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Archived Transcript for 19 Febuary 2002:
Pages 51 to 100
51
1 Mr Garnham about the discharge summary. She admitted
2 that it was riddled with inaccuracies and
3 unsubstantiated assertions. She agreed that it would
4 not have conveyed to anyone reading it what she now says
5 her real concerns were. She accepted in her evidence
6 that on the material given to them by her, social
7 services would not have appreciated that she had
8 concerns about physical abuse based on the old injuries
9 which emerged in the photographs.
10 Mr Garnham has referred of course to the missed
11 chances in Haringey as well as to missed chances
12 elsewhere. Those are revisited in his closing
13 submissions. We set out in detail our response to those
14 missed chances in our written submissions and I do not
15 propose to refer to those now.
16 I do wish to say something in the light of
17 Miss Hoyal's observations about the allegation that
18 somehow Haringey is making Lisa Arthurworrey
19 a scapegoat. She has not been singled out for
20 disciplinary proceedings. She has remained in the
21 Council's employment on full pay despite her suspension.
22 It continues to pay for counselling for her. Haringey
23 has not criticised her publicly either in the media or
24 in this Inquiry. I did not invite Mr Garnham to ask her
25 any questions when she gave evidence.
52
1 She was suspended in October 2000 on receipt of
2 a critical Part 8 review report. That review report was
3 not produced by Haringey but by the Area Child
4 Protection Committee. That concluded that appropriate
5 procedures were in place but the practice of those
6 involved was unsafe. If Haringey had wanted to make
7 Lisa Arthurworrey a scapegoat it could simply have
8 accepted that report and acted on it but Haringey did
9 not accept the report.
10 It is true that it subsequently conducted a further
11 investigation. The outcome was the Monaghan report
12 which the Inquiry has in its papers. Mr Monaghan
13 advised that there was a case to answer against a number
14 of staff of whom Lisa Arthurworrey is one. The director
15 has considered that advice and in the light of it has
16 begun disciplinary proceedings in which
17 Miss Arthurworrey will have a chance to explore and put
18 her side of these matters in answer to what is no more
19 than a prima facie case at this stage.
20 As far as Ms Baptiste is concerned, the Inquiry will
21 have to reach its own conclusions on the dispute between
22 her and Lisa Arthurworrey about the quality of
23 Ms Baptiste's advice to and supervision of her, based on
24 their evidence and in the light of the contemporaneous
25 notes and documents.
53
1 Haringey's position is that Lisa Arthurworrey, like
2 all its staff, ought to have had proper managerial
3 guidance and supervision or performance development
4 reviews in accordance with its guidelines. If she did
5 not, and that affected her handling of Victoria's case,
6 then Haringey would not seek to defend Ms Baptiste's
7 failure to advise and supervise Lisa Arthurworrey
8 adequately.
9 In saying that however it does not accept the
10 picture at times painted by Miss Arthurworrey in her
11 oral evidence of herself as an inexperienced worker who
12 needed to seek a manager's advice about almost anything
13 before taking either a decision or action. It too
14 invites you to consider her job application to Haringey
15 and her references, the training which she received
16 whilst in Haringey, which is fully documented, and the
17 universal view of her among those who worked with her as
18 a very good, competent and conscientious social worker.
19 In particular, Haringey does not accept that
20 Miss Arthurworrey lacked the competence or experience to
21 deal with Victoria's case when it was allocated to her.
22 We suggest that Miss Arthurworrey is one of those
23 witnesses who is not the person she was in 1999. That
24 may also be the case with Ms Baptiste. Haringey submits
25 that the psychiatric report dated 14th January 2002
54
1 produced to this Inquiry is evidentially worthless
2 insofar as it offers a retrospective opinion as to her
3 mental state in 1999, the psychiatrist having been
4 refused details of her medical history by Ms Baptiste.
5 It invites you to conclude on the basis of her own
6 evidence and that of Mr Duncan that during the period
7 she was supervising Miss Arthurworrey, there is no
8 evidence that establishes that she was suffering from
9 any form of mental illness or disorder, psychotic or
10 otherwise, at the time and that there was no reason for
11 Haringey to know or suspect that she might be, and
12 contrary to what was asserted yesterday by Mr Herbert,
13 there are people in social services departments who are
14 experienced and trained to spot mental illness in those
15 with whom they deal.
