|
Archived Transcript for 26 September 2001: Pages
1 to 50
1 Wednesday, 26th September 2001
2 (10.00 am)
3 THE CHAIRMAN: Good morning, ladies and gentlemen, may
4 I begin by welcoming you to the beginning of the public
5 hearing of the Victoria Climbie Inquiry. I should begin
6 by reminding you that on 25th February 2000,
7 Victoria Climbie died in the Intensive Care Unit at
8 St Mary's Hospital, Paddington. She died as a result of
9 months of the most appalling ill-treatment at the hands
10 of those who were supposed to be caring for her.
11 At the preliminary hearing of this Inquiry, on
12 31st May, I invited everyone present to observe a period
13 of silence in memory of Victoria. I am not asking for
14 that to be repeated today, because it is my hope that
15 every day, throughout the Inquiry, we will have before
16 us the memory of Victoria and what she suffered. It is
17 against that same background that I particularly welcome
18 Victoria's parents, Mr and Mrs Climbie. I am grateful
19 to them for travelling from the Ivory Coast to help us.
20 The ill-treatment and death of Victoria shocked the
21 nation. This Inquiry is an indication of the
22 commitment, especially by Ministers of Government, that
23 what happened to Victoria will be an enduring turning
24 point in securing the proper protection of children in
25 this country.
1
1 I remind you that on 12th January 2001, at the
2 Central Criminal Court, Marie-Therese Kouao and
3 Carl Manning were convicted of her murder. Both were
4 sentenced to life imprisonment.
5 Soon afterwards, the Secretary of State for Health
6 and the Home Secretary made clear their intention of
7 establishing a statutory inquiry into the circumstances
8 of Victoria's death.
9 On 20th April this year, I was appointed by the
10 Secretary of State for Health and the Secretary of State
11 for the Home Department to conduct three statutory
12 inquiries, together to be known as the Victoria Climbie
13 Inquiry.
14 The first inquiry is established under section 81 of
15 the Children Act 1989, and is concerned with the
16 functions of the Local Authority Social Services
17 Committees, insofar as they relate to children.
18 The second is established under section 84 of the
19 National Health Service Act of 1977, and is concerned
20 with matters arising under that Act.
21 The third inquiry is established under section 49 of
22 the Police Act 1996, and is, of course, concerned with
23 policing.
24 The terms of reference of the Inquiry require me, in
25 summary, to establish the circumstances leading to and
2
1 surrounding the death of Victoria Climbie, to consider
2 the services sought or provided for her, and for those
3 in whose care she found herself, from social services,
4 the health services, and the police, and to reach
5 conclusions and make recommendations as to how, so far
6 as possible, such events can be avoided in the future.
7 Finally, I am directed to deliver a report to the
8 two Secretaries of State who will then arrange for its
9 publication.
10 Ladies and gentlemen, you will appreciate that this
11 Inquiry is of some complexity. We understand it to be
12 the first to be established under three separate
13 statutory provisions. It will consider the actions of
14 staff employed by a large number of public authorities,
15 and the way in which those authorities managed and
16 co-ordinated their activities. Its work is important,
17 because we are charged with making recommendations that
18 may affect the way these agencies carry out their
19 functions in future.
20 In this Inquiry, I am supported by four main
21 assessors, and I would like to introduce them to you.
22 On my far right is Mr John Fox, who is a Detective
23 Superintendent, and head of the Specialist
24 Investigations Department in the Hampshire Constabulary.
25 On my immediate right is Dr Nellie Adjaye, a fellow
3
1 of the Royal College of Paediatricians and Child Health
2 and a consultant paediatrician with special interest in
3 community child health, currently working in Maidstone
4 and Tunbridge Wells NHS Trust.
5 To my immediate left is Mrs Donna Kinnair, who is a
6 nurse, health visitor and a Strategic Commissioner for
7 the Lambeth, Southwark and Lewisham Health Authority.
8 To my far left is Mr Nigel Richardson, the Assistant
9 Director, Children and Families, for North Lincolnshire
10 Council Social Services and Housing Services
11 Directorate.
12 I have been able to appoint Miss Mandy Jacklin, who
13 is sitting on my left, to be Secretary of the Inquiry,
14 and with the consent of the Attorney General, I have
15 appointed Mr Neil Garnham QC to be counsel to the
16 Inquiry, and Miss Caroline Gibson and Mr Neil Sheldon to
17 be junior counsel to the Inquiry. The solicitor to the
18 Inquiry is Mr Michael Fitzgerald.
19 Ladies and gentlemen, you will have realised that
20 the proceedings of this Inquiry will be held in public.
21 The work will be divided into two phases. Phase 1 will
22 be primarily backward-looking and will be concerned with
23 discovering what happened to Victoria and why it
24 happened while she was in this country. Phase 2 will be
25 concerned with wider questions. It will be
4
1 forward-looking and will be directed to the question as
2 to what recommendations might properly be made which may
3 help avoid, so far as possible, a tragedy of this sort
4 happening again.
5 I intend that this Inquiry will be thorough and
6 rigorous, and subject to those overriding objectives, it
7 will be conducted as speedily and economically as
8 possible.
9 The Inquiry will be inquisitorial and not
10 adversarial in nature. It is not litigation or
11 prosecution. It is not concerned with questions of
12 civil or criminal liability. It is an investigation.
13 There are, in legal terms, no parties entitled to
14 advance cases. There are no statutory entitlements for
15 any other person to call witnesses, cross-examine or
16 make submissions. I am empowered to take evidence on
17 oath or affirmation, and will do so in respect of all
18 witnesses. The questioning of witnesses will primarily
19 be conducted by counsel to the Inquiry, although I or
20 the assessors, through me, may wish to ask additional
21 questions.
22 Interested parties will not ordinarily be permitted
23 to call witnesses or to cross-examine. However, counsel
24 to the Inquiry will be very happy to consider any
25 requests for them to call additional witnesses. If such
5
1 a request is declined for any reason, I will adjudicate
2 on whether it is necessary for that witness to be
3 called.
4 Counsel to the Inquiry will also consider any
5 request from interested parties for particular lines of
6 questioning to be put to witnesses. Arrangements will
7 be made whereby interested parties can submit
8 suggestions to counsel to the Inquiry in advance, so
9 that they can be properly incorporated into the
10 proceedings. Again, if counsel declines or omits to put
11 these questions, I will of course, rule on any
12 submissions that I receive.
13 I am content for interested parties to attend the
14 hearing with their lawyers, but witnesses will be
15 required to give their evidence direct to the Inquiry,
16 and the role of lawyers in this instance will be
17 limited. I will, of course, invite interested parties
18 to make opening statements if they wish, although those
19 statements should be limited to 30 minutes. Those
20 representing interested parties will be permitted to
21 re-examine witnesses who they represent. I will allow
22 re-examination to cover any matter to which the witness
23 can speak, and which has not previously been dealt with
24 in the evidence. Such re-examination, however, will be
25 time limited.
6
1 The procedure to be adopted in this regard is set
2 out in the procedural guide which has now been published
3 by the Inquiry team. Interested parties will, of
4 course, be able to make final submissions.
