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Archived Transcript for 27 September 2001: Pages
1 to 50
1
1 Thursday, 27th January 2001
2 (10.00 am)
3 THE CHAIRMAN: Good morning, ladies and gentlemen. Just
4 before I invite Mr Garnham to continue with the opening
5 of the public hearings, could I ask you again just to
6 make sure that mobile phones are switched off? Thank
7 you very much.
8 Mr Garnham?
9 MR GARNHAM: Thank you, sir. Before I begin, can I just
10 indicate our proposed timetable for today? I expect
11 that I have got about 45 minutes or an hour left of my
12 opening statement, and then, sir, with your leave, we
13 will break for 10 or 15 minutes to enable people to sort
14 themselves out, and during that time copies of the
15 opening statement will be distributed to anybody here
16 who wants them in their final form, and then perhaps
17 after the break we can resume with the first of the
18 opening statements, which is to be made on behalf of the
19 Climbie family.
20 THE CHAIRMAN: I am grateful to you.
21 Opening statement by MR GARNHAM (continued)
22 MR GARNHAM: Sir, I ended yesterday by describing the manner
23 in which the relevant social services departments had
24 responded to the tragedy of Victoria's death. I now
25 turn to the response of the Health Service. Although
2
1 the response of the hospitals to Victoria's death has
2 been more muted, a number of significant amendments to
3 their guidelines and procedures have, it seems to us,
4 been put into effect. The extent to which these
5 amendments have been translated into tangible
6 improvements to the services offered to children will,
7 of course, require further exploration.
8 The Central Middlesex Hospital has undertaken no
9 internal review of its systems and procedures of which
10 we are aware. However, several of the recommendations
11 by the Brent Part 8 Review published in April of this
12 year to which I referred yesterday concerned the Central
13 Middlesex, and it would appear that some action has been
14 taken in response to them.
15 According to Dr Peter Lachman, the Clinical Director
16 for the Women and Children Services Directorate of the
17 Trust, the hospital's paediatric child protection record
18 has been provisionally amended to incorporate the
19 recommendations made in that Part 8 report. In
20 addition, Dr Schwartz has drafted an amended set of
21 Child Protection Guidelines for use at the hospital,
22 several of which seem to us to address particular
23 deficiencies that were revealed by Victoria's case.
24 Notably, all children who are placed under police
25 protection must now be seen by a social worker before
3
1 that protection is lifted.
2 The hospital's education service is to conduct daily
3 checks to ascertain whether each school age child
4 admitted to the hospital is attending school. If it is
5 found that such a child is not enrolled in the school,
6 he or she will be referred to the education welfare
7 service.
8 No child who is suspected of having been abused will
9 be discharged, it is said, without being reviewed by
10 a consultant paediatrician and assessed by a social
11 worker.
12 Some action has been taken at the North Middlesex.
13 According to Angela Gallagher, the Acting Assistant
14 Director of Operations for Acute Services at NMH, a
15 review of the hospital's child protection procedures was
16 commenced shortly after Victoria's death. It was
17 decided, however, that no major changes should be made
18 until after Haringey had completed their Part 8 review.
19 It was subsequently thought appropriate to await the
20 outcome firstly of the criminal trial of Kouao and
21 Manning and, secondly, this Inquiry before taking
22 significant steps.
23 Some work, however, has been done in the meantime.
24 Shortly after the conclusion of the criminal trial, the
25 Trust set up an Inquiry Team led by a Dr Drabu, the
4
1 Medical Director. The team made what seems to us to be
2 a series of apposite recommendations. Of particular
3 relevance would appear to be the following:
4 Firstly, where child protection concerns are
5 identified, a strategy meeting is to take place at the
6 hospital, at which a social worker is to be present.
7 Secondly, the lines of communication between health
8 professionals and social services is to be clarified and
9 improved.
10 Thirdly, only a consultant should discharge
11 a patient where child protection issues are involved.
12 It seems to us that a number of problems remain
13 unaddressed at present. One of the key concerns
14 identified by Dr Rossiter, both before and after
15 Victoria's death, was the absence of any Haringey social
16 services presence at the North Middlesex Hospital. You
17 will recall, sir, that in mid 1999, Haringey was reliant
18 on Enfield social workers to provide them with
19 information about children from their borough.
20 Despite Victoria's death, and the continuing
21 concerns of Dr Rossiter, there is, as we understand it,
22 still no Haringey social worker based at the North
23 Middlesex Hospital.
24 Finally, Victoria's case would appear to have
25 prompted Barnet, Enfield and Haringey Health Authority
5
1 to amend their Liaison Health Visiting guidelines so as
2 to include explicit procedures for dealing firstly with
3 school age children who attend hospital during school
4 holidays, and secondly with those children who are not
5 attending school at all. It would appear that the
6 purpose of these amendments is to address the conclusion
7 that previously existed as to the precise division of
8 responsibility between health visitors and school nurses
9 in relation to the follow-up of children like Victoria,
10 who are not attending a school.
11 I turn next, sir, to the police investigations after
12 Victoria's death. Following the death, the Metropolitan
13 Police commissioned an independent factual review of the
14 two police investigations concerning Victoria. That
15 review was called Operation Blue Martin. Although its
16 scope was narrow, and the enquiries it could make were
17 limited by concerns not to prejudice disciplinary
18 proceedings that might follow, the operation produced
19 a useful report.
20 It made a number of serious criticisms of Haringey
21 Child Protection Team.
22 First, there were found to be 28 separate areas of
23 concern highlighted on social services files that were
24 not mentioned on either CRIS report. These included
25 medical staff comments, such as the fact that Victoria
6
1 cried on the arrival of her "mother" but stopped when
2 she left; the fact that Victoria jumped to attention on
3 the arrival of her "mother", and the fact that Victoria
4 was frightened of her "mother's" partner.
5 Second, it was said that the three sergeants at
6 Haringey gave no active supervision to the investigating
7 officer, and the four supervising officers failed to
8 provide the assistance expected of them. It was pointed
9 out, however, that all four supervisors were being
10 expected to perform a function for which they had not
11 been trained.
12 Third, in a section entitled "Schedule of
13 Investigation", the investigators comment on a long
14 series of failures by the investigating officers in
15 respect of the crime report of 24th July and the crime
16 report of 1st November. Much of those comments mirror
17 observations made earlier in this opening statement.
18 The following comments, however, are particularly
19 worthy of note. It was said in the report that "12 days
20 after the start of the investigation" into the incident
21 of 24th July, the police had obtained no medical
22 statements, no photographs and no skeletal survey.
23 Medical ambiguities had not been addressed, there had
24 been no crime scene examination, no examination of the
25 hot water system, no local enquiries, no suspect
7
1 interview and no memorandum interview. The issues of
2 neglect had not been addressed, nor had the old
3 injuries. Finally, Manning had not been interviewed.