16 The criticism of Haringey is that Ms Baptiste's own
17 managers knew or ought to have known that she was
18 underperforming and did nothing about it. Much of the
19 evidence in relation to this comes from witnesses who
20 have not been called and whose evidence, which is often
21 disputed both by Ms Baptiste and other witnesses, has
22 not been effectively challenged.
23 Haringey submits that contrary to the impression
24 given at times the picture is a complex one and for that
25 reason we set out in our written submissions the detail
55
1 of it.
2 That evidence has to be balanced against the views
3 of the staff in the North Tottenham District Office
4 which led to the meeting on 5th July 1999. It appears
5 from the record of this that the concern was about her
6 availability to supervise. The staff were not then
7 complaining about the content of her supervision. That
8 is something you will have to bear in mind in assessing
9 the evidence of the staff who now tell you that the
10 content of the supervision was variable as well.
11 You have to decide whether the level of concern
12 about it which they now tell you they had was as great
13 at the time and, if so, why they did not raise it then
14 with Mr Duncan, an approachable and well respected
15 manager, who has told you that he was never told about
16 these problems.
17 The 5th July meeting also raised complaints about
18 the allocation of cases by Ms Baptiste. If you find
19 that she did allocate cases without reading them
20 properly or assessing whether it was an appropriate case
21 for the particular social worker to have or by placing
22 the file for the social worker to find, Haringey would
23 not seek to defend those practices, but she has not
24 admitted doing all of those things.
25 The Inquiry obviously has to consider in detail the
56
1 advice and supervision given by Ms Baptiste to
2 Lisa Arthurworrey in relation to Victoria's case. It
3 also has to look at their evidence and the material
4 available to them at the time in considering whether the
5 decision to classify the case as family support was
6 appropriate. If the Inquiry finds that
7 Miss Arthurworrey was advised to do so by Ms Baptiste
8 because the latter did not read the fax from the Central
9 Middlesex Hospital carefully enough and thought it was
10 the opinion of the North Middlesex Hospital, then
11 Haringey would not seek to defend that poor practice.
12 We merely observe in passing that it might assist social
13 workers and others if some consideration by the
14 Strategic Health Authority could be given to renaming
15 some of the hospitals which have Middlesex in the title
16 to make the position rather clearer.
17 The situation in the North Tottenham District Office
18 generally has been the subject of a good deal of
19 colourful evidence about the working relationships in
20 the North Tottenham District Office in the I&A teams,
21 much of it conflicting. This Inquiry needs to bear in
22 mind that the only evidence it has about the other teams
23 in the office is that the Children and Families Team
24 managed by Luciana Frederick was extremely well managed
25 and producing work to a very high standard indeed. It
57
1 would be quite wrong if the impression were to prevail
2 that what is now being said to you about what was
3 happening in one team in the North Tottenham District
4 Office represented the whole.
5 You have also been told that some of the managers in
6 that team have admitted to a wholesale disregard for the
7 procedures tools and guidance they were given by
8 Haringey. Both Ms Wilson and Ms Richardson have told
9 the Inquiry in considerable detail of the monitoring
10 systems, training programmes and personal effort they
11 put in to try to make sure that all the staff, including
12 those in the North Tottenham District Office, were aware
13 of and followed the policies such as the case recording
14 guidelines supervision and the use of the client index.
15 I turn then to the issue of restructuring, in
16 respect of which Haringey has been given a notice of
17 criticism of its members and senior officers. That
18 criticism is in two parts. Firstly, that they should
19 not have caused or permitted the restructuring of
20 Children's Services at all since it damaged staff
21 morale, increased problems of staff retention and had an
22 adverse effect on the standard of service provision to
23 children; and secondly that the then director and
24 assistant director failed adequately to manage the
25 process of change so as to ensure that the provision of
58
1 services to children was not adversely affected.