5 Arrangements have been made for the simultaneous
6 transcription of all oral evidence by means of this
7 system, which is called LiveNote. Any interested party
8 that wishes to take advantage of this service is invited
9 to contact the Secretariat. Smith Bernal, the company
10 who provide the LiveNote service, will make a charge for
11 this facility which will be based upon the Inquiry
12 meeting a proportion of the total bill and the balance
13 divided amongst the interested parties who subscribe.
14 I should make it clear again that this Inquiry is
15 not a vehicle for reconsidering the criminal charges
16 brought against Kouao and Manning. We take as our
17 starting point the verdict of the jury that those two
18 individuals were guilty of the murder of Victoria.
19 I welcome today the representatives of the media,
20 but may I ask them, in the usual way, to respect the
21 privacy of all those involved in the Inquiry, both
22 inside and outside the Inquiry room. In accordance with
23 the usual procedure, the media should not seek to
24 interview any witness who has started to give evidence,
25 until that evidence is completed, even if it goes over
7
1 to another day.
2 Ladies and gentlemen, to everyone, may I ask you, if
3 you have a mobile phone, will you ensure that it is
4 switched off. If that has happened, ladies and
5 gentlemen, I will now invite Mr Neil Garnham QC to open
6 the proceedings.
7 MR GARNHAM: Thank you, sir.
8 The way in which a society treats its children is
9 perhaps the best measure of its humanity. On learning
10 of the circumstances of her daughter's death, Victoria's
11 mother said that such a thing could not happen in the
12 Ivory Coast. Well, it happened here.
13 Victoria's death was not simply an isolated act of
14 madness by two sick individuals. Her ill-treatment was
15 prolonged. It was not hidden away, out of sight of the
16 authorities. As we shall discover, the signs were
17 there. In fact, it seems as if the signs were on
18 display time and time again, but they went unheeded.
19 Victoria Climbie died a miserable and lonely death.
20 Abused and ill-treated for months, she arrived at St
21 Mary's Hospital unconscious and suffering from
22 hypothermia. Her body temperature had fallen so far
23 that the hospital did not have a thermometer capable of
24 reading it. She had been imprisoned, beaten and
25 starved. She had been deprived of any form of human
8
1 comfort, and as she neared the end, can have had little
2 hope of any form of relief.
3 With the appalling circumstances of Victoria's death
4 at the forefront of our minds, it is my task to open
5 this Inquiry. I estimate that this opening will take
6 a full day, and copies of the text will be available at
7 the end of the day, should anyone want them. An outline
8 of the topics that I am going to cover is at page 1/13
9 of the red files that were distributed this morning.
10 Further copies are available at the back of the hall.
11 This opening, sir, is based on documentary material
12 gathered for the purpose over the last few months. It
13 is the first word, not the last word, on the subject.
14 It is intended to set the scene, to describe by
15 reference to the witness statements we have obtained and
16 the contemporary documents that we have collected what
17 appears to have happened.
18 (10.15 am)
19 The provisional views we express, like the evidence
20 on which they are based, will need to be the subject of
21 careful scrutiny over the next few months. However, we
22 hope, sir, that this Inquiry will assist in five
23 respects.
24 First, it will seek to describe the structure of the
25 relevant statutory agencies so that we have an
9
1 understanding of the background against which those
2 involved in Victoria's case were working.
3 Second, it will aim to identify the sequence of
4 events so far as it is revealed by the documents.
5 Third, it will consider the staffing, training and
6 resources of the relevant agencies, and how those
7 agencies worked together.
8 Fourth, it will consider the response of the
9 agencies so far to the tragedy of Victoria's death, so
10 that you can reach a judgment, sir, about what more
11 needs to be done.
12 Fifth, it will attempt to identify the missed
13 chances, and flag up areas where the conduct of
14 individuals and organisations looks as if it might
15 justify criticism. I emphasise the obvious: none of
16 what is said amounts to the concluded view of counsel to
17 this Inquiry, let alone the concluded view of the
18 Inquiry itself. It will be for you and your colleagues,
19 sir, to form a view about each of these matters, based
20 on the evidence we put in front of you.
21 Before I turn to address what must be the substance
22 of this opening, I want to say a word about Victoria,
23 a little about what happened to her, and describe how
24 she came to be in this country in the first place. As
25 we consider the response of the statutory agencies to
10
1 Victoria's case, it is essential that we do not lose
2 sight of the little girl who is at the centre of our
3 enquiries.
4 Victoria's mother gave evidence at the criminal
5 trial of Kouao and Manning. She described her daughter
6 as a bright, happy child. That seems to be the
7 impression she gave to many of those she came into
8 contact with in this country. As we will hear, in
9 July 1999, she was admitted to the North Middlesex
10 Hospital. I will return later to the circumstances of
11 that admission. For now, I want to describe how
12 Victoria was seen by those who were caring for her in
13 hospital.
14 Noelle O'Boyce was employed at the hospital as
15 a play specialist, and she spent some time with
16 Victoria. She remembers her well. She was, says
17 Ms O'Boyce, a delightful child.
18 Victoria loved role-playing. She would dress up and
19 play at shopping with a basket. She enjoyed painting
20 and drawing.
21 Dr Rossiter, the paediatric consultant at the NMH,
22 described how delighted Victoria was to receive some
23 secondhand clothes that Dr Rossiter brought into the
24 hospital for her. She said that Victoria had become
25 "a very special patient to staff during her time on the
11
1 ward. She was a little ray of sunshine".
2 Nurse Susan Jennings describes how Victoria arrived
3 at the hospital with no possessions. Staff gave her
4 dresses and presents. She used to dress up in a white
5 dress, and pink wellingtons, and go twirling up and down
6 the hospital ward.
7 Dr Rossiter arranged for Lucienne Taub, a nurse from
8 the special care baby unit, who was French and spoke the
9 language fluently, to befriend Victoria. Ms Taub speaks
10 fondly of Victoria. She says:
11 "Victoria was a very affectionate child and loved to
12 be cuddled and hugged. She used to see me coming and
13 run down the ward and jump into my arms and kiss me to
14 say hello. Victoria was very bright and she loved to
15 talk. I would sometimes take Victoria out into the
16 hospital grounds or up to the special care baby unit in
17 order to see the babies. Victoria loved those outings.
18 We were all so fond of her."
19 Much of what follows, sir, will require close
20 examination of complicated practices and procedures,
21 devised by public authorities. All of that is
22 necessary, but we should never forget, as we carry out
23 that exercise, that little eight-year-old girl who is at
24 the heart of this Inquiry, dressed up in pink
25 wellingtons, twirling up and down that hospital ward.
12
1 Contrast that with the picture Victoria presented on
2 24th February 2000. She had been taken by ambulance to
3 the Accident and Emergency Department of North Middlesex
4 Hospital, at 10.35 pm. She was extremely cold, and the
5 hospital had the greatest difficulty in warming her up.
6 She appeared malnourished. There was a fixed flexion
7 deformity of both knees. There were cuts to her hands
8 and wrists. There were numerous scars to her body. The
9 consultant in charge of her care, Dr Alsford, decided
10 she needed to be admitted to a Paediatric Intensive Care
11 Unit.
12 NMH approached Great Ormond Street. An hour later,
13 according to Dr Alsford, Great Ormond Street responded,
14 saying they were unable to take Victoria.
