Archived Transcript for 19 Febuary 2002: Pages 101 to 142


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1 who had the common sense to see and act on the evidence

2 of cruelty and neglect rather than just talk about it

3 and they were child centred enough to question the adult

4 version and to look for the inconsistencies.

5 It is said time and time again that the business of

6 child protection is the business of the whole community

7 and not just the professionals. Well in this case the

8 most striking conclusion to emerge is that the

9 professionals systematically ignored the evidence of

10 child abuse which was glaringly obvious to those who

11 stood outside of the system.

12 Thank you sir.

13 THE CHAIRMAN: Thank you very much indeed Ms Boye, I am

14 grateful to you. Ladies and gentlemen we will now

15 adjourn until 20 to 2.

16 MS BOYE: Sorry, before you stop can I just say I have

17 forgotten I was asked to mention by Mr and Mrs Climbie

18 that there will be a vigil on the anniversary of

19 Victoria's death which is on 25th February at 1 pm

20 outside Haringey Civic Centre and they have asked that

21 everybody who has attended this Inquiry, all members of

22 the public and indeed all lawyers regardless of whom

23 they represent, attend to lay flowers at 1 pm on the

24 25th.

25 THE CHAIRMAN: Thank you Ms Boye. Ladies and gentlemen, we

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1 will adjourn now until 20 minutes to 2.

2 (12.40 pm)

3 (The short adjournment)

4 (1.40 pm)

5 THE CHAIRMAN: Mr Garnham. I would like to remind you

6 Mr Garnham you also have an hour.

7 Closing submissions by MR GARNHAM

8 MR GARNHAM: Thank you sir. 55 days of evidence.

9 155 witnesses giving oral testimony. More than 40,000

10 questions from this side of the room alone. After all

11 of that, how much closer have we come to understanding

12 how it was that Victoria Climbie died in the

13 circumstances she did, because it was to answer that

14 question that this Inquiry was established.

15 Before we started we knew the immediate cause of

16 death, that much was clear from the post mortem. We

17 knew who killed her and how they killed her. That much

18 was established at the criminal trial. But what we did

19 not know was why no one intervened to stop her killing.

20 In order to address that question properly it is

21 necessary first to dispose of three arguments that seem

22 to us entirely specious but which have been raised

23 during the course of this Inquiry. In our submission

24 none of these arguments withstand analysis and none of

25 them should be allowed to distract the Inquiry as it

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1 considers the conclusions that should now be drawn.

2 The first is a suggestion that it was all in some

3 way the fault of Mr and Mrs Climbie. They should not

4 have let Kouao bring Victoria to Europe. That in our

5 submission is nonsense. It fails completely to

6 understand the culture from which Victoria came and it

7 attributes to caring, hardworking people of a developing

8 country the luxury of choice enjoyed by the middle

9 classes of middle England.

10 However Kouao presented when she gave evidence to

11 this Inquiry, she had persuaded all of the professionals

12 with whom she came into contact in this country that she

13 was both genuine and reasonable. There are no grounds

14 for concluding that she was any less believable when she

15 visited the Ivory Coast. It is also specious in the

16 present context because the reasons that brought

17 Victoria to England are and should be wholly irrelevant

18 to this Inquiry.

19 In an Inquiry that of necessity has concentrated on

20 errors and omissions, poor practice and lack of

21 foresight, it is important to understand the greatest

22 asset of these public services. They were provided to

23 Victoria without charge on the basis of her presence in

24 this country and her need. They were dependent neither

25 on citizenship nor bank balance. When Victoria was

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1 taken to the Central Middlesex Hospital by Avril Cameron

2 she was examined, treated and cared for without charge

3 and without inquiry as to her entitlement to admission.

4 In very many countries that would not be true. Whatever

5 other excuses or explanations were offered by the

6 agencies involved in the case, no one could ever suggest

7 that a lower standard of care was merited because

8 Victoria or her family could not meet the bill or had no

9 right to expect services.

10 Accordingly, the circumstances that brought Victoria

11 to Britain are completely immaterial to our Inquiry.

12 The second argument that has caused occasional

13 distraction is the suggestion that we are wrong to be so

14 critical of these public services because Victoria was

15 murdered by two sick individuals. The theory appears to

16 be that because some individual evil intervened the

17 blame to be directed against the agencies is somehow

18 reduced. That argument seems to us fundamentally

19 misconceived.

20 If child protection is ever to be a reality, the

21 fact that adults abuse children has to be a given. It

22 alone can seldom excuse a failure to act. It is simply

23 not open to agencies involved in an inquiry like this to

24 contend that they could never be expected to anticipate

25 the possibility that Victoria would be abused. Child

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1 abuse happens. The actions or inaction of the agencies

2 have to be tested against the evidence of maltreatment

3 that was available to them. If there was evidence

4 suggestive of abuse it is wholly irrelevant that others

5 were responsible for it.

6 In cross-examining Drs Schwartz and Rossiter we

7 suggested that child abuse could and should be treated

8 like any other disease process. There is a history to

9 be attained, an examination to be conducted,

10 investigations to be carried out, differential diagnoses

11 to be reached, treatment to be applied and steps to be

12 taken to prevent reoccurence. Both doctors agreed with

13 that analysis.

14 It seems to us that the parallel between child abuse

15 and any other disease process is valuable because it

16 avoids preoccupation with the fact that the cause of the

17 condition is human agency, and it recognises instead

18 that if the child is to be protected, that cause, like

19 any other, has to be identified, controlled and dealt

20 with.

21 Precisely the same considerations apply to the

22 police and social services. The involvement of a human

23 agency will be a consideration for social services, who

24 may have duties to other members of the family, and to

25 the police, who may have an offence to investigate. But

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1 just as these agencies would seek to intervene if they

2 were facing a natural disaster, so they must intervene

3 when the disaster facing a child is one created by her

4 carers. Considerations about the need for prosecution

5 or the rights of others must give way to protecting the

6 child if there is a significant threat to the child.