4 In respect of the investigation following the report
5 of 1st November, there was a similar list of errors and
6 omissions. The investigators talked about a totally
7 unacceptable delay between the report of 1st November
8 and the strategy meeting. There was said to be an
9 unacceptable delay in obtaining statements. It was
10 pointed out that there was no evidence to support the
11 assumption that the victim had returned to France, and
12 that it was totally unacceptable to close the matter
13 when child safety and welfare had not been assured.
14 On the face of it, those seem to be criticisms of
15 substance, and it will be necessary for the officers
16 concerned to address them with some care.
17 The Metropolitan Police also arranged a review of
18 Highgate Child Protection Team as a whole. That
19 investigation resulted in a report dated 8th March 2000,
20 prepared by DCI Philip Wheeler. Sir, it might be
21 thought that DCI Wheeler was a strange choice to
22 investigate the management of this particular CPT,
23 because as the Area Detective Chief Inspector, he had
24 the administrative responsibility for the team during
25 the period under investigation. Surprisingly,
8
1 DCI Wheeler takes the opportunity in this report to
2 comment on his own performance. He also provided the
3 police internal management review for the ACPC Part 8
4 review. It will be interesting to learn from him and
5 from his superiors why these arrangements were thought
6 appropriate.
7 Be that as it may, the report prepared by Mr Wheeler
8 is nothing short of devastating. He begins his
9 executive summary with the following words:
10 "The team reviewing Highgate CPT have found an
11 office bereft of administration systems and management
12 organisation. Supervision of case work has been poor
13 and unfortunately the Detective Inspector and Sergeants
14 have not played an active part in supervising their
15 officers to the full ... There is no disputing the fact
16 that the unit has been poorly managed and has drifted
17 into an administrative malaise."
18 Subsequently, DCI Wheeler said that that report was
19 not as harsh as it might have been. Specific criticisms
20 made of the team include the following: no supervisor
21 had responsibility for the files, and there was no
22 system for ownership of individual cases. The
23 administration of the CPT was in a mess, with no system
24 to ensure quality control of cases. There was no real
25 system for the allocation of work, and the recording of
9
1 officers' workload.
2 There seemed to be a collective lack of knowledge of
3 the procedure for creating and using files. The
4 structure for the exchange of information between the
5 police and social services needed to be finalised.
6 In addition, staff reported a lack of training, and
7 it was said that computer equipment was old and should
8 be reviewed with a view to replacing them. One would
9 have expected that after so damning an indictment had
10 been framed, steps would have been taken urgently to put
11 the matter right. Not so, it seems. A follow-up visit
12 to Haringey CPT was arranged for 30th March.
13 DCI Wheeler reports that he was "dismayed to find that
14 some of the remedial action I had requested to take
15 place had not been taken".
16 He concluded that report with the following
17 observation:
18 "The office now needs to be managed by DI Howard,
19 and the officers themselves need to realise that they
20 cannot continue to drift into work at hours to suit
21 themselves."
22 One has to pinch oneself to remember that this
23 criticism is made within six weeks of Haringey CPT
24 discovering that a child whose care had recently been
25 the subject of investigation by them had been tortured
10
1 and murdered by her carers.
2 The response of some officers seems to have been
3 that they believe they were being bullied by
4 DCI Wheeler. Sir, it will be a matter for you to
5 consider, but it seems to us that there was something
6 rotten in the state of Haringey CPT.
7 It is not as yet apparent to us why no similar
8 inspections were undertaken in respect of Brent CPT. On
9 the face of it, there were grounds for similar criticism
10 in respect of their investigation in July 1999. There
11 would appear to be some evidence that the Metropolitan
12 Police have begun to appreciate the need for substantial
13 reform in the organisation of CPTs.
14 The Serious Crime Group's Policing Performance Plan,
15 published in March this year, suggests that the Met have
16 already begun to learn the lessons of Victoria's case.
17 In the introduction, Detective Chief Superintendent
18 Derrick Kelleher explains how the inclusion of child
19 protection within the terms of reference of the new
20 Serious Crime Group is intended to send a message that
21 child protection is high on the MPS agenda. Mr Kelleher
22 acknowledges the need "to change the internal culture"
23 and to lay down professional standards that will "enrich
24 the MPS contribution to the 'working together'
25 framework". We look forward to learning how that
11
1 admirable ambition has been translated into practice.
2 The final part of this opening, sir, I devote to the
3 proper approach to evidence, and to the procedure for
4 this Inquiry. This Inquiry is an investigation. We are
5 here neither to hunt witches nor to gloss over mistakes.
6 We aim to discover not only where mistakes were made,
7 but also why they were made, and how it was that
8 structures designed to mitigate against the consequences
9 of human error failed to operate effectively.
10 As we do so, we must, we suggest, sir, remember the
11 very many cases in which the present arrangements have
12 worked effectively. Hundreds of children benefit every
13 year from efficient and timely intervention by social
14 workers, police officers and hospital staff. We would
15 do children like Victoria no favours if we demonise
16 entire professions as we seek to understand and remedy
17 the weaknesses and deficiencies highlighted by a single
18 case.
19 This Inquiry has the benefit of hindsight, and the
20 luxury of time to think. We must use those advantages
21 constructively, remembering that those whose actions we
22 are to consider seldom had either. The benefits and
23 dangers of hindsight have been considered in previous
24 inquiries. The Committee of Inquiry into the death of
25 Malcolm Page in 1981 said this:
12
1 "In our view the only proper criterion is to look at
2 decisions and actions within the context in which they
3 were made or taken and this context must necessarily
4 encompass the knowledge and experience of the
5 individuals involved and the pressures on the agencies
6 for which they worked."
7 The Panel of Inquiry into the circumstances
8 surrounding the death of Jasmine Beckford suggested that
9 that approach was not adequate. They said:
10 "In our view, in arriving at a sound judgment of
11 past conduct, we are helped rather than hindered by
12 hindsight, so long as we remind ourselves (as we do) of
13 certain basic principles. In judging the actions of
14 social workers or health visitors as at a particular
15 time, we should ask ourselves what such persons did
16 know, ought to have known, did foresee and ought to have
17 foreseen at that time, bearing in mind all relevant
18 circumstances. We are entitled to judge a person's
19 actions by reference to what was and should reasonably
20 have been in his or her mind at the relevant time. We
21 are not entitled to blame him or her for not knowing or
22 foreseeing what a reasonable person would neither have
23 known nor foreseen."
24 With that approach, sir, counsel to this Inquiry
25 respectfully agree.
13
1 Before turning to procedural matters, I would wish
2 to pay tribute to the enormous effort of the Secretariat
3 in preparing for these hearings. They have turned what
4 was a scruffy floor of a Government office block into
5 a well-designed, well-equipped hearing room. They have
6 turned a vast quantity of loosely sorted materials
7 supplied in response to our requests into a well
8 structured and well organised collection of documents.
9 They have produced a searchable electronic index,
10 incorporating a brief description of all the documents
11 in the bundle, which is a positive pleasure to use.
12 They have obtained witness statements from over 237
13 witnesses, cross-referenced their statements to the
14 documents, and collected the statements together in
15 sensibly arranged bundles. And they have done all that
16 on time and on budget. We for our part, sir, are
17 extremely grateful.