15 THE CHAIRMAN: I am sorry to interrupt. I have had
16 a request from Victoria's parents if we could go
17 a little slower for the interpreter to keep up. I am
18 sorry to have interrupted.
19 MR GARNHAM: I will do my best.
20 An hour later, according to Dr Alsford, Great Ormond
21 Street responded, saying that they were unable to take
22 Victoria. At about 1.30 am, Dr Alsford contacted
23 St Mary's Hospital, Paddington, who promptly indicated
24 that they could admit Victoria. She was transferred to
25 the Paediatric Intensive Care Unit at St Mary's. On
13
1 arrival, she was in a critical condition. She suffered
2 repeated episodes of respiratory and cardiac arrest.
3 She developed symptoms of kidney failure.
4 About 3.00 pm of 25th February, Victoria went into
5 cardiac arrest again. Attempts at cardiopulmonary
6 resuscitation failed, and Victoria was declared dead.
7 She had died of multiple systems failure, brought about
8 by neglect and hypothermia.
9 A post-mortem was conducted on 26th February.
10 Dr Nathaniel Carey concluded that she had died of
11 hypothermia developed in circumstances of neglect and
12 ill-treatment. He said that there was undoubted
13 evidence of repeated systematic abuse. The appearances
14 were in keeping with the use of some form of weapon or
15 weapons.
16 Dr Carey recorded changes to the skin of the
17 buttocks which, in his opinion, represented a response
18 to prolonged contact with urine and faeces, with
19 inadequate cleaning of the skin thereafter. There were
20 areas of ulceration and linear scarring on the wrists
21 and lower legs that he regarded as being in keeping
22 "with binding of the limbs, either to one another, or to
23 some object."
24 He went on to say that the factors relevant to the
25 development of hypothermia, in Victoria's case, were
14
1 inadequate nutrition, a cold environment, inadequate or
2 wet clothing, and binding which restricted movement.
3 Dr Carey also noted a number of small round scars on
4 Victoria's body which, in his view, could represent
5 healed cigarette burns. He noted a twisting injury to
6 the lower end of the left femur which, in his opinion,
7 must have occurred in the few days preceding death.
8 That injury would require more force than simple rough
9 handling, and was strongly suggestive of physical abuse.
10 Finally, Dr Carey described evidence of
11 malnutrition. He said it was the result either of
12 a short period of severe malnutrition, or a more
13 prolonged period of inadequate nutrition, or
14 a combination of the two. He told the jury at the trial
15 of Kouao and Manning that Victoria was both acutely and
16 chronically malnourished and that the chronic period may
17 have lasted for many months. This was the worst case of
18 child abuse he had ever seen.
19 We now have a pretty good idea how Victoria got into
20 the state in which she presented at the North Middlesex
21 in February last year. Their verdict indicates that the
22 jurors were satisfied that it was maltreatment at the
23 hands of Kouao and Manning that led to Victoria's death.
24 In reaching that conclusion, the jury had the
25 benefit of hearing the account Manning gave to the
15
1 police shortly after his arrest on 26th February. He
2 was interviewed by DC Alan Boyd and PC Paul Rodnell.
3 The transcript of that interview makes for chilling
4 reading. It is material for our investigation because
5 it provides evidence of what was happening to Victoria,
6 and it is in the light of all the evidence, including
7 that material, that we must judge the adequacy of the
8 response of the public services.
9 Manning told the police that the reason that he and
10 Kouao first began treating Victoria as they did was that
11 she had developed first urinary incontinence and then
12 incontinence of faeces. The urinary incontinence began
13 about a week after she and Kouao had moved in with
14 Manning in July 1999, and followed an argument between
15 Manning and Kouao. Manning's response was to discipline
16 Victoria. At first, that took the form of slapping
17 Victoria. By late July, he was using his fist.
18 In either late July or late August -- Manning seems
19 uncertain -- Victoria began to suffer faecal
20 incontinence as well. Initially, Kouao's and Manning's
21 response was to make Victoria clear up her own mess.
22 Then in October, he and Kouao began to take more drastic
23 action. Because it was becoming difficult to keep the
24 sofa on which Victoria slept clean, Kouao and Manning
25 decided to put her to bed each night in the bath. She
16
1 was required to sleep there naked and without blankets.
2 This cruelty was made worse by the fact that the
3 bathroom was unheated, and in a course of action that
4 was as illogical as it was barbaric, Victoria's arms and
5 legs were bound with masking tape, which must have made
6 it impossible for her to get out of the bath to use the
7 lavatory.
8 The conclusion that Victoria was bound with masking
9 tape is supported not only by Manning's admissions but
10 also by scientific evidence obtained for the criminal
11 trial to the effect that her DNA was discovered on
12 masking tape found at the premises.
13 Further refinements of this torture were to follow.
14 First, Kouao and Manning wanted to prevent little
15 Victoria soiling the bath, so from late October or early
16 November until January 2000, she was put each night into
17 the bath inside a black plastic sack. The result was
18 that she lay in her own waste products.
19 Second, it had been the practice of Kouao and
20 Manning to cut Victoria free from her bindings each
21 morning. Later on, she would be left trussed up in the
22 plastic bag in the bath all day and all night, sometimes
23 more than 24 hours at a time.
24 Third, in early 2000, Kouao and Manning began to
25 leave Victoria alone in the flat in that condition. The
17
1 bathroom had no windows, and Victoria would be left
2 inside he room with the door shut and the lights off.
3 What must have gone through the mind of this little girl
4 is unimaginable. Here she was in a foreign country in
5 mid-winter. She was abandoned for hours on end, naked
6 and tied up in a rubbish bag, lying in an unlit,
7 unheated room.
8 One entry in Manning's diary makes for particularly
9 disturbing reading. The entry for 31st December 1999 is
10 now being displayed on the screen. Manning is
11 describing a row that he and Kouao had on New Year's
12 Eve. I will read the entry precisely as he writes it:
13 "Marie was sitting at de bus stop. She threw
14 herself to de floor and started rolling about on de
15 ground and kicking her feet like a spoilt child. After
16 a minute or so, she got up from the ground and walks to
17 de flat in bare feet, to release 'Satan' from her
18 bag~..."
19 It appears from that and other entries that Manning
20 had got into the habit of referring to Victoria as
21 "Satan".
22 Victoria was fed with the same food as Kouao and
23 Manning, except by the time she was given it, the food
24 would be cold, and fed to her on a piece of plastic
25 while she was tied up in the bath. She would eat it
18
1 like a dog, pushing her face into the plate, except, of
2 course, that a dog is not usually tied up in a plastic
3 bag full of its own excrement.
4 To say that Kouao and Manning treated Victoria like
5 a dog would be wholly unfair. She was treated far worse
6 than any dog. When she was allowed out of the bath,
7 Victoria would clean herself before being required, by
8 Kouao and Manning, to sweep and clean the flat. She was
9 not allowed out to play. The only trips she was given
10 were to church.
11 (10.30 am)
12 According to Manning, in January 2000, he and Kouao
13 became concerned that the condition of Victoria's skin
14 might cause social workers to ask "undue questions". So
15 although the rest of the ill-treatment continued, he and
16 Kouao stopped putting Victoria in a plastic bag, and
17 would instead require her to wear large-sized disposable
18 nappies. She continued, however, to be kept in the
19 bath, with her feet and hands tied.