7 What follows from that it seems to us is that it is

8 critical for all three services to talk to the child

9 whenever that is practicable. So often it is only by

10 that elementary step that it is possible to get beyond

11 the picture painted by the abuser.

12 What has emerged during the course of this Inquiry

13 is an astonishing reluctance on the part of members of

14 all of the agencies involved to speak to Victoria during

15 the process of assessing whether she had been abused or

16 was at risk of being abused. Neither Dr Rossiter nor

17 anyone else at the NMH took a proper history from

18 Victoria for fear of being accused of putting ideas in

19 her head. Brent Police Child Protection Team did not

20 interview Victoria at the Central Middlesex for fear of

21 tainting the evidence that might be given at any

22 subsequent trial. You will recall in that context the

23 evidence we heard from Deputy Assistant

24 Commissioner Howlett who suggested that that approach

25 was flawed.

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1 Lisa Arthurworrey told us that on the occasions when

2 she saw Victoria alone she spent a total of about half

3 an hour talking to her, contenting herself otherwise

4 with speaking to Kouao, the person who if Victoria was

5 being maltreated was almost bound to be involved in that

6 maltreatment.

7 Accordingly, sir, it is our submission that you

8 should treat with the greatest caution any suggestion

9 that the agencies are less to blame because Kouao and

10 Manning did the killing. Of course they did but that

11 does not assist the agencies one jot as they attempt to

12 explain their conduct.

13 The third specious argument we would invite you to

14 dismiss first surfaced in the opening statement of some

15 of the interested parties. It is to the effect that we

16 have set too high a standard, that we have to be more

17 realistic, resources are not infinite and the agencies

18 have other considerations which might reasonably be

19 regarded as more important at a particular time.

20 Whether it is education for Haringey or

21 counter-terrorism for the police, it has been suggested

22 that it is understandable that resources and management

23 attention would at particular times be directed at

24 concerns other than child protection.

25 We would invite you to reject that argument too.

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1 First, we say it is not good enough to plead a need to

2 concentrate on one aspect of performance. One of the

3 hallmarks of good management is the ability to address

4 many problems at once and you sir are entitled to test

5 the agencies involved in Victoria's case against the

6 standards of best management. It is not sufficient for

7 any of these agencies to behave as one witness to this

8 Inquiry described it like an under 10 football team with

9 every player rushing to one part of the pitch because

10 that was where the ball was last kicked.

11 Second, we have been told repeatedly that identified

12 problems are not the result of inadequate resources.

13 They are instead, we are told, the results of individual

14 error. That may be right but it does not seem to us

15 that it goes far enough. There may be much to be said

16 for the view that cars and buildings and fax machines

17 are no more than tools to help people do their jobs, but

18 that being so, sir, your attention ought first to be

19 directed to the quality of the staff appointed, the

20 adequacy of their training and the intelligence of their

21 supervision and management.

22 These above all are the fundamentals that competent

23 management strives to preserve even when times are hard

24 and resources tight. And if they fail to do so then

25 they are worthy of censure even if there are competing

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1 concerns that seem to the managers more important at the

2 time.

3 The danger of arguments such as the three with which

4 I have just dealt is that they may distract the Inquiry

5 from one of the basic questions it must address. What

6 could and should the agencies concerned have done to

7 save Victoria? That was the question we posed in

8 opening this Inquiry when we identified 12 principal

9 occasions when it seemed to us that action could and

10 perhaps should have been taken.

11 It is to that question and those occasions that we

12 now turn. In doing so we do not suggest that they are

13 the only matters with which you will be concerned but

14 they seem to us to have survived the evidence and to

15 continue to provide a useful starting point for an

16 analysis of Victoria's case.

17 In the light of the evidence, however, it is

18 necessary for us to refine our analysis somewhat. As we

19 anticipated, the chance presented by the admission to

20 the North Middlesex Hospital was multi-faceted. The

21 evidence suggests that an even wider group of those

22 involved had missed chances to intervene than we had

23 originally thought.

24 We identified the visit to 267 Somerset Gardens on

25 16th August as a missed opportunity. To that we would

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1 now add for your consideration the visit on

2 28th October.

3 We do not seek to present to the Inquiry a settled

4 view on these missed chances, some of which require the

5 resolution of direct conflicts of evidence.

6 As Counsel to this Inquiry our principal role has

7 been to identify the issues to be addressed and to

8 adduce the evidence necessary to resolve them. We do

9 not believe it to be our function in respect of areas of

10 dispute now to urge the adoption of any particular

11 conclusion.

12 In our written submissions which we made available

13 to the interested parties on Friday, and which are

14 available today to anyone who wants to see them, we set

15 out to identify the key evidence relevant to the

16 12 missed chances. We also sought to analyse that

17 evidence, not with a view to persuading you as to

18 a particular conclusion you should reach, sir, but to

19 identify the questions you might wish to consider as you

20 did so.

21 Today we seek to summarise that analysis. Put

22 shortly, we would submit that there is a wealth of

23 evidence upon which you could properly conclude that

24 even given the actions of Kouao and Manning, Victoria's

25 death was not inevitable. There is evidence which

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1 supports the view that the agencies could have

2 intervened to save her. What you make of that evidence,

3 sir, is a matter for you.

4 This morning Miss Lawson decided to criticise the

5 approach that this Inquiry has taken to the eliciting of

6 evidence from witnesses. It would appear that Haringey

7 would have preferred the Inquiry to have been conducted

8 without criticism of their managers and staff because it

9 was argued such criticism damages morale. They would

10 also have preferred us to avoid creating a climate of

11 suspicion and mistrust between members and officers. We

12 were told that it is to be regretted that those staff

13 "actually involved in doing the job at all levels have

14 lost the opportunity to offer their reflections in an

15 open minded atmosphere".