18 At the end of July, we circulated to interested
19 parties the Inquiry's main bundles of documents. These
20 bundles run to 56 volumes and are contained in the black
21 files. They represent a selection from the material
22 gathered in over the last few months. The test we have
23 applied in including material has been "apparent
24 relevance" to the list of issues. It is inevitable that
25 on occasions we will have excluded some documents that
14
1 prove to have some relevance, and I apologise in advance
2 for that. However, where we have judged that material
3 supplied to us does not satisfy the test that I have set
4 out, it has been filed, indexed and retained, so that it
5 can be added to the bundles when necessary.
6 We have selected from the main Inquiry bundles
7 a small quantity of material that seems to us to be
8 critical to the Inquiry's business in Phase 1. This is
9 contained in the two red files, and we have called these
10 the core bundles. They were circulated to the
11 interested parties yesterday morning. The first volume
12 contains core material specific to Victoria's case; the
13 second contains core material of general application.
14 Most of this material is also found in the main bundles.
15 The reason for duplicating it in the core is to provide
16 an easily accessible collection of the material which we
17 anticipate will be referred to most frequently.
18 Amongst the documents in core bundle 1 are a number
19 of documents generated by the Inquiry team. Copies of
20 this material have been made available to the press and
21 the public. At first, there is a detailed chronology.
22 We would invite interested parties to read that
23 carefully, and let us know as soon as is convenient any
24 corrections that are required. We aim to present that
25 to you, sir, in a final form before the end of Phase 1,
15
1 as an agreed document that will help you construct your
2 final report. It is for that reason that I stress the
3 importance of interested parties considering that
4 document with some care.
5 Second, there is a collection of organograms,
6 describing in diagrammatic form what we understand to be
7 the relevant structures of the agencies. I have already
8 referred to those diagrams in the course of this
9 opening. Again, we would be grateful for corrections
10 from the organisations concerned of any errors in those
11 documents. We envisage using them as a working guide
12 during the course of the Inquiry.
13 Only interested parties who have signed
14 a confidentiality undertaking have been provided with
15 copies of the Inquiry's bundles. That undertaking, sir,
16 we would invite you strictly to enforce. I should make
17 clear, for the avoidance of doubt, that it is our view,
18 and I understand to be yours as well, sir, that on
19 a proper interpretation of the undertaking, it is
20 entirely permissible for interested parties to show the
21 documents to witnesses called by the Inquiry whom they
22 represent.
23 Witnesses who are not represented by those acting
24 for interested parties will be permitted sight of
25 relevant documentation in advance of giving evidence if
16
1 they wish, upon signing a similar undertaking.
2 Sir, the Inquiry is keen to facilitate the accurate
3 reporting of its proceedings, and it may be that the
4 press will want to have sight of documentation for that
5 purpose. If the material concerned is already in the
6 public domain, so that there will be no breach of
7 confidentiality in disclosing it to journalists, it will
8 be provided on request. Where the documents concerned
9 are confidential or sensitive, there will be no
10 disclosure to the media, except on your direction. We
11 would invite you, sir, to give such directions in
12 public, and only having heard from all those with a
13 legitimate interest.
14 You have indicated, sir, that you and your assessors
15 will have regard, during the course of this Inquiry, to
16 various reports and publications that are already
17 publicly available. To ensure that the interested
18 parties and others know precisely what documentation of
19 this sort is to be taken into account by this Inquiry,
20 the Secretariat will maintain a library list. A copy of
21 that list in its current form is included in the red
22 bundles that we have produced.
23 Next, sir, witnesses. We have also produced and
24 circulated a bundle of witness statements divided into
25 seven volumes. These are the seven green files. That
17
1 bundle contains copies of statements received from
2 witnesses whom we envisage either calling to give
3 evidence or inviting the Inquiry to read. We have
4 circulated to interested parties and published on our
5 website a provisional schedule, setting out the dates on
6 which we propose calling witnesses. That schedule also
7 identifies the statements we intend inviting you simply
8 to read. The status of evidence given orally and
9 evidence read is identical. We propose calling
10 witnesses whose evidence is either critical to an
11 understanding of Victoria's life here, or is both
12 important and potentially controversial.
13 I should make it clear that we remain willing to
14 consider requests from any quarter for us to add to the
15 lists of witnesses to be called, to add to the list of
16 statements to be read, or to alter the way in which we
17 propose handling the evidence of any individual witness.
18 We are also happy to consider any request to alter
19 the order shown in the schedule, whether to meet the
20 personal convenience of witnesses, or to ensure fairness
21 to those likely to be criticised. In general, our
22 approach has been to call witnesses in ascending order
23 of seniority. That seems to us generally to be
24 preferable, because those who supervise ought to be
25 asked about the actions of their supervisees, having
18
1 heard them give their evidence.
2 We are conscious, however, that there may be good
3 reasons to vary that approach; in particular, where an
4 individual fears that they may be subject to criticism
5 by witnesses who are timetabled to appear after them.
6 We will consider sympathetically requests that they
7 ought to be heard later.
8 In the ordinary course, sir, we would invite you to
9 permit all witnesses who are due to give evidence, or
10 who have already given evidence, to remain in this room
11 if they so choose. There may be occasions, however,
12 when it will be appropriate for us to invite you to
13 direct that particular witnesses remain outside this
14 hearing room until the time has come for them to be
15 called.
16 In the case of most witnesses, we will invite you to
17 treat their statements as evidence-in-chief. We do not
18 propose taking witnesses through these statements
19 paragraph by paragraph, but will work on the assumption
20 that you, sir, and your colleagues have read the
21 statements before the witness is called. The purpose of
22 our questioning will then be primarily to explore
23 questions that arise from the written statements, and
24 apparent conflicts between the evidence of different
25 witnesses. It may be more convenient in the case of
19
1 some witnesses, most notably Victoria's parents, for us
2 to take them through their statements in rather more
3 detail.
4 For entirely understandable reasons, both logistical
5 and emotional, Mr Climbie's statement was not supplied
6 to us until late on Tuesday evening, and we still await
7 the statement of his wife. We will distribute these
8 statements as soon as we are able, but it may be that
9 our procedures will need to be a little more flexible
10 when they give their evidence tomorrow.
11 (10.30 am)
12 It follows from what I have said that members of the
13 public and the press will not hear all of the evidence
14 which you will be taking into account. Accordingly, we
15 will make available to them copies of the witness
16 statements once the witness has been sworn. Or in the
17 case of those statements that are read, once the
18 statement has been read or summarised.
19 In your statement, sir, to the preliminary meeting
20 in May of this year, you indicated that the Inquiry
21 would adopt a procedure that enabled those who might be
22 criticised properly to address the proposed criticism.
23 The procedure we propose adopting is set out in the
24 procedural guide contained in the red bundles. In
25 essence, we will seek to ensure that where our reading
20
1 of the documentation suggests that there may be grounds
2 for criticism, the agency concerned will receive
3 a letter at least seven days in advance of the date on
4 which the witnesses are to be called, setting out the
5 gist of the possible criticism, both against the
6 organisation as a whole and the relevant members of
7 staff.