2 In relation to the first criticism, the Inquiry has
3 been unable to clarify whether the thrust of it is (a)
4 the Management Team should not have undertaken any
5 restructuring at all or (b) they should have undertaken
6 some other form of restructuring and if so what form it
7 is suggested that it should have taken or (c) that it
8 was appropriate to restructure as they did but it should
9 have not have been done at that time or (d) they should
10 have abandoned the proposals in the face of staff or
11 trade union opposition at the local level, or none of
12 the above. This lack of analysis on the Inquiry's part
13 makes it rather difficult to answer the criticism but we
14 do so under the following heads.
15 Firstly, we raise a legal question of whether or not
16 that matter is within this Inquiry's terms of reference
17 at all. The Inquiry is charged with examining the
18 discharge by Haringey of its social services functions
19 in respect of Victoria, Mrs Kouao and Mr Manning during
20 the period from October 1999 to February 2000.
21 The decision by the Council to restructure its
22 organisation is not such a function. The functions are
23 defined in the legislation and the relevant function as
24 far as Victoria is concerned is the exercise of its
25 powers and duties under the Children Act. The fact that
59
1 the restructuring included the reorganisation of the
2 management of the Social Services Department as well as
3 the Housing Department or specifically its Children and
4 Families Service does not we say bring it within the
5 Inquiry's terms of reference.
6 We set this out in more detail in our written
7 submissions and we will be happy to address the Inquiry
8 further on it if you consider that it is a point which
9 needs to be further investigated.
10 In saying that, we are not suggesting that you
11 cannot look at the factual aspects to it in reaching
12 your conclusions, but we say that it is not within your
13 terms of reference to criticise Haringey for that
14 decision.
15 If it is within your terms of reference, we request
16 whether the Inquiry should substitute its own judgment
17 of the wisdom of that decision for that of the elected
18 members and senior officers at the time and whether it
19 has the material upon which to do so.
20 If it does consider that it has the power to
21 criticise, it should nevertheless, we suggest, be very
22 slow to do so.
23 Further, we say the decision to restructure was in
24 fact soundly based as a means of delivering services to
25 the residents of Haringey. The rationale for it was
60
1 described as entirely appropriate by the Joint Review
2 Team in 1999. The restructuring was intended to provide
3 a leaner management structure as part of a wider
4 strategy for delivering the Government's Quality
5 Protects and best value policies and the modernising
6 agenda. It has remained in place substantially
7 unchanged since then, notwithstanding the separation of
8 the Housing and Social Services departments. It has not
9 been the subject of adverse criticism by the Social
10 Services Inspectorate who described it as broadly
11 welcomed by its staff group and particularly by managers
12 in the year 2000.
13 The factual basis for the criticism both as to the
14 process of restructuring and its consequences is we say
15 flawed and does not stand up to scrutiny.
16 That point overlaps with the second criticism which
17 is that the managers did not adequately manage the
18 process of change, so that the provision of services to
19 children was not adversely affected. Haringey accepted
20 in opening that there were problems with the
21 implementation of the structural changes.
22 I also suggested to you that Haringey is not
23 a monolith and that within the organisation there are
24 bound to be different views at different levels of the
25 organisation of what went on. One of the difficulties
61
1 in evaluating this part of the evidence is that the
2 staff involved and their trade union representatives
3 were not we say questioned with the same scepticism and
4 rigour as the senior managers about the process. In
5 consequence only a one sided and incomplete picture of
6 the restructuring process and its effects has been
7 presented to the Inquiry in the oral evidence. That is
8 why we have set out in detail in our written submissions
9 the chronology of events evidenced by the documents
10 which you have. We hope that you will find it helpful
11 in redressing the balance.
12 We also set out why we do not accept that the
13 picture now being painted by the staff is accurate.
14 Haringey is not an organisation in which bad news does
15 not travel upwards. Within the bundles there are
16 numerous instances of front line staff both collectively
17 and individually writing to the Director or Assistant
18 Director about all sorts of matters. Both of them told
19 you about the meetings they had with the staff and the
20 other ways in which they would have expected to hear
21 what was going on. They did not.
22 The members from whom you have heard are
23 approachable and would expect to hear about these
24 problems from a variety of sources, if the situation
25 were as bad as is now claimed. In particular there are
62
1 close links with the trade unions, both formal in
2 regular meetings and between members and unions and
3 informal meetings as well.
4 The fact that the trade unions did not raise
5 concerns about the fact of restructuring in
6 circumstances where they might have been expected to do
7 so is we say significant.