16 It does not entirely surprise us that Haringey would

17 have preferred such an approach. But for our part we

18 doubt whether, had it been adopted, it would have come

19 close to providing an understanding of how and why

20 things went wrong whilst Victoria's case was being

21 handled by Haringey.

22 In making her submissions in this regard Miss Lawson

23 purported to speak on behalf of directors of other

24 social services who might fear that other tragedies such

25 as the one that befell Victoria could occur on their

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1 patch. For our part we suspect that directors of social

2 services outside Haringey might be a little more robust

3 than that, welcoming vigorous inquiry that dares to

4 expose errors of practice that put children at risk.

5 I turn now to the first of our 12 missed

6 opportunities, the visits by Kouao and Victoria to

7 Ealing Social Services during the spring of 1999.

8 Between 26th April 1999 and 7th July of that year Kouao

9 visited Ealing Social Services on about 14 occasions.

10 She was accompanied by Victoria on at least seven of

11 those visits. We do not know precisely when the

12 physical abuse of Victoria started but given the

13 evidence of Mrs Ackah it would be a reasonable

14 conclusion that it was happening at some stage during

15 this period.

16 We heard from a number of Ealing witnesses about

17 Victoria's presentation and about concerns that Ealing

18 staff had about her relationship with Kouao. Perhaps

19 the most striking description was that of Deborah Gaunt.

20 Whilst Kouao was well presented, Miss Gaunt thought

21 Victoria looked like an Action Aid poster. It is also

22 noteworthy that despite their rather limited dealings

23 with Kouao and Victoria, staff at Ealing suggest that

24 they have clear recollections of the two of them. You

25 may wish to consider, sir, why that should be so if this

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1 was just one of many housing cases with which Ealing

2 were bombarded at the time.

3 Staff had discussions amongst themselves about

4 Victoria and Kouao but that did not seem to prompt any

5 meaningful assessment of Victoria's needs. It is

6 perhaps the absence of any real assessment that is the

7 most striking feature of this period of Victoria's life.

8 Pamela Fortune, who became the allocated social worker

9 on 30th June 1999, said that whilst she had spoken to

10 Victoria, no proper assessment of her needs was ever

11 completed.

12 The assessment form for the meeting of 17th June is

13 telling. The box which is supposed to include details

14 of Victoria's education instead includes details about

15 Kouao's education. The box for conclusions and

16 recommendations has been left blank as has that for

17 management decisions. The form states that a home visit

18 should be included or considered as part of the

19 assessment. No such visit took place, nor it seems was

20 it ever contemplated.

21 These were early days in Victoria's life in Britain.

22 There is no doubt that this was one of hundreds of cases

23 with similar presenting features and it is likely that

24 the abuse of Victoria was not as severe then as it was

25 to become. The shame nonetheless is that the

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1 opportunity was not taken properly to record what was

2 known and to conduct the sort of assessment that would

3 have been ordinarily required.

4 Brent's social services involvement with Victoria

5 began with a telephone call from Esther Ackah, a distant

6 relation of Kouao's. Mrs Ackah said that during this

7 call she reported that she thought Victoria's life was

8 in danger. This was not recorded by Samantha Hunt and

9 it will be a matter for you to decide, sir, whether you

10 find that Mrs Ackah's recollection is accurate in this

11 regard.

12 But whether or not an assertion to that effect was

13 made, witnesses from Brent were clear that the referral

14 as recorded by Miss Hunt should have prompted an

15 immediate child protection investigation. Understanding

16 exactly why it did not do so is far from

17 straightforward.

18 Edward Armstrong asserted that his team never

19 received the 18th June referral. Instead he said they

20 were dealing with a child in need referral made three

21 days later. It might be thought that there is some

22 support for this assertion from the evidence of

23 Mrs Ackah, who was clear that she made two telephone

24 calls to social services, one on 18th June and one a few

25 days later. However, the purpose of the second call was

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1 to chase up the first referral and would not be expected

2 to generate a separate referral form. Furthermore,

3 there is no reference to this 21st June referral on the

4 file. Mr Armstrong said that a match was made between

5 the referral his team was dealing with and the referral

6 that came in on 14th July from Central Middlesex

7 Hospital. Printouts produced by Ealing suggest that the

8 only match that was made in fact was with the 18th June

9 referral.

10 A visit was made to Nicoll Road by Monica Bridgeman

11 and Lori Hobbs at about 3 pm on 14th July. They found

12 no one at home. In evidence Miss Bridgeman could not

13 recall much about the referral, save that it had

14 something to do with a child's well-being and

15 accommodation. She was clear that had she seen a copy

16 of Samantha Hunt's referral before going out on the

17 visit, she would have argued strongly that this was

18 a case for the Child Protection Team. Certainly one

19 might reasonably have expected a rather different

20 approach to the visit to Nicoll Road.

21 The Inquiry heard evidence about the state of

22 administrative chaos in Brent at the time, and sir you

23 may take the view that this provided fertile ground for

24 a child protection referral to be mishandled.

25 Whilst human error is a fact of life, such error is

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1 less likely to occur when there are robust systems in

2 place.

3 In looking at whether events in Brent constitute

4 a missed opportunity it is worth considering what might

5 have happened if a child protection investigation had

6 taken place. By this time the evidence from Mrs Ackah

7 suggests that Kouao's abuse of Victoria had begun.

8 Although it is a matter of speculation precisely what

9 a more thorough assessment of Victoria's situation would

10 have revealed, it would not be unreasonable to have

11 expected some action in respect of Victoria's schooling

12 and some assessment of her general needs.

13 That just might have meant that thereafter there was

14 someone in authority keeping a look out for this little

15 girl.