8 We have already sent out a number of notices of
9 potential criticism, giving parties rather more than the
10 seven days' notice we promised. We will endeavour to
11 keep ahead of schedule with other parties' notices as
12 well.
13 Sir, the Inquiry has sought statements from both
14 Manning and Kouao. Manning has responded
15 constructively, and his statement is in volume 7 of the
16 green files. Kouao refused to answer any of our
17 questions when a solicitor instructed by the Inquiry
18 visited her in Durham Prison. We are now considering
19 the best way to elicit their evidence, and would be
20 happy to consider representations from any interested
21 party on that subject.
22 Sir, we circulated yesterday a short framework
23 document relating to phase 2 of this Inquiry. A copy
24 will be sent to those who have already expressed an
25 interest in that work, and again, there is a copy in the
21
1 red files. The notice will also be displayed on the
2 Inquiry's website. We would invite recipients to
3 respond to that notice by no later than 5th November.
4 Sir, consistent with your wish to ensure that this
5 Inquiry is conducted in an open and transparent manner,
6 it seems to us that it would be right if we indicate
7 publicly the nature of the relationship between counsel
8 to this Inquiry on the one hand and you and your
9 assessors on the other.
10 We understand there to be two primary elements to
11 our role. First, to present to you the evidence that we
12 consider relevant to the issues that you have to
13 address. Second, to advise you on matters of law and
14 evidence. Our position is not the same as counsel
15 representing one party in a court of law. It is right
16 that those observing or taking part in this Inquiry
17 should know from the outset that one inevitable
18 consequence of our dual role is that there will be a far
19 greater level of communication between counsel to the
20 Inquiry and the Chair than would be the case in an
21 ordinary court or tribunal.
22 Sir, it is inevitable that there will be those
23 hearing this opening who will disagree with some of what
24 they have heard. I repeat, this opening statement is
25 based on the material we have seen to date. It is not
22
1 to be taken as setting out the concluded view of counsel
2 to the Inquiry, let alone of the Inquiry itself. But we
3 hope that by exposing our thinking thus far, it will
4 provoke further thought and comment.
5 It may well be that interested parties will wish to
6 put forward a different analysis of the available
7 material in their opening statements which are to
8 follow. But it is to the evidence of the witnesses that
9 the Inquiry must look for definitive answers.
10 It is hardly possible, sir, for us to imagine the
11 grief and anger felt by Victoria's family and friends on
12 learning of the circumstances of her death. Many who
13 did not know Victoria shared that anger. There are
14 occasions on which anger is not only justified but can
15 be fashioned into a force for good. It gives us, sir,
16 a keen resolve to discover the truth. It will be our
17 submission that this Inquiry should look for signs of
18 change, rather than for excuses.
19 What is most needed is not more protocols and
20 procedural documentation, although that may have its
21 place, but a change in mindset, and a willingness to
22 learn from the tragedy of Victoria's death. Thank you,
23 sir.
24 THE CHAIRMAN: Thank you very much indeed, Mr Garnham. May
25 I first of all say how much I welcome the generous
23
1 tribute that you paid to the Secretariat of this
2 Inquiry. In my view, that is richly deserved and
3 I appreciate it very much.
4 Mr Garnham, I and my colleagues, and I suspect we
5 are not alone, have been extraordinarily helped by your
6 penetrating, searching, forensic analysis of the issues
7 that we will need to consider over the next weeks and
8 months, and we are most grateful for the very
9 comprehensive review that you carried out in your
10 opening address.
11 What I would like to suggest, ladies and gentlemen,
12 now is that we have a break for ten minutes, which will
13 take us until 10.45 am. During that time, Mr Garnham
14 will distribute the document that he referred to, and
15 then we will begin, if we may, with Victoria's family.
16 So 10.45 am, ladies and gentlemen. Thank you very much.
17 (10.35 am)
18 (A short break)
19 (10.45 am)
20 THE CHAIRMAN: Thank you very much, ladies and gentlemen, we
21 now move on to the opening statements by the interested
22 parties, and I am going to invite Ms Dodson QC to speak
23 on behalf of Victoria's parents.
24 Opening statement by MS DODSON
25 MS DODSON: Mr and Mrs Climbie wish me first to thank
24
1 Lord Laming for enabling them to attend this Inquiry,
2 and for providing access to legal representation and
3 translation facilities which they very much appreciate.
4 They endorse the terms of reference of the Inquiry,
5 which reflect their own concerns. These are twofold.
6 Firstly, to have answered in the course of part 1 of the
7 Inquiry the many unanswered questions about why Victoria
8 died, as opposed to how; and secondly to make
9 a contribution to the protection of other children at
10 risk, which is the business of part 2.
11 The information which Mr and Mrs Climbie had
12 available to them at the conclusion of the trial of
13 Kouao and Manning suggested to them that Victoria's
14 death was contributed to by professional shortcomings on
15 the part of individuals, social services, police and
16 medical personnel which had the consequence that Kouao
17 and Manning were able to continue to abuse Victoria
18 until she died. They have been concentrating with their
19 own lawyers on preparing their statements of evidence to
20 the Inquiry, and have had little opportunity to consider
21 the evidence of other interested parties. It was
22 therefore with an increasing sense of shock, not unmixed
23 with anger, it has to be said, they listened to
24 Mr Garnham's opening address to the Inquiry yesterday.
25 It became apparent to them, in the course of
25
1 yesterday, that not only were far more individuals, on
2 far more occasions, involved in the series of errors and
3 omissions which contributed to Victoria's abuse, neglect
4 and death but also there were far more deep-rooted and
5 wide ranging problems than they had supposed in the
6 child protection systems in Britain, sophisticated as
7 they may seem by comparison with anything with exists in
8 the Ivory Coast.
9 Mr and Mrs Climbie now realise that very probably,
10 those systems are themselves defective in many respects,
11 that systems which are adequate are not operated
12 correctly, that there is a significant lack of
13 sufficient resources, in particular in relation to the
14 police child protection system perhaps, and serious
15 shortcomings in liaison between child protection
16 agencies.
17 So far as individual failings are concerned, Mr and
18 Mrs Climbie believe that those professionals who failed
19 to protect Victoria should be called upon to account for
20 their actions, and they hope this Inquiry will do that.
21 They wish to make it clear that this is not in order to
22 punish the individuals involved, but in the hope of
23 improving professional practice in the future.
24 By way of example, Mr and Mrs Climbie have cited
25 during our discussions the difficulty which some
26
1 observers seem to have had in identifying what they see
2 as by then an obviously abnormal relationship between
3 Victoria and Kouao. They doubt whether this difficulty
4 would have arisen had Victoria been a British child,
5 whether black or white. They think it demonstrates an
6 unthinking assumption of racial or cultural differences
7 where none exists, and which must surely be capable of
8 remedy.