8 We also suggest that there is no evidence that there
9 was a general adverse effect on the standards of service
10 provision to children and their families in consequence
11 of the restructuring.
12 There is a specific issue to which I have already
13 referred about the impact to which we refer, the impact
14 of the process on the particular managers,
15 Carole Baptiste and Dave Duncan, and whether it had any
16 impact on the latter's supervision.
17 Questions of whether the restructuring damaged staff
18 morale and the problems of staff retention are we say
19 more complex. The problems of staff recruitment and
20 retention are multi-faceted. The extent to which they
21 had a direct impact at the material time on the staff of
22 the North Tottenham District Office is disputed.
23 The exit interviews given in the period leading up
24 to January 2000 showed that only two of the social
25 workers leaving the department, not just the North
63
1 Tottenham District Office, gave restructuring as
2 a reason for leaving. Two.
3 There are other reasons identified as contributing
4 to the problems of staff recruitment and retention: the
5 national shortage of social workers and the particular
6 problem in London of outer London boroughs like Haringey
7 which have inner city problems. The authorities have
8 tried to tackle the problem cooperatively to avoid
9 leapfrogging each other.
10 The creation of new Quality Protects posts which has
11 made recruitment to front line posts harder. It is true
12 that Haringey has used some of that money to create new
13 social worker posts, for example it did so during the
14 summer of 1999 in the North Tottenham District Office
15 and has done so more recently to provide social workers
16 in the North Middlesex Hospital.
17 The problem is that many of the Quality Protects
18 posts, whether in Haringey or elsewhere, are often for
19 project work and are less stressful and thus more
20 attractive than managing front line services, or being
21 part of those services.
22 A third complication has been the creation of
23 specialist asylum teams. Haringey as you are aware has
24 the largest number of asylum seekers in London, probably
25 in the country. The new teams were necessary to deal
64
1 with the multiple problems faced by those families.
2 Although Central Government provided additional funding
3 for this, it could not magically produce the additional
4 social workers to implement its strategy. Thus social
5 workers have had to be pulled from other teams to staff
6 the asylum team.
7 It has also been suggested that Haringey was the
8 author of its own misfortune because it compounded the
9 difficulties caused to staff by the restructuring by
10 then introducing changes to the social workers' terms
11 and conditions. That argument we say is seriously
12 flawed for the reasons that we set out in detail in our
13 written submissions.
14 All the agencies who were the subject of this
15 Inquiry have acute staff shortages and problems with
16 recruitment. The police you have heard have a large
17 number of vacancies, the health organisations and social
18 services try to fill the gaps by using temporary or
19 agency staff. Some of those staff come from overseas.
20 In some of those countries the basic training for social
21 workers is actually better than it is here. Some agency
22 staff are more experienced and better trained than the
23 regular staff. Haringey's aim nevertheless is to have
24 all its social workers' posts filled by permanent staff
25 and you have heard the evidence of the progress that it
65
1 is making towards doing so.
2 Linked to that is the criticism levelled against
3 members and senior officers that they caused or
4 permitted the Haringey Children's Services to spend less
5 than the sum allocated to that standard spending
6 assessment about which you have already heard so much
7 without adequate justification.
8 Haringey's response is set out in full in our
9 written submissions. I highlight only the following
10 points. There is not a shred of evidence that the
11 alleged lack of funding of the children's services had
12 any impact on the way in which Victoria's case was
13 handled in Haringey. She was allocated a qualified
14 social worker. There was no facility to which she might
15 have been referred to which it is said she was not
16 referred because of lack of funds. Lisa Arthurworrey
17 has not suggested that any failure to investigate or
18 assess this case more fully on her part was due to her
19 not having the time to do so because of her case load
20 although we recognise that it was high. She does not
21 say at any point that she would have handled the matter
22 differently. She might have done.
23 The question of whether the standard spending
24 assessment is in any event an appropriate measure for
25 gauging the appropriate level of the Council's spending
66
1 is a matter on which you have heard detailed evidence
2 from Mr Travers on behalf of Haringey as well as
3 comparable officers in other authorities. The tenor of
4 their song is the same. The standard spending
5 assessment is a formula to determine the distribution of
6 the revenue support grant element of funding for local
7 authorities. Although it purports to be a needs based
8 formula, it is not an assessment of an individual
9 authority's need to spend but is designed to reflect
10 relative need as between authorities. He points to the
11 occasion in December 1998 when as a result in the change
12 of methodology which removed ethnicity as a factor from
13 the standard spending assessment formula, almost £8
14 million was cut from the grant to Haringey at a stroke.