16 When considering whether the admission to the

17 Central Middlesex Hospital constituted a missed

18 opportunity, it is worth recalling that it came about

19 because Avril Cameron had felt sufficiently concerned

20 about Victoria to take her to hospital. The question

21 that arises is whether if there was enough to worry her,

22 should there have been enough to worry the

23 professionals?

24 On admission Victoria was examined by

25 Dr Rhys Beynon, an SHO in Accident and Emergency. He

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1 said he would have noted anything he saw which

2 contradicted what he had been told by Avril Cameron. He

3 noted nothing of the sort. He referred Victoria to

4 Dr Ajayi-Obe who felt that scabies could not explain all

5 the marks on her body. Her diagnosis was of

6 non-accidental injury.

7 It would seem from the contemporaneous material such

8 as it is that when Dr Schwartz examined Victoria later

9 that day she came to a very different conclusion, namely

10 that Victoria was suffering from scabies and that that

11 explained the marks on her body.

12 In her evidence, however, Dr Schwartz said that she

13 had concerns beyond the scabies. Although she did not

14 think that there was physical abuse, she thought that

15 there might be other child protection issues. Although

16 it is self-evidently sir a matter for you, we would

17 submit that there is little evidence to suggest that

18 a diagnosis of scabies was wrong. The trouble with

19 Dr Schwartz's opinion as reported to others was not the

20 inclusion of scabies but the exclusion of anything else.

21 When Dr Dempster wrote to social services the

22 following day, not only did she say that all Victoria's

23 scratches were due to scabies, but also that there was

24 no longer a child protection issue.

25 It seems to us that the explanation for that

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1 inadequate description of Victoria's condition had two

2 possible causes. Either communication between

3 Drs Schwartz and Dempster was poor or Dr Schwartz's

4 examination was flawed in concentrating on the diagnosis

5 of scabies to the exclusion of everything else.

6 No one at the hospital ever challenged that

7 conclusion or attempted to reconcile it with information

8 coming from Miss Cameron. Brent CPT which had been

9 contacted the night before abandoned their investigation

10 because of it. Brent Social Services similarly regarded

11 the Schwartz diagnosis as the end of the matter. Once

12 Dr Schwartz had reached her conclusion, it was as if the

13 critical faculties of all the other professionals were

14 simply suspended.

15 This deference to the consultant is disturbing.

16 Dr Schwartz said that she neither wanted it nor expected

17 it. But if, as seems to be the case, it is a reality in

18 child protection work, it is something the Inquiry will

19 need to address head on. It may be that the guiding

20 principle should be respectful uncertainty rather than

21 doctor knows best.

22 I turn next to the visit of Kouao to Ealing's Acton

23 area office on 15th July.

24 There had been communication between Brent's

25 Elzanne Smit and Ealing's Pamela Fortune prior to this

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1 visit. It is unclear precisely what information was

2 exchanged but Pamela Fortune believes that she would

3 have passed on more than the fact that the case had been

4 closed by Ealing. She agreed, however, that she did not

5 pass on the concerns about the differences in appearance

6 between Kouao and Victoria and the lack of

7 a mother/daughter relationship.

8 Also it would seem that she did not pass on the

9 problems that she had experienced in engaging Kouao in

10 the assessment process on 17th June.

11 She agreed to pass on the assessment that Ealing had

12 done subject to the approval of her manager. This

13 turned out to be nothing more than a letter sent to

14 Kouao on 30th June explaining why Ealing could no longer

15 fund her accommodation.

16 When Kouao turned up at Ealing's offices on

17 15th July, Pamela Fortune should have had a basic grasp

18 of the situation from both the Brent and the Ealing

19 perspectives, and from personal experience of Kouao's

20 difficult behaviour at what was intended to be an

21 assessment on 17th June.

22 Now on top of this she was aware from Elzanne Smit

23 that there had been child protection concerns and that

24 apparently one paediatrician had thought it was a case

25 of non-accidental injury. You may feel, sir, that the

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1 alarm bells should have been ringing.

2 Pamela Fortune was told by Bernadette Wilkin that

3 Kouao had left Victoria unattended in the reception for

4 about an hour. Miss Fortune said in evidence that she

5 felt that she could not do much about this as staff were

6 unclear how long she had been left and Kouao said that

7 she had left Victoria for about five minutes. There

8 seems to have been no attempt to resolve those

9 differences. It is at least arguable that

10 Miss Fortune's response showed a greater preoccupation

11 with the possible health hazard to staff from scabies

12 than with Victoria's needs.

13 Kouao was referred back to Brent.

14 In her evidence Miss Fortune was clear that by this

15 time she believed this was no longer a Brent case and

16 that her responsibility was ended. It would seem that

17 a valuable opportunity to pool the information held by

18 Ealing and Brent was lost.

19 Victoria was admitted to the North Middlesex

20 Hospital on 24th June, after Kouao brought her into the

21 Accident and Emergency department suffering from scalds

22 to her head and face. Whilst she was in hospital she

23 was safe. She was seen by many doctors and nurses.

24 Many told you, sir, that they had concerns about the way

25 in which her burns had been sustained, about the

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1 numerous other marks on her body, and about her

2 relationship with Kouao and Manning when they came to

3 visit.

4 Victoria was discharged 13 days later. When she

5 left there was no arrangements for her to be seen again

6 by doctors or health visitors. Social services did not

7 believe that there was anything serious to be worried

8 about so she went back to Kouao and Manning.

9 In opening this Inquiry we suggested that it would

10 be necessary to consider how effectively the hospital

11 used the information and the intelligence gleaned by its

12 staff. After much evidence on that topic that issue

13 remains but the question now goes deeper. You will

14 wish, sir, to reflect on the question whether concerns

15 expressed by nursing staff in evidence represent their

16 genuine thoughts at the time or whether they merely

17 reflect their horror about what they learned

18 subsequently.