9 So far as organisational and systems failures are
10 concerned, Mr and Mrs Climbie are not able to comment in
11 any detail upon these, nor would it be appropriate for
12 them to do so. They have not read any of the reports of
13 the numerous inquiries into the deaths of children, some
14 of which were referred to by Mr Garnham in his opening
15 address. Even so, they have had no difficulty in
16 identifying two of the things which recur over and over
17 again in those many reports, and which will no doubt
18 appear in yours. First, the way in which the interests
19 of the adult were the focus of attention, while those of
20 the child were all but forgotten; and second, the
21 lamentable failure of the child protection agencies to
22 work together as they have so often been enjoined to do.
23 The Inquiry team should be aware that at the time
24 Victoria left the family home, and indeed at the time
25 she died, Mr and Mrs Climbie had no knowledge, either
27
1 first-hand or hearsay, of the problem of child abuse.
2 They have been shocked and horrified by what they have
3 been told about the extent of the problem in Britain,
4 and in particular about the number of children who have
5 been killed by those who were supposed to be caring for
6 them. They were taken aback to say the least when they
7 heard how many inquiries have taken place into the
8 deaths of those children, but they continue to hope that
9 this one, unlike its predecessors, will be effective in
10 improving the position of children at risk of abuse in
11 the future.
12 We understand that after I have completed my short
13 address, you are going to see a short film by
14 Simon Israel, which was shown on Channel 4 News on
15 Sunday evening. It conveys more clearly than I can the
16 social and economic circumstances of the Climbie family,
17 and the reasons why Mrs Kouao's offer to educate
18 Victoria in Europe was seen as a piece of extraordinary
19 good fortune.
20 Mr and Mrs Climbie believe that professionals and
21 the public, the latter both here and in Ivory Coast,
22 need to be made aware of the potential risk to children
23 such as that which they made with Ms Kouao, and of which
24 they themselves were completely unaware until it was too
25 late. For that reason, they welcome Lord Laming's
28
1 decision to hold this Inquiry in public, and the
2 opportunities they have been afforded to talk to
3 journalists about Victoria's case, and they are grateful
4 for the publicity her case has been given in the media.
5 Thank you.
6 THE CHAIRMAN: Thank you very much indeed, Ms Dodson. We
7 are very happy to see the film now.
8 (Videotape played)
9 THE CHAIRMAN: Ms Dodson, I am grateful to you, and indeed
10 to Channel 4, for that very helpful film. I now call
11 upon Ms Mayer for Ealing. We heard here absolutely
12 every word that Ms Dodson said very clearly, but
13 I notice by movements at the back that might not have
14 been entirely so, so might I suggest to all advocates
15 that they keep the microphone as close as they can, or
16 speak up. Thank you very much indeed. Ms Mayer?
17 Opening statement by MS MAYER
18 MS MAYER: Sir, on 26th April 1999, Victoria Climbie came to
19 Ealing Housing Services' offices. She came with
20 Marie-Therese Kouao who purported to be her mother.
21 Victoria was a quiet and well behaved child.
22 Julie Winters, the homeless persons officer on duty,
23 noted that whilst many children create havoc during the
24 one hour or so initial interview, Victoria did not. She
25 sat quietly without interrupting. She became a little
29
1 tearful when told in French by Kouao that Ealing cannot
2 assist with housing. She repeated "une maison" a few
3 times.
4 Neither Ms Winters nor anybody else at the London
5 Borough of Ealing had or indeed could have had an
6 inkling that within ten months, less one day, this
7 little girl would be dead, having been put through the
8 most horrendous torture and torment by the same Ms Kouao
9 and her partner in crime Carl Manning, having been
10 possibly let down by the system which was designed to
11 protect her and all other children in this country. The
12 London Borough of Ealing offers Victoria's parents and
13 family their deep sympathy and condolences.
14 Ealing's involvement with Victoria was short and
15 relatively uneventful. Their active involvement
16 commenced on 26th April 1999 with Kouao's application to
17 the Housing Department for housing, and ended with the
18 case being closed on 7th July 1999, a week before
19 Victoria's first admission to the Central Middlesex
20 Hospital. This makes the involvement just under ten
21 weeks long. These appear to have been effectively the
22 first ten weeks of Victoria's stay in the
23 United Kingdom.
24 Kouao visited Ealing's offices for the very last
25 time on 15th July 1999, a week after the case has been
30
1 closed. Victoria arrived with Kouao from France. There
2 is no indication why she came to Ealing, save that
3 Ealing gets many foreign visitors and asylum seekers,
4 most because of our geographical proximity to Heathrow.
5 Ealing appears to have been simply a random first stop
6 in this case. Our Housing Department could not help.
7 Kouao was not eligible for housing or any other
8 statutory benefits because she has not passed the
9 habitual residence test. The case was, we will submit,
10 properly referred to our social services referral intake
11 team, and an appointment was arranged for Kouao and
12 Victoria to come into the office on 29th April.
13 Despite the fact that the only statutory provision
14 under which Kouao could have received any assistance was
15 Section 17 of the Children Act 1989, the National
16 Assistance Act is used to offer help to destitute adults
17 rather than adults with children, and Section 17 deals
18 specifically with children in need. The local authority
19 approached this case as one of destitution.
20 Victoria was in need because she had nowhere to
21 live, and there was allegedly a shortage of funds for
22 food. The fact that all that Kouao wanted was financial
23 assistance categorised the case psychologically and
24 consequently in practical terms, for those who dealt
25 with it, as a destitution case. Victoria's needs as an
31
1 individual child in need were not properly assessed.
2 There were at that time no indicators whatever that this
3 was a case with child protection concerns.
4 It is likely that an assessment at that stage would
5 not have made anybody the wiser in respect of events
6 which were to follow, or indeed about Victoria's real
7 needs, but that we shall never know.
8 On 30th April 1999, Judith Finlay, who was then
9 Senior Commissioning Manager, and now Director of
10 Children's Services, was asked to authorise a Section 17
11 payment for Kouao. This local authority had two
12 effective options; either to say to Kouao that we would
13 not be helping her, and she should be returning to
14 France where, according to her, she had family and
15 financial means; knowing what we now know, we very much
16 doubt she would have returned. Or alternatively,
17 authorise a payment on a temporary basis and assess the
18 situation. We chose the latter.
19 Kouao was by then advised to appeal Ealing's
20 habitual residence decision. She had sufficient
21 initiative and know-how so as to approach a local firm
22 of solicitors, Young & Co, even before she approached us
23 on 26th April. These solicitors took her matter on and
24 a little later threatened us with judicial review if we
25 did not provide Kouao with accommodation.
32
1 So it came to pass that Kouao was sent to a hostel
2 at Nicoll Road where other families from Ealing have
3 been from time to time accommodated. The hostel was
4 within the boundaries of the London Borough of Brent,
5 but we remained financially responsible for Kouao and
6 Victoria and regarded ourselves as such.
7 It was not our practice, nor was it the practice of
8 any other local authority we know, to notify social
9 services of the local authority within which
10 accommodation was found that a child in need has been
11 placed within their boundaries. Perhaps this is a
12 matter this Inquiry will look into, and if so, sir, we
13 would welcome views about the practicalities of this.