20 In addition to this treatment, Victoria also endured
21 assaults at the hands of Manning and Kouao. In addition
22 to the slaps and punches to which I have already
23 referred, Manning described at the trial how Kouao used
24 to strike Victoria on a daily basis, with a shoe,
25 a coathanger and a wooden cooking spoon. She would
19
1 strike her toes with a hammer. Victoria's blood was
2 found on Manning's football boots. Her skin showed
3 marks consistent with the undersole of a trainer-type
4 shoe. Manning also admitted that on occasions, he would
5 take a bicycle chain to her.
6 Manning was asked by the police whether Victoria
7 cried when she was struck by the bicycle chain. He
8 replied, "That's it. You could beat her and she
9 wouldn't cry at all. She could take the beatings and
10 the pain like anything."
11 There are, sir, no grounds for believing that
12 Manning overestimated the level of cruelty that he and
13 Kouao inflicted on Victoria. Therefore, as we consider
14 the evidence from the statutory agencies, Manning's
15 evidence gives us an idea of the minimum level of
16 maltreatment that Victoria was suffering.
17 After her arrest, Kouao declined to co-operate with
18 the police, when they sought details of Victoria's next
19 of kin. She was interviewed at Colindale police station
20 by WPC Young; she refused to give any particulars except
21 to confirm that Victoria was born in the Ivory Coast.
22 Accordingly, PC Young began to examine documents
23 that had been found at 267 Somerset Gardens, London N17,
24 the flat shared by Kouao and Manning. Amongst the
25 documents she found were a number of passport-sized
20
1 photographs, including two of young girls. An identical
2 photograph of one of these girls was displayed on
3 Kouao's passport, showing her to be Anna Kouao.
4 PC Young had, by that time, become suspicious as to
5 the true identity of the deceased child. As a result,
6 she showed those photographs to DI Keith Niven, and
7 asked him whether the deceased child was in the
8 photographs. He identified Victoria as one of those in
9 one of the photographs, but not the one displayed in
10 Kouao's passport.
11 Further police enquiries resulted in a family member
12 being found in Paris. That person travelled to London
13 and was interviewed. As a result of that information,
14 the police made contact by telephone with another
15 relative in Abidjan; that person was asked to locate
16 Francis Climbie, and on 10th March 2000, PC Young was
17 asked to speak to Mr Climbie by telephone at the home of
18 the relative. She told him that they regretted to say
19 that she believed that his daughter had died. He told
20 her that he had already heard of the death.
21 Arrangements were then made for Mr Climbie and his wife,
22 Bertha Ehoura, to travel to London where they identified
23 the body of their daughter.
24 It may be of some significance when we come to
25 consider the extent of the enquiries by the police child
21
1 protection teams whilst Victoria was alive that the
2 police were able to discover so much about Victoria
3 after she had died.
4 When the conviction of Kouao and Manning was first
5 reported in the press, there were those who expressed
6 the view that it was clear that race played no part in
7 this case. This, after all, was a black child murdered
8 by black carers. The social worker and the police
9 officer who, according to the press, were most
10 immediately involved in the case, were black; race, it
11 was said, must therefore be irrelevant.
12 We, for our part, are not so sure. We would urge
13 the Inquiry not just to keep an open mind on the subject
14 but to keep its antennae attuned to the possible
15 significance of race. We have seen no evidence thus far
16 of overt racism, but assumption based on race can be
17 just as corrosive in its effect as blatant racism.
18 Furthermore, race can affect the way people conduct
19 themselves in other ways. Fear of being accused of
20 racism can stop people acting when otherwise they would.
21 Fear of being thought unsympathetic to someone of the
22 same race can change responses. Assumptions that people
23 of the same colour, but from different backgrounds,
24 behave in similar ways can distort judgments.
25 It seems to us that it may be possible that race
22
1 played some such part in the present case. At this
2 stage, we would do no more than urge you to be alive to
3 that possibility, sir, and in relation to those
4 instances where you find that Victoria's needs were not
5 treated as paramount, to consider closely the reasons
6 why.
7 I turn next to look at Victoria's history before she
8 arrived in Britain. Adjo Victoria Climbie was born near
9 Abidjan in the Ivory Coast. She was known to her family
10 as Victoria. Kouao was subsequently to give Victoria's
11 date of birth at 24th December 1991, but that was
12 contradicted by the evidence of Victoria's real mother,
13 given at the criminal trial.
14 Victoria's family lived in a region called Abobo.
15 A photograph of that area is now being shown on the
16 screens. This, like a number of photographs we will
17 display, have been provided by the family's solicitors,
18 and we are grateful for their permission to use them.
19 In 1998, Victoria's father Francis worked at the
20 Novotel Hotel in Abidjan, and her mother worked selling
21 cold fruit juices in the town. Their home was a three
22 bedroom house equipped with electricity and running
23 water.
24 Victoria was part of a large family. She was one of
25 seven siblings, and had a large extended family. It is
23
1 quite common in the Ivory Coast for children to go to
2 live with other relatives, particularly if that
3 facilitates their education. Thus, for example,
4 Victoria's mother had left her parents' village home at
5 the age of seven to go and live with her aunt in Abidjan
6 so as to be able to attend school.
7 Her mother described Victoria as small in stature
8 and very bright. She had learned bladder and bowel
9 control by the time she was three. As a child, she had
10 been in good health. The only significant illness she
11 had suffered was malaria, from which she made a good
12 recovery.
13 She began her education at a private school near her
14 home at the age of six, and was regarded as a promising
15 student. She was one of a class of 73. There is now
16 being shown on the screens two photographs of her
17 school. The first is of her headmaster and father
18 standing outside the school; the second is of the
19 classroom.
20 In about October 1998, Victoria's family was visited
21 by an aunt of her father, namely Marie-Therese Kouao.
22 She had travelled from Paris for the funeral of her
23 brother, Natchia. Kouao was Marie-Therese's maiden
24 name, but she was divorced, and used that surname
25 throughout the period with which we are concerned. She
24
1 was a woman of 42 at the time of her visit to the Ivory
2 Coast, although she was subsequently to lie about her
3 age to the public authorities in Britain.
4 Kouao told Victoria's father that she had made
5 arrangements to take back with her a child by the name
6 of Anna Kouao, the daughter of one of their mutual
7 relatives. The plan was that Kouao would arrange for
8 the education of Anna in France. Those arrangements had
9 fallen through, and accordingly, Kouao suggested to
10 Victoria's parents that she might instead take one of
11 their daughters to Europe, in order to educate her.
12 Kouao told Victoria's parents that she worked in a
13 French airport, and was being transferred to London.
14 Victoria's parents were happy with that suggestion,
15 because it would be an honour for the whole family to
16 have a child educated in Europe. All of the Climbie
17 children were keen to go with their great-aunt, but
18 Kouao selected Victoria.
19 She told her parents that she wanted to call
20 Victoria "Anna" during the trip, and it was by that name
21 that Victoria was known during her life in England.
22 When Victoria left her family, she was fit and well.
23 Her skin was in good condition. She was happy about the
24 prospect of the trip.