19 In addition, if their evidence as to what they were

20 thinking at the time is accurate, you will need to

21 consider how well they recorded that information and how

22 competently the hospital used it in forming a composite

23 picture of Victoria.

24 Finally and perhaps most critically you will need to

25 consider how effectively the hospital passed on that

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1 information to social services.

2 If there are deficiencies in the way information was

3 passed to Haringey by the hospital, one way in which

4 those deficiencies might have been corrected would have

5 been through the inquiries made by social services and

6 the police prior to Victoria being discharged. You

7 heard from both Lisa Arthurworrey and Karen Jones about

8 the meeting with Kouao on 5th August and with Victoria

9 on the 6th. The question that arises is easier to pose

10 than to answer: To what extent did Miss Arthurworrey

11 and Ms Jones elicit sufficient information about Kouao

12 and Victoria to enable them to form a competent judgment

13 about the safety of Victoria's discharge?

14 I turn next to the referral to the Tottenham Child

15 and Family Centre.

16 Before a full, accurate assessment of the response

17 of that centre to the referral it received on 5th August

18 can be made, it is necessary first to consider why the

19 referral was made and of what it consisted. That

20 however is easier said than done. The principal

21 difficulty is that Barry Almedia, the social worker at

22 the North Tottenham District Office who made the

23 referral, was far from clear as to why he did so and

24 what he said.

25 A number of possibilities were canvassed during the

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1 course of his evidence without any clear picture

2 emerging. Mr Almedia was at least sufficiently frank to

3 admit that he did not really think through the referral

4 before he made it, or consider whether it was an

5 appropriate thing to do at the time.

6 The fact that the referral may have been confused

7 and inappropriate does not of itself explain the failure

8 of the centre to respond to it. Sylvia Henry said that

9 she realised as soon as the case was allocated to her on

10 13th August that further inquiries needed to be made of

11 the referrer and it was for this reason that she called

12 Barry Almedia. It was during the course of that call

13 she says that she was told that Victoria and Kouao had

14 left the borough and the case was closed.

15 The question of when that call was made occupied us

16 for some time. It would seem to us, sir, that there are

17 only four possible conclusions from which you can

18 choose. They are as follows.

19 1. Ms Henry made the call promptly after being

20 allocated the case and was misled by someone at North

21 Tottenham.

22 2. Ms Henry did not make the call until after it

23 was suspected by North Tottenham that Kouao and Victoria

24 had left, in other words she did nothing with the

25 referral for at least four months.

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1 3. Ms Henry was told something entirely different

2 to that which she wrote down on her file, namely that

3 Victoria and Kouao had left and the case was closed.

4 4. Ms Henry wrote the entry on the file after

5 Victoria's death in an effort to explain why no action

6 had been taken on a referral that had been allocated to

7 her.

8 The question of whether the centre could or should

9 have done more to prevent Victoria's death will depend

10 in large measure on which of those conclusions you

11 prefer, sir.

12 Victoria had the misfortune to be admitted to the

13 North Middlesex Hospital at a time when the post of

14 liaison health visitor with responsibility for A&E was

15 vacant. It will be a matter for the Inquiry to consider

16 whether the ad hoc rota system that had been put in

17 place to fill this gap was sufficient to provide an

18 adequate service to vulnerable children such as

19 Victoria.

20 The answer to that question may be dependent in

21 large measure on the Inquiry's resolution of one of the

22 starkest conflicts of evidence we heard. Rachel Crowe

23 said she referred Victoria's case to Launa Brown at the

24 end of July. Launa Brown said that she did not.

25 Rachel Crowe said that she sent Victoria's A&E admission

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1 card together with her handwritten notes to Launa Brown

2 at the Lordship Lane clinic. Launa Brown said that they

3 were never received.

4 Unfortunately neither Miss Brown nor Miss Crowe felt

5 inclined during the course of their evidence to abandon

6 their preferred version of events. Elizabeth Fletcher,

7 on whose advice Rachel Crowe said she was acting when

8 she made the referral to Launa Brown, was unable to

9 provide any assistance on the matter and she could not

10 remember whether or not she had any involvement in

11 Victoria's case.

12 It may be however that this is a conflict that the

13 Inquiry feels that it does not need to resolve. Whether

14 the failure lies with Rachel Crowe in failing to make

15 the referral or with Launa Brown in failing to act upon

16 it, the result was that Victoria was never seen by

17 a health visitor and so was deprived of the services

18 that were described in the evidence. Perhaps the most

19 important of these would have been a visit.

20 According to Launa Brown, there is no question that

21 one would have been made had the case been referred as

22 Rachel Crowe claimed. Whether or not any visit by

23 a health visitor would have achieved any more in terms

24 of protecting Victoria than the ones conducted by

25 Lisa Arthurworrey, we will never know. It is to those

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1 visits that I now turn.

2 Lisa Arthurworrey made two visits to

3 Somerset Gardens during which she was able to observe

4 Victoria and her interaction with Kouao and Manning.

5 The first took place a few days after Victoria had been

6 discharged from the hospital, the second a few days

7 after she had started to sleep in the bath. On neither

8 occasion according to Miss Arthurworrey did she see or

9 hear anything that would have indicated to her that

10 Victoria was the victim of abuse.

11 Two questions arise. First, given what she did see

12 and what she did hear during the course of those visits,

13 should she at least have considered the possibility of

14 abuse?

15 Second, should she have done more to ensure that she

16 had sufficient information on which to form a proper

17 judgment?

18 As to the first of those questions, it is plainly

19 the case that Kouao and Manning did not make things easy

20 for Miss Arthurworrey. Care was taken with the

21 presentation of the flat, Victoria was well dressed and

22 well behaved on both occasions, and Miss Arthurworrey

23 was told a whole series of lies concerning for example

24 Manning's fiancee, the sleeping arrangements in the flat

25 and Kouao's long-term intentions. To borrow the

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1 expression used by Manning at the trial, the visits were

2 "put up jobs" designed to mislead Miss Arthurworrey.