14 Kouao came to social services offices on a number of
15 occasions between 30th April and 15th July 1999. On the
16 whole, her visits were concerned with collecting money
17 or, as of 24th May, complaining about the accommodation
18 at Nicoll Road. Three of the social workers,
19 Deborah Gaunt, Pamela Fortune and Cecilia Schreuder,
20 went to look at Nicoll Road on two separate occasions,
21 neither of which were before the accommodation of
22 Victoria there. Kouao's complaints were not
23 substantiated. We do however readily accept that
24 Victoria was not seen on those occasions and her
25 individual needs were not addressed.
33
1 We are conscious that we failed to observe that
2 Victoria was not attending school, though in the context
3 of a child from abroad, and whilst consideration was
4 being given to returning her and Kouao to France,
5 perhaps one can understand, if not excuse, the reason
6 for this oversight.
7 We also accept that we did not investigate the
8 nature of child minding arrangements for Victoria on
9 occasions when she was absent from the office when Kouao
10 came in, and although we were told that Victoria was the
11 child minder, we neither checked the information nor
12 enquired whether the child minder was registered. It
13 would appear that the initial categorisation as
14 a destitution case, rather than a genuine child in need
15 case, diverted the focus from Victoria to finances. In
16 any event, it is fair to say that in April to July 1999,
17 by virtue of the then priorities of allocation of
18 manpower and resources, children in need under
19 Section 17 came low in the list of priorities of
20 children with problems. Children who were in need by
21 virtue of, for example, Section 20 of the Children Act,
22 and thus accommodated by the local authority, or
23 children in respect of whom there were child protection
24 concerns, received resounding priority. This has since
25 changed.
34
1 In view of Kouao's persistent attendance in our
2 offices, her continuing complaints about the
3 accommodation, and her solicitor's letters confirming
4 and embroidering her complaints, the case was allocated
5 around the end of June to Pamela Fortune. She wanted to
6 know in which direction the case was going. It was
7 still being dealt with as a financial case only; no
8 visit to Victoria took place.
9 In the last week of June, a management decision was
10 taken and recorded. It was taken on the basis of the
11 following information: there was no evidence of an
12 appeal of the habitual residence test decision; Kouao's
13 plans were inchoate, it was clear that she had
14 accommodation, friends, family and an entitlement to
15 financial benefits in France and she started working on
16 6th June, thus her entitlement for funding ended.
17 On our own legal advice we offered her and Victoria
18 a one-way ticket to France. This she refused; she
19 wanted the money, not the tickets. This we refused.
20 On 7th July 1999, Kouao came into the office and was
21 advised of the cessation of funding and of the case
22 being closed. We did not and could not have known that
23 the day before, Kouao and Victoria moved to live with
24 Manning. Victoria was last seen in our offices on
25 15th July. She was left unattended for just under one
35
1 hour, Kouao bringing her in and leaving her there.
2 Pamela Fortune, who was told about this, spoke to Kouao
3 on her return and reprimanded her.
4 Pamela, as the previously allocated social worker,
5 had knowledge of the background. She knew that Victoria
6 had been taken to the Central Middlesex Hospital, having
7 received the helpful call about this on 14th July from
8 a Brent social worker. She also knew, since she was
9 told on 15th July, that although the original referral
10 to the hospital was due to suspected child abuse, the
11 medical diagnosis was in fact one of scabies, and
12 Victoria was returned to her mother.
13 Bearing in mind that it was confirmed to us that
14 there were no child protection concerns on
15 15th July 1999, the leaving of Victoria in our offices
16 for one hour or so seemed to be worthy of reprimand, but
17 at that time not more than that. I emphasise that at
18 that time, this was in the context of seemingly
19 unsubstantiated child protection concerns.
20 (11.15 am)
21 We sent to Brent a copy of a letter dated 30th June
22 which had been sent to Kouao. This letter explained the
23 rationale behind the cessation of Ealing's involvement
24 and we heard nothing else from Brent. John Skinner, the
25 then Assistant Director, cannot and does not recall
36
1 a conversation between him and Eddie Armstrong of Brent
2 about Ealing accepting responsibility for this case. He
3 would have remembered it, since it would have been
4 highly irregular for him, as an Assistant Director, to
5 take any referrals, let alone one which ordinarily would
6 have been made to the duty team. This alleged
7 conversation is not documented either in Brent or in
8 Ealing. You, sir, and the Inquiry team may have to
9 decide, having heard the evidence, whether it had taken
10 place.
11 Insofar as a decision to return the case to Ealing
12 is concerned, we submit that this decision was never
13 communicated to us. The last we knew of this case, and
14 of Victoria, was that such concerns as may have existed
15 on 14th/15th July had dissolved, and that Victoria was
16 released to the care of her mother.
17 The London Borough of Ealing recognises the need for
18 finding ways so that events such as the ones which
19 brought about the death of Victoria are not repeated.
20 Each inquiry of the magnitude and nature of this
21 Inquiry, and there have sadly been a number in the past
22 30 years, brings about awareness and improvements in
23 filling existing gaps in current practices.
24 We are committed to assisting this Inquiry in every
25 way we can. Any proposals to improve existing systems
37
1 and procedures will be welcomed. Individual social
2 workers and Ealing management have asked themselves
3 repeatedly, with the benefit of hindsight, whether and
4 if so where they have gone wrong, and how they can
5 tighten up their procedures.
6 An independent review was commissioned by
7 Judith Finlay on behalf of the management shortly after
8 Victoria's death, to critically review our existing
9 procedures, and a number of changes have already taken
10 place. I mention only a few.
11 Ealing have merged their housing and social services
12 teams so as to provide better service and improve the
13 communication between these two departments, the work of
14 which is often inextricably linked. The department is
15 reviewing all their eligibility criteria in respect of
16 children in need and child protection. A homeless
17 families procedure has been produced. A general
18 training team, team-based training days and actual
19 learning sets are in place to increase skill development
20 and support implementation of assessment framework.
21 A partnership is being developed with a voluntary
22 organisation and family welfare association to increase
23 the delivery of support services to families in need of
24 advice and assistance.
25 Before I end, sir, a little information about Ealing
38
1 and its social services in the past four to five years.
2 We are a busy local authority, and a large borough,
3 within which some parts are relatively affluent and some
4 are poor, and socially and economically deprived.
5 Victoria arrived at Ealing just one month after our
6 social services had been subject to a relatively
7 positive Social Services Inspectorate report. This
8 report, of March 1999, followed an earlier inspection
9 and report of December 1997, where this local authority
10 was criticised for numerous aspects of their structure,
11 procedure, and generally the way they had been run, and
12 had been put on special measures.
13 In the 1999 to 2000 financial year, Ealing received
14 5,406 referrals dealing with children. In 2000 to 2001,
15 there were 6,131 referrals. Since April of this year,
16 in the last six months, we have had 3,623 referrals
17 dealing with children. As you see, we are a very busy
18 local authority when it comes to social work.