25 Victoria and Kouao went first to stay with Kouao's
25
1 brother in the Ivory Coast, and from there they flew to
2 France. Victoria's parents heard news of Victoria
3 thereafter on just three occasions. First, a sister of
4 Kouao's by the name of Antoinette came on holiday to the
5 Ivory Coast in about February 1999. She brought with
6 her an album of photographs of Victoria and a message
7 from Kouao, to the effect that she was looking after
8 Victoria, and that she should not worry.
9 Second, Victoria's mother received a Christmas card
10 early in 2000 containing some photographs of Victoria.
11 One of them had written on the reverse, "She is growing
12 up well and she finds herself well".
13 Third, again early in 2000, the family received some
14 further photographs posted to them by Kouao's brother.
15 On the back of one of the photographs was a message:
16 "In the name of Christ, God bless you and the child
17 is well."
18 Our knowledge of Victoria's life in France is not
19 complete. It seems likely that she left the Ivory Coast
20 in October or November 1998, and remained in France
21 until April 1999. When first seen by Ealing Social
22 Services, Kouao said that she had previously been living
23 at 9 Rue George Melies, Villepinte. She worked at the
24 French Airport Authority in Paris and, it seemed, earned
25 a good wage. The police found wage slips in her flat
26
1 showing that Kouao was earning 16,790 Francs, or about
2 £1560 per month.
3 Nonetheless, she had made claims for benefit in
4 France, and the French authorities were seeking to
5 recover some of those monies when she came to England.
6 She lived in a rented four-bedroomed house. According
7 to French police, Kouao had living with her in France
8 her three sons and a daughter.
9 Ester Ackah, a witness from whom we will hear in the
10 early part of this Inquiry, shares a half brother with
11 Kouao. Mrs Ackah met Kouao for the first time on
12 a visit to Paris in August 1998. Her statement provides
13 a useful description of Kouao's life in Paris, and her
14 relationship with her other children, but this visit
15 predates Victoria's arrival in France.
16 It seems that soon after her arrival, Victoria was
17 enrolled in the Jean Moulin Primary School in
18 Villepinte. By December of that year, Kouao was
19 receiving formal warnings from the school about
20 Victoria's absenteeism. That pattern continued, and in
21 February 1999, a "Child At Risk Emergency Notification"
22 was issued by the school. A social worker became
23 involved, and reported a difficult mother/child
24 relationship between Victoria and Kouao.
25 (10.45 am)
27
1 The pattern of absenteeism continued until 1st
2 April 1999, when Kouao gave the school notification that
3 she was removing Victoria so that she could undergo
4 "treatment in London". She gave the London address of
5 Esther Ackah as her forwarding address.
6 Our papers include an interesting official report
7 from the French police. They interviewed the
8 headteacher at Victoria's primary school after her
9 death. He makes a number of potentially significant
10 observations.
11 First, he says that Victoria's teacher once told him
12 that Victoria suffered an incontinence problem, although
13 it was not regarded as significant.
14 Second, he says that he was worried by the fact that
15 Victoria tended to fall asleep in class.
16 Third, he refers to medical certificates, all of
17 which assert that Victoria needed rest, that led the
18 school to believe that she was clinically ill and being
19 monitored by doctors.
20 Fourth, Victoria and Kouao came to the school to say
21 goodbye to other pupils on 25th March. It was noted
22 that she had a shaven head, and was wearing a wig. The
23 headmaster ends his statement by saying that Kouao
24 appeared very polite and correct, and that she appeared
25 to be looking after Victoria, taking her to school each
28
1 day, and collecting her each evening.
2 Before I describe Victoria's arrival in Britain, and
3 her first contact with the agencies concerned, it might
4 be helpful if I outline the structure of those agencies.
5 The terms of reference for this Inquiry makes clear
6 that its focus is to be the manner in which
7 Social Services, health services and the police
8 discharge their functions in relation to Kouao, Victoria
9 and Manning.
10 In order to put the matter into context, as
11 I consider the structure of each agency, I will mention
12 briefly when it was that Victoria came into contact with
13 those agencies. I will return later to deal in more
14 detail with the precise circumstances of these contacts.
15 First, social services. Local authority social
16 service functions in relation to safeguarding and
17 promoting the welfare of children are consolidated in
18 the Children Act 1989, but the only statutory provision
19 governing how those social service functions are
20 delivered are those set out in the Local Authority
21 Social Services Act of 1970.
22 Section 2 provides that each local authority shall
23 establish a Social Services Committee, to which the
24 local authority Social Services functions must be
25 referred.
29
1 Section 7 requires local authorities to act in their
2 social service functions under the general guidance of
3 the Secretary of State.
4 In 1991, the Department of Health issued guidance
5 under section 7 on inter-agency working arrangements.
6 The publication known as "Working Together Under the
7 Children Act" has become of critical importance in the
8 work of all agencies concerned with safeguarding and
9 promoting the welfare of children.
10 A successor to "Working Together" entitled "Working
11 Together To Safeguard Children" was published by the
12 Department of Health after lengthy consultation in
13 December 1999. Given the period identified as relevant
14 for the purpose of the Inquiry, it is to the 1991
15 version that we will primarily need to refer. A copy of
16 it is to be found at page 2/1 in the red bundles that
17 were distributed this morning.
18 Paragraph 2.4 of the 1991 version describes the need
19 for a joint forum in each local authority area to be
20 known as the Area Child Protection Committee, for
21 developing, monitoring and reviewing child protection
22 policies.
23 Paragraph 2.9 states that the lead responsibility
24 for the appointment of the Chair and the Secretariat
25 should rest with social services departments. Local
30
1 authority functions in relation to housing are set out
2 in parts 6 and 7 of the Housing Act 1996. That
3 legislation is supported by a Code of Guidance.
4 Throughout the relevant period and to date, that
5 guidance was only in draft form.
6 During the relevant period, Victoria and Kouao were
7 known to three local authorities: Ealing, Brent and
8 Haringey. I want to say a little about each of them.
9 A fourth, Enfield, was involved to the extent that they
10 provided the hospital social work team at North
11 Middlesex Hospital where Victoria was admitted on 24th
12 July 1999. Enfield liaised with Haringey Social Services
13 under an agreement in respect of the Haringey residents.
14 As we shall hear, on 26th April 1999, Kouao,
15 accompanied by Victoria, attended the Homeless Persons
16 Unit run by Ealing's Housing Department in the Acton
17 area office, and was subsequently referred to social
18 services.
19 At the time, Ealing's housing and social services
20 departments operated as two separate directorates,
21 accountable to the Chief Executive. The Chief Executive
22 has overall responsibility for the efficient management
23 and execution of the Council's functions and statutory
24 obligations. An organogram showing the relevant
25 elements in the structure of Ealing's social services
31
1 and housing departments can be found at page 01/098 and
2 following in the red bundles.
3 The responsibility for the delivery of children's
4 services within the borough rested with the Assistant
5 Director of Children's Services, who also acted as Chair
6 of Ealing's Child Protection Committee, and was directly
7 accountable to the Director of Social Services.