3 It may be thought that the fact that they succeeded

4 so conspicuously is attributable at least in part to

5 Miss Arthurworrey's willingness to take what she saw and

6 heard at face value. She never troubled to speak to

7 Victoria at any stage during those two visits. She

8 never sought to discover how Victoria spent her days.

9 She never attempted to gain any independent confirmation

10 of the story that she was given. She never sought to

11 take any active steps to address the fact that Victoria

12 was not receiving any education.

13 She accepted during the course of her evidence that

14 she should have done all of these things. The fact that

15 she did none of them may be explained in part by the

16 agenda with which she approached these meetings. The

17 principal item on it, according to Miss Arthurworrey,

18 was Kouao's housing application. The reason therefore

19 that Miss Arthurworrey never arrived at a realisation of

20 the abuse Victoria was suffering might be that she

21 started out from the wrong place.

22 On 20th August 1999 Petra Kitchman received a letter

23 from Dr Rossiter. It ended in the pithy style that we

24 have come to see as the trademark of Dr Rossiter. She

25 wrote:

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1 "I have enormous concerns about this child who is

2 now lost to follow-up somewhere in Haringey. What are

3 you going to do?"

4 Potentially that letter gave rise to an opportunity

5 for social services to intervene with Victoria because

6 it alerted them to Dr Rossiter's concerns.

7 It seems to us three principal questions arise from

8 that letter. First, did Dr Rossiter send the letter to

9 the wrong person? Second, did Ms Kitchman speak to

10 Lisa Arthurworrey about the letter before replying?

11 Third, was the response by Haringey Social Services to

12 that letter adequate?

13 Petra Kitchman was not a caseworker. She was

14 a child protection adviser. It was Lisa Arthurworrey

15 who was the allocated social worker. Dr Rossiter knew

16 that from her earlier conversation with

17 Miss Arthurworrey. Yet she chose nonetheless to write

18 to Ms Kitchman. However efficient the communication

19 might be between adviser and allocated worker, writing

20 to Ms Kitchman was unlikely to have the same immediate

21 impact as writing direct to the person with

22 responsibility for the case.

23 However, we would hesitate to suggest criticism of

24 Dr Rossiter in this regard. Her principal concern was

25 her patient's welfare rather than the structure adopted

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1 by social services to manage their work. Ms Kitchman

2 was Haringey's link worker with the hospital and

3 Dr Rossiter had communicated with her in the past and

4 knew and respected her. No one had ever suggested that

5 she should not express her concerns through Ms Kitchman.

6 That being so, it seems to us that the Inquiry is

7 entitled to look critically at the way Haringey dealt

8 with the letter. That brings us to another stark

9 conflict of evidence, this time between two of their

10 employees.

11 It plainly was necessary for Ms Kitchman to talk to

12 Miss Arthurworrey about the letter. Kitchman says she

13 did. Arthurworrey says she did not.

14 Whatever Kitchman did was plainly insufficient

15 because there is no record of what she did or how

16 Miss Arthurworrey responded and more particularly

17 nothing of substance happened as a result.

18 If the letter from Dr Rossiter was a warning bell to

19 Haringey Social Services, for one reason or another it

20 went unheeded.

21 Dr Rossiter wrote again on 2nd September. The

22 importance of this letter was it enclosed a copy of

23 Victoria's discharge summary. The importance of the

24 discharge summary was that it made clear that the

25 consultant responsible for Victoria's case at the NMH

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1 believed that there were marks on Victoria's body which

2 were not due to scratching induced by scabies but were

3 at least possibly the result of chastisement perhaps

4 with a looped wire.

5 Properly understood, that letter would have made it

6 impossible for social services to persist in their

7 belief that there were no child protection concerns in

8 relation to Victoria. But it was not properly

9 understood. The letter was again addressed to

10 Petra Kitchman. It was six weeks before Ms Kitchman

11 replied. Whatever the details of the explanation, no

12 one suggests that the speed of response was adequate.

13 It was common ground between Kitchman and

14 Arthurworrey that the two of them spoke following

15 receipt of this second letter but they differ on the

16 most important points, namely whether there was

17 discussion about the discharge summary or whether

18 Arthurworrey was shown that document.

19 In evidence Miss Arthurworrey made her points in

20 graphic terms. She said that if she had seen the letter

21 and the discharge summary she would have "run to my

22 manager, because it would have meant that the Section 47

23 investigation was completely flawed." Whether it was

24 because Ms Kitchman did not show her the discharge

25 summary or Miss Arthurworrey did not read it properly,

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1 it is of the greatest regret that Miss Arthurworrey did

2 not go running to a manager and did not appreciate that

3 the entire basis on which she had been managing the case

4 was misconceived.

5 Petra Kitchman's reply demonstrated that the error

6 had not been appreciated. In fact, Ms Kitchman

7 continued to repeat it. She told Dr Rossiter that the

8 question of physical abuse had been investigated at the

9 CMH where it had been confirmed that the marks were due

10 to scabies. The investigation at the CMH predated the

11 admission to Dr Rossiter's hospital by a fortnight. The

12 conclusions of the former hospital could never be

13 decisive as to marks found by the latter.

14 The crying shame about this stage of the history is

15 that although Dr Rossiter noticed the error being made

16 by Kitchman and Arthurworrey, Kitchman and/or

17 Arthurworrey, she failed to appreciate the depth of

18 misunderstanding it demonstrated and so all concerned

19 continued to deal with Victoria on an entirely false

20 basis. She had been abused. There was evidence of it.