19 By March of 1999, 85 per cent of social work staff
20 were in permanent employment at Ealing, contrasted with
21 temporary and agency staff. The intake team load was
22 not particularly heavy, 11.25 cases per worker. All
23 social workers were being regularly supervised. By
24 December of 1999, Ealing were removed from special
25 measures.
39
1 This information is presented, sir, so that you and
2 this Inquiry are aware that Ealing do not intend to pray
3 in aid in this particular case the lack of adequate
4 sufficient resources. It is not that money was no
5 object; on the contrary, as you well know, from the
6 figures we have provided to this Inquiry, Ealing
7 allocated to their social services funds well outside
8 the original budget for 1999, so as to try and run an
9 efficient and effective service.
10 Thus, in April to July 1999, there may have been
11 errors in our procedures, errors of judgment and any
12 other human errors which this Inquiry may identify,
13 pinpoint and advise how to rectify. This time, we shall
14 not, however, say that in our case money is behind the
15 events which culminated in the unforeseen but
16 nevertheless so tragic death of Victoria.
17 Thank you.
18 THE CHAIRMAN: Thank you very much indeed, Ms Mayer. The
19 advocate for the North Middlesex Hospital and the
20 Central Middlesex Hospital is Mr Mason.
21 Opening statement by MR MASON
22 MR MASON: Thank you, sir. This opening statement is made
23 on behalf of all the NHS bodies who are interested
24 parties at this Inquiry. They are the North-West London
25 Hospitals NHS Trust, and North Middlesex University
40
1 Hospital NHS Trust, which were and remain the bodies
2 responsible for Central Middlesex and North Middlesex
3 Hospitals respectively; Barnet, Enfield and Haringey
4 Health Authority, which is the successor to Enfield and
5 Haringey Health Authority; and finally, Haringey Primary
6 Care Trust, which has taken over the responsibilities of
7 the former Haringey Community Health Trust.
8 I have been asked on behalf of the NHS, as well as
9 specifically these interested parties and Brent and
10 Harrow Health Authority to express deep regret at what
11 happened to Victoria, pass on to Victoria's parents,
12 Mr and Mrs Climbie, and the rest of her family, every
13 sympathy, not only from the NHS but also from the many
14 members of staff who remember Victoria as such
15 a delightful young girl. She was a little star on the
16 ward, as a nurse at North Middlesex described her to me.
17 On behalf of the NHS I would also like to apologise
18 to Victoria's family for any shortfalls that there may
19 have been in the care provided to Victoria by the NHS.
20 The NHS is committed to learning lessons from tragedies
21 like this as well as less serious adverse events, and
22 making sure that they are learnt throughout the
23 organisation to build a safer NHS for patients.
24 We welcome this Inquiry and very much hope that it
25 will achieve its aim of reducing the risk of a similar
41
1 event happening in the future by identifying
2 improvements that can be made to practice and procedure,
3 and where more resources need to be allocated and/or
4 existing resources better utilised.
5 I would now like to turn to what happened at the
6 Central Middlesex Hospital. The North-West London
7 Hospitals NHS Trust fully accepts the findings and
8 recommendation of the Part 8 review of the Brent Area
9 Child Protection Committee which reported in April this
10 year. In particular, it accepts that there was a delay
11 of a few hours on 14th July 1999 in making the child
12 protection referral to Brent Social Services; the
13 hospital's documentation could have been better, both in
14 relation to the recordings and the assessments that were
15 made of Victoria's condition, and also that on
16 discharge, the hospital did not have details of the
17 address to which Victoria had been taken, nor of her GP.
18 Thirdly, inadequate information was given by the
19 hospital to Brent Social Services.
20 The Trust has in fact already taken a number of
21 steps to improve practice and procedures, including
22 working with other agencies on procedures to improve
23 communication with other health bodies, social services,
24 and the local education authority. A review is also
25 being conducted to consider whether consultant
42
1 paediatric cover at the Central Middlesex Hospital can
2 be increased, and indeed that has now taken place and
3 there is improved cover.
4 Whilst the shortcomings that have been identified
5 were regrettable, the Trust does not believe that there
6 is any reason to think that they made any material
7 difference to what happened after Victoria's discharge
8 on 15th July, either in the short or long-term. Social
9 services and the police were involved on 14th July, and
10 the police were able to take out a police protection
11 order that day.
12 What happened over the next few days in and outside
13 the hospital was to a large extent the result of the
14 medical assessment made by Dr Ruby Schwartz, an
15 experienced consultant paediatrician, who was also the
16 hospital's named doctor for child protection issues,
17 when she saw Victoria at the hospital on the evening of
18 14th July.
19 As Dr Schwartz has described in her statement to the
20 Inquiry, she has had more experience in dermatology or
21 dealing with skin conditions than most paediatricians.
22 In her judgment, Victoria was suffering from scabies.
23 This is a skin infection caused by mites which causes
24 intensive irritation to the skin, which usually results
25 in the patient scratching. In adults the infection is
43
1 found predominantly between the fingers and toes, but in
2 children the infection can be much more generalised and
3 it can involve any areas of the body. Dr Schwartz also
4 diagnosed a secondary infection arising from the
5 scabies.
6 In addition to the scabies and the scabies related
7 infection, Dr Schwartz did note other marks on Victoria
8 which were indicative of old injuries, but it was not
9 possible to date these, and they did not show
10 a configuration pattern typical of non-accidental
11 injury. In other words, a diagnosis of physical abuse
12 could not be made from them.
13 The marks which were present when Dr Ruby Schwartz
14 examined Victoria on 14th July were very different from
15 those present when Victoria attended North Middlesex
16 Hospital on 24th July. It may be significant that the
17 time between the two hospital admissions was when Kouao
18 took Victoria to live with Manning. At the time of the
19 criminal trial, Dr Schwartz was accused in an initial
20 Part 8 report from the London Borough of Haringey and by
21 some sections of the media of getting it wrong when she
22 made her diagnosis of scabies. This is not accepted,
23 either by Dr Schwartz or by the Trust.
24 Dr Mann, the consultant dermatologist at North
25 Middlesex Hospital who saw Victoria, did not see any
44
1 sign of scabies, but that was only to be expected, given
2 that she had been treated two weeks previously.
3 Furthermore, Kouao herself had scabies on 14th July,
4 which she may well have caught from Victoria or
5 vice versa, because it is highly infectious. We know
6 that Kouao received treatment for her own scabies and
7 pointed out the marks on her hands to one of the social
8 workers from the London Borough of Ealing,
9 Pamela Fortune, who saw Kouao on 15th July. This is in
10 Pamela Fortune's witness statement to the Inquiry.
11 Dr Schwartz' conclusion that there was no evidence
12 on 14th July that Victoria had suffered physical abuse
13 did not mean that the hospital's child protection
14 concerns had gone away. To the contrary, although by
15 15th July there was no medical reason to keep Victoria
16 in hospital, Dr Schwartz remained concerned at that time
17 about issues of neglect and/or emotional abuse of
18 Victoria. However, these were issues that could be
19 assessed in the community and social services were
20 dealing with the case.
