E notes do not

18 contain the record of Victoria's GP or school. This is

19 perhaps not surprising when a child, like Victoria, is

20 brought in by someone who does not know the child very

21 well.

22 Victoria's address is recorded in the paediatric

23 notes made later that day. However, this has

24 highlighted a deficiency in the Trust's A&E procedures

25 in that without details of either a GP or school nurse

49



1 there was no flow of information from the A&E department

2 to community health services in children of school age.

3 That loophole has now been closed, as described in

4 evidence by Alistair Stinson, Assistant Director of

5 Nursing for Accident and Emergency for the Trust, and

6 Valerie Tyrell, specialist nurse for child protection

7 for Brent employed by Parkside Health Trust.

8 2, Paediatric Department involvement. This started

9 when Dr Beynon called Dr Ajayi-Obe. Dr Ajayi-Obe was

10 the locum registrar in paediatrics at the time. She

11 came and saw Victoria who at that time was with

12 Avril Cameron, and took a very detailed history and

13 examined Victoria thoroughly. From the history and her

14 findings she had real concerns about the possibility of

15 child abuse. She spoke to Dr Schwartz, although

16 unfortunately we have not been able to ascertain exactly

17 when this occurred, and raised the alarm with Brent

18 Social Services who in turn involved the police.

19 One issue that was explored by Mr Garnham in some

20 detail was the question of whether or not Victoria had

21 extensive bruising at the time of that examination.

22 This was certainly a concern that Mrs Cameron had had.

23 Indeed, Dr Ajayi-Obe's own note under the heading

24 "Presented Complaint" states: "complaining of multiple

25 bruises and scars all over body". The reference to

50



1 "complaining of" is of course a reference to what

2 Mrs Cameron said, not Victoria herself.

3 However, this reference to multiple bruising is not

4 supported by Dr Ajayi-Obe's note of her examination. In

5 her medical report sent to social services, Dr Ajayi-Obe

6 wrote:

7 "I charted the bruises on the body charts on that

8 same document under the heading of 'Physical

9 Examination'. There are references to scars and marks

10 but not bruises."

11 In oral evidence whilst being taken through the body

12 maps the only bruise that Dr Ajayi-Obe identified was

13 a small bruise on Victoria's right-hand. There was

14 a mark on Victoria's right cheek that Dr Ajayi-Obe

15 described as a bruise, a graze, and there were some

16 marks that she could not now identify. In answer to

17 questions I put to her, Dr Ajayi-Obe thought it was

18 possible that she did not refer to bruising on the

19 medical examination form because she did not think at

20 the time that there was any clinically significant

21 bruising.

22 Another issue that has arisen is that of the deep

23 cuts noted by Dr Ajayi-Obe, although deep in this

24 context is a subjective term. Some of the cuts were

25 infected. Dr Ajayi-Obe thought it was possible that