21 The doctors had noticed the evidence. The social

22 workers had eventually been informed of it but the

23 assumption being made about the sequence of events was

24 never challenged. Those assumptions continued to

25 dominate everything that happened to Victoria's case

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1 thereafter.

2 Perhaps the most significant of the chances to

3 intervene and save Victoria was amongst the last. On

4 1st November 1999 Kouao telephoned the North Tottenham

5 District Office to report that Victoria had been

6 sexually abused by Manning. The overwhelming likelihood

7 is that that allegation was untrue but its significance

8 is that it brought Victoria to the attention of both the

9 police and social services at a critical stage of what

10 remained of Victoria's life. There is no doubt that by

11 then Victoria was being seriously abused. The physical

12 abuse probably started in or before June 1999 and

13 Manning told us that it was in about October 1999 that

14 he and Kouao had begun requiring Victoria to sleep every

15 night in the bath.

16 Following the telephone call Victoria arrived at

17 North Tottenham with both Kouao and Manning. Manning

18 was told to leave but Kouao was spoken to by

19 Miss Arthurworrey and Valerie Robertson.

20 The following day Kouao was back in the office

21 withdrawing the allegation. Sensibly that retraction

22 did not lead to the cancellation of a strategy meeting

23 fixed for 5th November.

24 In our written submissions we suggest that there may

25 be grounds for criticising the delay in arranging that

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1 meeting but in truth far more important was the manner

2 in which the recommendations made at that meeting were

3 addressed. 15 apparently well thought out pieces of

4 work were identified as being necessary. None of them

5 were completed. In many ways what is even worse is that

6 no one much noticed.

7 We have largely avoided, sir, drawing conclusions in

8 these submissions on disputed matters, but not a single

9 witness from whom we have heard seeks to justify the

10 actions of either the police or social services

11 following the November meeting. The truth is that

12 nothing was done despite the fact that it was

13 universally recognised at the time that the making and

14 retracting of the allegations of sexual abuse suggested

15 at the very least serious problems in the relationship

16 between Kouao and Victoria.

17 Manning was told that he would be interviewed by the

18 police as a result of the allegations made by Victoria.

19 In an entry with which we are now well familiar sir, he

20 wrote in his diary that the 5th November was the "day of

21 judgment". It ought to have been. It was not because

22 of the almost complete inactivity on the part of social

23 services and the police, and Victoria was left to suffer

24 another three and a half months of abuse.

25 Our last missed opportunity covers the visits by

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1 Lisa Arthurworrey to 267 Somerset Gardens in December

2 1999 and January 2000.

3 In a sense the evidence on this topic adds little to

4 that relevant to the last. The visits were intended to

5 be the means by which contact was re-established with

6 Kouao so that the work identified at the strategy

7 meeting could be taken forward.

8 It is said that it was because Kouao could not be

9 traced that so little happened. Lisa Arthurworrey first

10 attempted to contact Kouao by letter inviting her to an

11 appointment at the North Tottenham District Office. She

12 wrote to Kouao at the flat at Somerset Gardens.

13 A strange choice of address because Miss Arthurworrey

14 says that at that stage she believed that Kouao and

15 Victoria were still at the home of the Kimbidimas. The

16 choice of address was, she says, an error although as it

17 happens that error means she was writing to the correct

18 address. Victoria had been back at Manning's flat since

19 2nd November. But Miss Arthurworrey offers her mistaken

20 belief as an explanation for why she was not surprised

21 that Kouao did not turn up for the appointment.

22 Thereafter Miss Arthurworrey tried three times,

23 twice in December and once in January, to visit Kouao

24 and Victoria at home. She says that the three attempts

25 were at different times of day. On the first two

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1 occasions she did not get beyond the front door of the

2 block of flats. On the third occasion she got in but

3 received no reply to her knock at the door.

4 It is of course possible that there was no one at

5 home on any of these occasions. It is also possible

6 that there was, Victoria alone but unable to ask for

7 help. Those attempts having failed, Miss Arthurworrey

8 reported the matter to her supervisors. It seems that

9 she regarded it as at least a possibility that the

10 family had moved back to France, an option that had been

11 discussed at the time of the home visit in October.

12 Somehow that possibility became something close to

13 a certainty, so that Ms Kozinos was able to write in her

14 notes of the supervision of 23rd December "family have

15 left the area".

16 The third spot check which followed was intended to

17 address residual concerns but after that all that

18 remained to be done was to complete the paperwork and

19 close the case.

20 According to Angella Mairs the case was closed on

21 the morning of 25th February 2000. Victoria was

22 pronounced dead at St Mary's Paddington at 3.30 pm that

23 same day.

24 Sir, the Inquiry now alters its focus. From the

25 backward looking forensic exercise of trying to discover

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1 what happened to Victoria we now turn to consider the

2 changes that are necessary for the future. The aim is

3 simple to state if rather more difficult to achieve. It

4 is to make recommendations as to how the system of child

5 protection in this country should be changed so that the

6 next time -- and there will be a next time -- chances to

7 save vulnerable children like Victoria are not thrown

8 away. Thank you sir.

9 THE CHAIRMAN: Mr Garnham, I am grateful to you. Thank you

10 very much indeed.

11 Ladies and gentlemen, as counsel has just indicated,

12 the work of this Inquiry has been organised in two

13 phases. Although different in character they are

14 connected, in that the evidence of Phase I of the

15 Inquiry will inform the issues to be discussed in

16 Phase II. So this is not the time for the Inquiry to

17 reach any conclusions. That time will come later.

18 In accordance with the procedures previously

19 notified to interested parties to the Inquiry,

20 representatives of interested parties may shortly

21 collect from the reception area here on the 6th floor

22 copies of the closing written submissions made to the

23 Inquiry which we have heard. One set of all of the

24 closing written submissions contained in two lever arch

25 files is available to each interested party. But I must

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1 remind the interested parties that these closing

2 submissions are made available to them subject to the

3 confidentiality undertaking given at the beginning of

4 the Inquiry.