21 I now move on to North Middlesex Hospital, where
22 Victoria was admitted on 24th July. North Middlesex is
23 fortunate in having a very experienced team led by
24 Dr Mary Rossiter, a consultant paediatrician who is
25 particularly experienced and respected in the child
45
1 protection field. She has been responsible for the
2 paediatric aspects of child protection in her local
3 district since 1974, and is currently the designated
4 paediatrician for the Haringey Area Child Protection
5 Committee, as well as being the named doctor for child
6 protection at the North Middlesex University Hospital
7 NHS Trust. She is the current President of the Section
8 of Paediatrics and Child Health at the Royal Society of
9 Medicine. She has a particular interest in the
10 multicultural aspects of paediatrics, and has special
11 expertise in working with people from all races and
12 cultures.
13 The North Middlesex Hospital too accepts that the
14 care given to Victoria whilst she was in hospital fell
15 short of best practice in a number of ways,
16 particularly:
17 (a) some of the record keeping was not as good as it
18 should have been, the evidence for physical abuse was
19 not documented as fully as the evidence of possible
20 emotional abuse and/or neglect.
21 (b) photographs were taken of Victoria's injuries by
22 the hospital photographer. These photographs show clear
23 evidence of physical abuse, but regrettably, for reasons
24 which remain unclear, they do not appear to have been
25 reviewed by any clinician.
46
1 (c) there is no evidence that Victoria was formally
2 reviewed by a doctor immediately prior to discharge from
3 the hospital. The agreed plan had been that there was
4 no medical reason why Victoria could not be discharged
5 from hospital, provided that discharge was to a safe
6 environment.
7 However, as Dr Rossiter wrote a few days later, she
8 herself probably would have discharged Victoria on
9 6th August because the joint social services and police
10 assessment had been performed, and those agencies had
11 reported back to the hospital that they had checked and
12 were satisfied with the home environment.
13 THE CHAIRMAN: Mr Mason, I am terribly sorry to interrupt
14 you. I wonder whether or not you and the other
15 advocates could go just a little slower for the
16 interpreter for the parents of Victoria. I really am
17 sorry to interrupt. If you want to go back a little
18 bit, I fully understand.
19 MR MASON: Would the interpreter like me to go back?
20 THE CHAIRMAN: Well, not too far, but I did not want to
21 undermine your train of thought, or the arguments you
22 were advancing. If you could just begin at whatever you
23 think is an appropriate point in your submission, and if
24 I could ask you and the other advocates just to go
25 a little slower.
47
1 MR MASON: I do apologise.
2 THE CHAIRMAN: No, thank you.
3 MR MASON: I will go back a few lines.
4 However, as Dr Rossiter wrote a few days later, she
5 herself would probably have discharged Victoria home on
6 6th August because the joint social services and police
7 assessment had been performed, and those agencies had
8 reported back to the hospital that they had checked and
9 were satisfied with the home environment.
10 (d) while social services were informed of the
11 hospital's concerns in relation to physical abuse, as
12 well as emotional abuse and neglect, with hindsight it
13 would have been better if more emphasis had been put on
14 the evidence for physical abuse.
15 (11.30 am)
16 Following the criminal trial, the Trust conducted an
17 internal review, and has taken a number of actions to
18 improve performance in all the areas identified above.
19 These have been set out in Angela Gallagher's second
20 statement to the Inquiry, and include improved
21 guidelines, increased information technology provision,
22 and training.
23 Looking now in more detail at what happened when
24 Victoria was admitted to North Middlesex Hospital on
25 24th July 1999, she was admitted with burns on her head,
48
1 said to have been caused by Victoria pouring hot water
2 over herself to relieve itching caused by the
3 antiscabies lotion. Opinion amongst hospital staff was
4 divided as to whether or not this was a non-accidental
5 injury. However, within a day or two it became clear
6 that there was other evidence of child abuse,
7 particularly of emotional abuse and neglect, but also of
8 injuries indicative of child abuse.
9 Dr Rossiter has said in her statement to the Inquiry
10 that these injuries could easily have been inflicted
11 after Victoria had left Central Middlesex Hospital nine
12 days earlier.
13 The Trust's child protection procedures were invoked
14 without delay following Victoria's arrival at North
15 Middlesex, because of the possibility that the burns
16 might be a result of child abuse. Social services, and
17 through them the police, were involved from the start.
18 By all accounts, Victoria thrived in hospital. When
19 she left the hospital 13 days later, she was medically
20 fit to leave and was discharged to an environment
21 assessed by social services and the police to be safe.
22 At that point, the Trust's responsibility for
23 Victoria came to an end. However, the Inquiry may think
24 it reflects credit on Dr Rossiter that she did not
25 believe that her moral responsibility for Victoria had
49
1 ended on 6th August. As can be seen from her statement
2 to the Inquiry and the documentation, she continued to
3 be very worried for Victoria's future, and she continued
4 to express those concerns to social services, both
5 verbally and in writing. It is perhaps typical of the
6 very high standards that Dr Rossiter sets of herself
7 that she now wishes she had done even more.
8 For the sake of completeness, I should add that
9 Victoria was seen once more at the North Middlesex
10 Hospital. This was on 24th February 2000, when Victoria
11 was admitted late at night in an absolutely terrible
12 state. Despite the best efforts of Dr Alsford and
13 others, there was not very much that they could do.
14 Victoria was soon transferred to a specialist unit at
15 St Mary's Hospital, Paddington, where sadly every effort
16 to save Victoria's life failed.
17 Turning to Barnet, Enfield and Haringey Health
18 Authority, the role of its predecessor health authority
19 at that time was essentially one of co-ordination to
20 ensure that all Health Service bodies for which it was
21 responsible had proper child protection procedures in
22 place. The action that the health authority has taken
23 subsequent to this tragedy was to examine its
24 predecessor's role in the events, and to identify each
25 point of interaction between the NHS and other agencies.
50
1 This was to identify what did happen, what should have
2 happened, and to act to correct any shortfalls from best
3 practice. The health authority is currently working
4 jointly with Brent and Harrow Health Authority to
5 promote a full understanding of all the issues and to
6 ensure implementation of a full action plan.
7 The former Haringey Community Health Trust has also
8 reviewed the issues surrounding the lack of community
9 NHS involvement with Victoria after she left North
10 Middlesex Hospital, and it has revised its policies and
11 procedures in the light of lessons learned.
12 Haringey Primary Care Trust has carried on with the
13 work done by its predecessor, and is continuing to work
14 with other bodies to ensure effective implementation.
15 Finally, I would like to return to the point I made
16 earlier about the NHS's commitment to learning lessons.
17 If the Inquiry's aim of risk reduction is to be
18 achieved, it is essential that its recommendations have
19 been implemented and reviewed if they are not found to
20 be working as well as might have been hoped.
21 On behalf of all the NHS interested parties, and
22 Brent and Harrow Health Authority, I am authorised to
23 state that it is their intention not only to implement
24 every relevant recommendation that the Inquiry may make,
25 but also to demonstrate that commitment publicly.
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