8 Following a critical Social Services Inspectorate
9 inspection, Ealing was placed on "special measures" in
10 December of 1997, and was being actively monitored by
11 the Department of Health. A part of Ealing's response
12 was to reorganise children's services under five
13 operations managers. These managers were directly
14 accountable to John Skinner, Assistant Director
15 Children's Services. During the relevant period, Judith
16 Finlay was the operations manager responsible for all
17 Children's Services provided from the Acton area office.
18 There was a dedicated referral and assessment team that
19 handled all new referrals and initial assessments. The
20 team comprised a team manager, Sarah Stollard; a senior
21 practitioner, Sharmain Lawrence; and on average eight
22 social workers and three group assistants. One of the
23 social workers was Pamela Fortune, who was allocated
24 Victoria's case in June 1999.
25 Next, Brent.
32
1 Victoria came to the attention of Brent Social
2 Services on two separate occasions. The first was as
3 a result of an anonymous phone call on 18th June to one
4 of Brent's one-stop-shops. The second was following
5 a phone call from a paediatric registrar at the
6 Central Middlesex Hospital, where Victoria had been
7 admitted on 14th July. Both phone calls relayed child
8 protection concerns.
9 As with Ealing, Brent's housing and social services
10 departments operate at two separate directorates, whose
11 directors report to the Chief Executive. The organogram
12 showing the structure of Brent social services
13 department is at page 1/103.
14 The functions of the local authority were delivered
15 by a range of business units. Lucille Thomas was the
16 Business Unit Director for the children's social work
17 unit, reporting to the Director of Social Services. She
18 was responsible for all aspects of Brent's childcare
19 services.
20 From mid July 1999, David Charlett, as
21 Assistant Director, Child Protection, took on management
22 accountability for both the duty team and the
23 Child Protection Investigation and Assessment Team,
24 reporting directly to Lucille Thomas. The duty team
25 received referrals and undertook child in need
33
1 assessments. The Child Protection Team was responsible
2 for undertaking all investigations under section 47 of
3 the Children Act 1989.
4 Those two teams shared a room, and were managed by
5 a manager, and supported by two senior social workers,
6 who in turn supervised the social workers in the teams.
7 Michelle Hines, who was allocated Victoria's case
8 following the 14th July hospital referral, was one of
9 the senior social workers in the team, reporting to
10 Tina Roper, the team manager.
11 Next, Haringey.
12 Victoria came to Haringey's attention after an
13 admission to the North Middlesex Hospital on 24th July.
14 Haringey had no social work presence at NMH, but in
15 accordance with a service level agreement with Enfield
16 Social Services, had arranged for the Enfield Hospital
17 Social Work Team to pass on any hospital referrals in
18 relation to Haringey residents direct to the
19 Haringey Duty Team.
20 The Assistant Director for Children's Services in
21 Haringey during the relevant period was Carol Wilson.
22 She reported to Mary Richardson, who at the time was
23 director of both Housing and Social Services. The
24 organogram showing the structure of Haringey Social
25 Services department is at 01/102 in the red files.
34
1 The arrangements for the management of Children's
2 Services changed in practice in April 1999, when all
3 Children's Services were brought together under one
4 manager. Within Carol Wilson's command were, amongst
5 others, the Commissioning Managers Children and Families
6 for the two area offices of North Tottenham and Hornsey;
7 the Commissioning Manager Access Services, who was
8 responsible for the emergency duty team, and the
9 Service Manager, Child Protection Quality and Review,
10 who was responsible for child protection advisors.
11 Haringey went through a major restructuring exercise
12 in 1999. In September of that year, Dave Duncan, who
13 had until then been Acting Commissioning Manager
14 Children and Families for the North Tottenham office,
15 became Commissioning Manager Children and Families for
16 both North Tottenham and the Hornsey area offices.
17 It was to Caroline Rogers at the North Tottenham
18 Children's Social Services duty office that Karen Johns
19 of the Enfield North Middlesex Social Work Team first
20 referred Victoria's case on 27th July 1999.
21 Lisa Arthurworrey, who was allocated Victoria's case
22 on 29th July, was a social worker in the Investigation
23 and Assessment B Team. Her senior practitioner was
24 Barry Almeida, and her team manager was Carol Baptiste.
25 From January 2000, and as part of the restructuring,
35
1 the numbers of team managers was halved and the numbers
2 of senior practitioners -- renamed "practice managers"
3 -- increased. As a result, the two investigation and
4 assessment teams were merged under the management of
5 Angela Mairs, and three practice managers, including
6 Barry Almeida and Rose Kozinos.
7 Second, to Health Services.
8 In the period prior to Victoria's first admission to
9 hospital on 24th February 2000, she and Kouao had been
10 associated with three general practitioners and two
11 hospitals in two separate London Health Authorities.
12 I will deal with general practice first.
13 (11.00 am)
14 On 8th June 1999, Victoria was registered with
15 Dr I Patel. His surgery is close to the bed and
16 breakfast accommodation in Nicoll Road, Harlesden where,
17 as we will hear, Victoria and Kouao were placed by the
18 London Borough of Ealing at the end of April 1999.
19 On 30th June 1999, Kouao registered herself with
20 Dr GK Israni of the Greenhill Park Medical Centre, and
21 was seen just once by Dr Israni on the occasion of her
22 registration. This practice is separate from that of
23 Dr Patel's, but is also located close to the address in
24 Nicoll Road.
25 At the point of Victoria's registration in early
36
1 June 1999, she was seen by a practice nurse. However,
2 in line with what we believe to be fairly typical
3 practice, the GP did not see Victoria at the time of her
4 registration. Victoria was not taken to see a doctor at
5 this practice at any time subsequent to this.
6 On 20th July, Kouao registered herself at the
7 practice of Dr Barnett at the Somerset Gardens practice,
8 London N17. This practice is close to the flat owned by
9 Carl Manning, where, as we shall hear, Victoria and
10 Kouao moved in early July 1999. Kouao's registered
11 address for this practice was Manning's flat. Kouao
12 made several visits to this surgery on her own account,
13 between 20th July 1999 and February of 2000.
14 On 24th November, Victoria was also registered with
15 the Somerset Gardens practice. However, as with her
16 previous registration in June, at no time was she seen
17 by a practice doctor.
18 When a registered patient moves between general
19 practice, a medical notes transfer system operates, and
20 that is standard across the country. General practice
21 registration requires the completion of a form which is
22 then signed, either by the patient or, in the case of
23 a child, on his or her behalf by the parent. The
24 registration form is then sent to the general practice's
25 host health authority, and the host health authority
37
1 requests the general practice medical notes from the
2 previous health authority. That authority obtains the
3 medical notes from the GP, checks them out, and sends
4 them on to the new health authority where they are
5 checked in and forwarded to the new GP. That process
6 routinely takes between six and eight weeks.
7 Thus, on 21st December 1999, in line with this
8 administrative process, although taking somewhat longer
9 than usual, Kouao's general practice records relating to
10 her registration with Dr Israni were received at the
11 Somerset Gardens practice. Victoria's previous general
12 practice records were received at the Somerset Gardens
13 practice some time after her death.
14 During the relevant period, both Victoria and Kouao
15 had contact with hospital services. I shall address
16 these in more detail later. However, despite the fact
17 that each of them had registered with a general
18 practice, the identity of the GP was never recorded in
19 either Victoria or Kouao's hospital notes. The reasons
20 for that are unclear.