5 Ladies and gentlemen, apart from hearing the final

6 submission from the London Borough of Enfield we have

7 now reached a milestone along the way in the work that

8 this Inquiry has been charged with. But I do not

9 propose to close Phase I of this Inquiry for three

10 reasons.

11 First, because as we consider the details of the

12 case of Victoria's death it may be that grounds for

13 criticism may emerge which have not yet been put to the

14 witnesses. In those circumstances no criticism will be

15 made of the witness in the final report of the Inquiry

16 without him or her being given the chance either in

17 writing or if necessary orally to respond to those

18 criticisms.

19 Second, we have been in receipt of further

20 information right up until the 30th January. This

21 documentation is of some length and complexity and we

22 have not yet had the chance to consider it in detail.

23 Reading it further may necessitate the Inquiry calling

24 for further evidence.

25 Third, points may emerge during our consideration of

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1 the oral and written submissions which prompt us to seek

2 further evidence. One example springs immediately to

3 mind. Yesterday Miss Marsh made final submissions on

4 behalf of the NSPCC. She said much that was of interest

5 but much of it was not based on evidence we have heard

6 to date. It may well be that we will seek a statement

7 from Miss Marsh so that her comments become evidence

8 rather than just submissions to the Inquiry.

9 In those circumstances you will understand that I am

10 not going to require interested parties to return their

11 bundles of documents to the Inquiry at this stage. The

12 Solicitor to the Inquiry will write to the interested

13 parties on this subject at a later date indicating when

14 those bundles should be returned. In the meantime

15 interested parties are reminded of their obligations to

16 keep that material safe.

17 Before we finish, I would like to take the

18 opportunity to thank Mr and Mrs Climbie for being with

19 us throughout Phase I of this Inquiry. For reasons that

20 we have all become very familiar with it must have been

21 a gruelling and distressing experience for them. But

22 I hope it has at the very least reassured them of the

23 serious intent of the British Government in establishing

24 this Inquiry, and indeed the way in which this Inquiry

25 has been conducted will I hope be evident to them that

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1 we are all committed to learning the lessons from the

2 terrible ordeal suffered by Victoria.

3 As I said when I opened the Inquiry, it is my hope

4 that some enduring good will come from Victoria's tragic

5 death, not least being that the safeguards for children

6 at risk in this country will be made that much more

7 robust. The very least we can do is to aim to ensure

8 that nothing like this happens again.

9 I will say more later on this but I would like to

10 say a special word of thanks to Counsel to the Inquiry,

11 Mr Neil Garnham QC and his team for the painstaking and

12 thoroughly competent job they have done in presenting

13 the evidence to this Inquiry. It has been a formidable

14 task done extremely well. The core bundle of documents

15 is so much larger than any of us could have anticipated,

16 as was the number of witnesses who in one way or another

17 have given evidence so far to the Inquiry. The fact

18 that our timetable was exceeded only by a few weeks is

19 an enormous tribute to their hard work and their

20 thoroughness and I include in my appreciation of the

21 hard work by the legal team Mr Michael Fitzgerald the

22 Solicitor to the Inquiry.

23 May I also thank the advocates for the interested

24 parties for the part that they have played in Phase I of

25 the Inquiry. I and my colleagues have been greatly

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1 helped by your efforts and I speak on their behalf as on

2 my own. Thank you very much indeed.

3 Organising an inquiry of this kind is exceedingly

4 difficult, and there are of course a host of other

5 people who have contributed so much to the work of the

6 Inquiry, and I know that it is always dangerous to

7 embark upon a list for fear of being incomplete in that.

8 However, I would like to take the chance especially as

9 they are here to particularly thank the stenographers

10 who have worked so hard and done such an excellent job,

11 the LiveNote operator, the sound specialist, the

12 receptionist, the representatives of the media and

13 Mr Paul Rees, the security staff, the Secretariat who

14 have worked so tirelessly and the witness managers who

15 have been very thoughtful in all that they have done.

16 They have all carried a very heavy workload in

17 a thoroughly reliable and competent way.

18 But those of us who have been here from the outset

19 and indeed been here through the time the evidence has

20 been given will be all too well aware of the other staff

21 that have worked on the third floor of this building and

22 I am sure that all of you who have some understanding of

23 the work that they have done will agree with me that

24 they have done a quite outstanding job of work. They

25 have remained cheerful, enthusiastic and very committed

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1 to the task despite being subject at times to very great

2 and unexpected pressures. We are fortunate to have such

3 an able and pleasant team in support of the Inquiry.

4 On that note I would particularly like to pay a very

5 warm tribute to my professional advisers and the two

6 analysts. I have greatly admired their ability and

7 their commitment and I have benefited enormously from

8 their knowledge and their skill. We could not have

9 chosen a better team.

10 There of course are others that I have not

11 mentioned, but I hope that everybody in this Inquiry in

12 whatever capacity will accept my warmest thanks for the

13 part that they have played in getting us this far.

14 There is of course a long way to go before we complete

15 the important and challenging task which we have been

16 given.

17 Before I adjourn the proceedings today I would like

18 to say a collective and very warm thank you to you all.

19 That said, ladies and gentlemen, and I hope you accept

20 the sincerity of my thanks for what you have all done,

21 I now adjourn the proceedings until 10 am on Wednesday

22 27th February when we will hear the final submissions

23 from the London Borough of Enfield. After that, we will

24 move on to the first of the seminars for Phase II of

25 this Inquiry, which as you know will take place on

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1 15th March 2002. Ladies and gentlemen, I am very

2 grateful to you all and I now adjourn the proceedings

3 until the 27th February. Thank you.

4 (2.45 pm)

5 (Adjourned until Wednesday, 27th February 2002 at 10.00 am)

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