21 I turn now to Victoria's hospital attendances. On
22 Wednesday, 14th July, Victoria was taken to the Accident
23 and Emergency Department of the Central Middlesex
24 Hospital. CMH is just over a mile by road from the
25 address in Nicoll Road. An organogram showing the
38
1 structure of the CMH is at 01/097 of the red files.
2 Following an initial consultation in A&E, Victoria
3 was admitted to the Barnaby Bear Ward for assessment.
4 She remained on the Barnaby Bear Ward overnight and was
5 discharged the following afternoon.
6 CMH is situated in north-west London, within Brent
7 and Harrow Health Authority. It is part of the
8 Northwest London NHS Trust. That Trust was formed on
9 1st April 1999 by the merger of the CMHNHS Trust with
10 the Northwick Park and St Mark's NHS Trust.
11 At hospital ward level, ward managers were
12 responsible to service managers for the day-to-day
13 running of their wards. However, where ward managers
14 were also members of the nursing staff, they were
15 additionally accountable to the Director of Nursing,
16 Graham -- now Sir Graham -- Morgan, for their
17 professional practice. In the same way, doctors were
18 accountable to the Medical Director for
19 Clinical Quality.
20 In July 1999, the Directorate of Paediatrics was
21 headed by the Clinical Director,
22 Dr Mary Bridget Edwards, now retired, and by Samantha
23 Jones, the Service Manager. The Barnaby Bear Ward was
24 managed by Nurse Paula Johnson.
25 As well as Clinical Director of the Directorate of
39
1 Paediatrics, Dr Edwards held the role of the
2 Health Authority's Designated Doctor for Child
3 Protection for Parkside NHS Trust, linking directly in
4 this capacity with the Brent Area Child Protection
5 Committee, of which she was Vice Chair.
6 Dr Edwards' role as Clinical Director of the
7 Paediatric Directorate was to co-ordinate and facilitate
8 medical inputs to the Paediatric Directorate. That work
9 included managing her fellow Trust consultant
10 paediatricians, one of whom was Dr Ruby Schwartz. As
11 well as Consultant Paediatrician, Dr Schwartz acted as
12 the CMH's named doctor for child protection.
13 On Saturday, 24th July 1999, Victoria was taken by
14 Kouao to the Accident and Emergency Department of the
15 North Middlesex Hospital. The NMH is just over half
16 a mile by road from Manning's flat in Somerset Gardens.
17 That hospital is part of Barnet, Enfield and
18 Haringey Health Authority.
19 In 1999, NMH was a Trust in its own right, the North
20 Middlesex NHS Trust. The Trust board comprised, amongst
21 others, a Chief Executive and four executive directors.
22 The executive directors assumed particular
23 responsibilities throughout the hospital. All directors
24 reported directly to the Chief Executive. Below the
25 executive team were a number of directorates, each
40
1 headed by a lead clinician and an operations manager.
2 The organogram showing the structure of the NMH is at
3 01/099 in the red files.
4 In 1999, the Paediatric Directorate lead clinician
5 was Dr Maud Meates; the operations manager was
6 Angela Gallagher, and the lead nurse was
7 Beatrice Norman. As lead nurse, she fulfilled the role
8 of named nurse for child protection at NMH.
9 Within the Paediatric Directorate, Dr Meates managed
10 the senior and junior medical staff. These included
11 Dr Mary Rossiter, who was also the named doctor child
12 protection role within the hospital, and the role of
13 designated doctor for child protection for Barnet,
14 Enfield and Haringey Health Authority. In that
15 capacity, Dr Rossiter had direct links with Haringey
16 Area Child Protection Committee.
17 The Health Authority's Designated Nurse child
18 protection in the community was Liz Fletcher, an
19 employee of Haringey Primary Care NHS Trust, another
20 Trust within Barnet, Enfield and Haringey Health
21 Authority. In the same way that Elizabeth Tyrell
22 established working links with CMH's named nurse for
23 child protection, so Liz Fletcher would be required to
24 establish working links with community nurses and with
25 North Middlesex Hospital's named nurse.
41
1 A word on the role of the designated and named
2 doctor and nurses for child protection. These terms
3 first appeared in 1991 in "Working Together under the
4 Children Act", the guide to arrangements for
5 inter-agency co-operation to which I have referred.
6 When commissioning child protection services, each
7 Health Authority must enlist the help of a senior doctor
8 and nurse experienced in child protection to advise on
9 the content of contracts in relation to the protection
10 of children. This is the role of the designated doctor
11 or nurse for child protection.
12 In addition to this, each provider unit concerned
13 with children should have the services of at least one
14 senior doctor or nurse with a high level of skill and
15 expertise in child protection. This senior nurse or
16 doctor should be able to identify the training needs of
17 medical and nursing staff working with children in
18 relation to child protection, so as to ensure that
19 proper protocols are in place in relation to child
20 protection, to ensure the provision of a source of
21 information and advice on child protection, and to act
22 as a reference point for other agencies, for example
23 social services, so that advice is co-ordinated for
24 these bodies.
25 In effect, the named doctor and nurse for child
42
1 protection are the field experts in all aspects of child
2 protection, and are expected to lead their professional
3 colleagues in matters relating to the protection of
4 children within their working environments.
5 On the occasions of both admissions to hospital, an
6 A&E doctor identified Victoria's presenting complaint as
7 indicative of abuse and so, in line with internal
8 protocols, referred her on to a higher medical authority
9 within the hospital. On both occasions, Victoria was
10 seen eventually by the hospital's named doctor for child
11 protection, with outcomes we will hear more of in a
12 moment.
13 Third, the Met.
14 The Metropolitan Police has undergone a number of
15 structural changes over the last two or three years.
16 A proper appreciation of the responses to Victoria's
17 case necessitates an understanding of those changes.
18 Since April 2000, the basic street-level policing of
19 London has been carried out by 33 Borough Operational
20 Command Units, BOCUs. 32 of those BOCUs operate to the
21 same boundaries as the 32 London boroughs. One BOCU is
22 dedicated to Heathrow Airport. The senior officer in
23 each BOCU is normally of Chief Superintendent rank, and
24 he reports directly to the Assistant Commissioner
25 (Territorial Policing) at Scotland Yard. Overlaid
43
1 across this structure are units dealing with specialist
2 types of policing, including child protection. These
3 are controlled from the centre by the Assistant
4 Commissioner (Specialist Operations).
5 Until early 2000, however, there was an extra tier
6 of command known as the Area Tier. There had originally
7 been five areas in the Met. These included the
8 north-east area, known as 3 Area, and the north-west
9 area, known as 2 Area. They were commanded by an
10 Assistant Commissioner and each was supported by two
11 commanders, one of whom was designated Commander
12 "Crime". These areas were about the size of a medium
13 provincial police force.
14 The work of each area was divided between operation
15 command units (OCUs). The officer in charge of each
16 Crime OCU was formally a Detective Chief Superintendent.
17 Until the end of February 1999, the Commander
18 (Crime) of the north-east area was David Kendrick.
19 Commander Kendrick also had a force-wide portfolio
20 responsibility for child protection policy, although he
21 was not in operational command of the CPTs that were
22 outside his area. On his retirement, she was succeeded
23 by Michael Craik. The Commander (Crime) for the
24 north-west area in April 1999 was Commander Campbell.
25 During April of 1999, the Metropolitan Police
44
1 service began a restructuring process. The structure,
2 which I shall now attempt to describe, is the one that
3 existed from the time of that restructuring process
4 through until April of 2000. It was this structure that
5 pertained throughout the period that Victoria was alive
6 in this country. An organogram of the arrangements as
7 we understand them can be found at 01/100 in the red
8 files.
9 In April 1999, the five areas were reduced to three.
10 Commander Campbell retired. The north-east and
11 north-west areas were amalgamated and Michael Craik
12 became the Commander (Crime) for the newly formed north
13 area. Mr Craik was directly accountable to Assistant
14 Commissioner Dunn, who had overall responsibility for
15 the policing of north area. Mr Dunn was in turn
16 accountable to the Deputy Commissioner and ultimately
17 the Commissioner, Sir Paul, now Lord, Condon.
18 Beneath area level, the structure was not greatly
19 altered by the reorganisation. The Northwest Crime OCU
20 and the Northeast OCU remained as they were. The
21 Northeast Crime Unit was headed by Detective Chief
22 Superintendent John Chaplin; the Northwest Unit by DCS
23 David Cox.
24 It is convenient now to trace the lines of
25 accountability down from David Cox to those directly
45
1 involved with Victoria. Answerable to Cox were two
2 Detective Superintendents. Initially, they were
3 Detective Superintendent Susan Ackers and
4 Detective Superintendent Camilleti. A third Detective
5 Superintendent was engaged, but by about the time that
6 Detective Superintendent Gary Copson arrived, Detective
7 Superintendent Ackers was transferred away.
8 Answerable to the Detective Superintendents was
9 a Detective Chief Inspector, Philip Wheeler. He had
10 a number of responsibilities in the Northwest Crime OCU.
11 These included managing informants, the firearms inquiry
12 team, the quality assurance unit and training. In
13 addition, he was responsible for the six child
14 protection teams, CPTs, in the area. Wheeler says that
15 he repeatedly pointed out to his superiors that his
16 workload and number of roles was excessive.
17 All these CPTs were borough based. During 1999,
18 there were six or seven -- the statements we have
19 received are ambiguous -- CP teams in north-west London
20 under the command of DCI Wheeler. They include the
21 Haringey team based at Highgate police station and the
22 Brent team based at Edgware police station. The officer
23 in charge of Haringey was DI Howard. His team included
24 Sergeants Bird, Hodges and Cooper-Bland. PS Bird was the
25 line manager of PC Jones, the officer who had direct
46
1 responsibility for Victoria's case in Haringey.
2 The officer in charge of Brent was DI Anderson. His
3 team included Police Sergeants Smith and Gorry and
4 PC Dewar, who had responsibility for Victoria's case in
5 Brent. It is unclear to us at present who was supposed
6 to be PC Dewar's line manager.
7 This structure ought to have provided the means for
8 providing proper supervision. Whether that happened in
9 practice, however, is open to doubt. Both DIs Howard
10 and Anderson thought that DCI Wheeler was their manager,
11 but he says he was not. He says that he had been told
12 that his role in the relations of the CP teams was
13 "merely administrative support", not meaningful
14 supervision.
15 I turn next to Victoria's life in this country. As
16 I describe these events, photographs of the places she
17 lived and the premises she visited will be displayed on
18 the screen.
19 We cannot as yet be certain as to the date when
20 Kouao and Victoria came to England. Since Kouao was
21 a French national, there is no immigration record of her
22 arrival in this country. Kouao told some of the
23 agencies concerned, and alleged in the criminal trial,
24 that they arrived in March, but our papers include
25 a copy of the airport ticket produced by Kouao to Ealing
47
1 to establish her identity. That suggests that Kouao and
2 Victoria flew by British Midland from Paris to London on
3 24th April 1999. That is consistent with documents from
4 a French travel company which appear to show that Kouao
5 made arrangements in France to rent a double room in bed
6 and breakfast accommodation in Ealing. It is also
7 consistent with the evidence of the owner of the bed and
8 breakfast accommodation, a Mrs Mandic, who says that
9 Victoria and Kouao stayed at her house in Acton between
10 24th April and 1st May 1999.
11 It would appear that from early on, Kouao wanted to
12 stay in England for rather longer. Within days of
13 arriving in England, she made enquiries of the London
14 Borough of Ealing with a view to obtaining accommodation
15 and financial assistance for herself and Victoria. Then
16 at the end of her week, she was asking Mrs Mandic
17 whether she and Victoria could stay longer.
18 At about 4.30 in the afternoon of 25th April, Kouao
19 and Victoria arrived uninvited at the home
20 of Esther Ackah, a distant relative, in Hanwell, London
21 W7. Victoria was introduced to Mrs Ackah as "Anna".
22 The first thing she noticed was that the little girl was
23 wearing a wig. Later that afternoon, Mrs Ackah took
24 Kouao and Victoria to meet her daughter, Grace. Early
25 on in that meeting, Grace confronted Kouao, suggesting
48
1 it was not right to put an adult's wig on a child like
2 Victoria. Grace removed the wig from Victoria's head.
3 It was immediately apparent that she had no hair, and
4 that her scalp was covered in patchy marks. Grace was
5 also struck by how small and frail Victoria looked.
6 On 26th April, Kouao attended Ealing Homeless
7 Persons Unit in accordance with an appointment that had
8 been made for her. She was seen by Julie Winter,
9 a Homeless Persons Officer. Kouao spoke to Miss Winter
10 in English, indicating that although Victoria spoke only
11 French, she did not need a French interpreter.
12 Initially, Kouao indicated that she had three other
13 children, but subsequently informed Miss Winter that
14 they were in France. Kouao provided documentation to
15 confirm her identification, and proof of the date of her
16 arrival in the UK. She told Miss Winter that both she
17 and Victoria were in good health, that she was not
18 registered with a GP and that she was currently
19 unemployed. She said that her purpose in coming to the
20 UK was to spend one year here to improve her English.
21 She had obtained seven nights accommodation in a B&B as
22 part of the flight package. She had no other
23 accommodation once that period expired.
24 Kouao said that she had resided in France since
25 birth, and that her other children were still being
49
1 educated there.
2 Unsurprisingly, Ms Winter concluded that Kouao was
3 not habitually resident in the UK. Her ties at that
4 stage were with France, rather than this country. She
5 had no well worked out plans for staying in this
6 country, and admitted that she did not intend to
7 resettle here.
8 Ms Winter suspected that Kouao was not eligible for
9 assistance with rehousing, but agreed to discuss the
10 matter with a senior officer. Having done so, she
11 confirmed to Kouao that she was not eligible for
12 rehousing. It appears that Victoria understood the gist
13 of that response. For the first time she spoke, and
14 implored Miss Winter in French to find "une maison" for
15 her. She was tearful. Miss Winter advised Kouao that
16 she might obtain assistance from social services under
17 the National Assistance Act as someone who was destitute
18 and responsible for a dependent child. An appointment
19 was made for Kouao to attend the relevant offices on
20 30th April.
21 The following day, 27th April, Kouao returned to the
22 Council offices. She saw Mr William Martin, a social
23 worker in the emergency duty team, and requested money
24 for food and essential items. She gave Mr Martin her
25 French social security number. Mr Martin telephoned the
50
|