15 There was not in reality a corresponding reduction
16 in the need for Children's Services between those two
17 financial years. The representations made by Haringey
18 at the time of this to Central Government are in the
19 bundles.
20 Similarly, if Haringey had spent to the standard
21 spending assessment limit on all the services which are
22 covered by it, it would not have had the £7 million it
23 needed to spend on the homeless because the standard
24 spending assessment does not cover this. This has been
25 acknowledged by Central Government, most recently in the
67
1 White Paper "Strong Local Leadership - Quality Public
2 Services." This contains a strong critique of the
3 standard spending assessment which is an accurate
4 reflection of the criticisms made of it by local
5 authorities to this Inquiry. Haringey adopts paragraphs
6 3.1 5 to 23 of that White Paper as part of its argument.
7 It may well be that if that White Paper had been
8 published in August of last year rather than in December
9 a considerable amount of time in these hearings might
10 have been saved.
11 Haringey already has one of the highest levels of
12 Council Tax in the country. Apart from the political
13 commitment to contain Council Tax, the capping
14 provisions during the relevant periods effectively
15 limited the extent to which Council Tax could be raised
16 without a corresponding drop in the grant provided by
17 Central Government. We set out the effect of the
18 figures.
19 Members also considered the effect of raising
20 Council Tax on those caught in the poverty trap. Such
21 rises in themselves have a disproportionate impact on
22 poor and disadvantaged, including poor families with
23 children, and members are very conscious of the
24 disparities of affluence within the borough.
25 Haringey, like other local authorities, has been
68
1 since the 1980s subject to pressure from Central
2 Government to curb expenditure. It emphatically rejects
3 the suggestion that senior officers informed members
4 that the proposed level of spending meant the Council's
5 statutory duties towards children could not be met or
6 were at dangerous levels. You have seen the individuals
7 concerned and will have to form your own judgment about
8 whether they would not have responded to that situation
9 were it the case.
10 Ms Richardson told that you the cuts were less
11 severe in the Children's Services than in some of her
12 other services and that she tried to ensure that they
13 were protected. The figures show that the Council spent
14 more each year on its Children's Services than it had
15 done in the previous year during this period. The
16 members of Haringey Council remain committed to doing so
17 and in the year 2001 to 2002 increased the money spent
18 on children's services by over a million pounds.
19 Haringey transferred responsibility for the
20 management of day care provision for the under fives
21 from social services to the Education Department and
22 some money followed that transfer. Money in those
23 services benefits all children in the borough but is
24 especially important for the disadvantaged and for those
25 from ethnic minority communities. When the Government
69
1 wished to encourage other councils to follow Haringey's
2 example it made funds available for them to do it.
3 Because Haringey had already done it, it got no money at
4 all.
5 But again, Haringey questions whether this Inquiry
6 should substitute its own judgment of the wisdom of
7 those budget decisions for that of the elected members
8 and senior officers at the time and does it have the
9 material upon which to do so? This Inquiry may think
10 that it can say Haringey should have spent more on its
11 Children's Services but with respect it cannot say what
12 it should have spent less on. Other social needs, if
13 ignored, can lead to deaths or have an adverse impact on
14 children.
15 If it spends less on refuse collection what about
16 disease? If it spends less on libraries or swimming
17 pools or parks, who suffers? If it spends less on roads
18 and street lighting so that there are more accidents,
19 who suffers? If it spends less on housing, who suffers?
20 If it spends less on its adult mental health and
21 community care services or on its drug dependency
22 programmes or its care for the elderly, their families
23 as well as the individuals concerned suffer. Children
24 live in those families. What other tragedies might we
25 investigate if those commitments were not maintained?
70
1 You have heard not only from the senior officers but
2 from the councillors who have embraced the concept of
3 their role as corporate parents and have told you how
4 they have set about fulfilling it. They do depend, as
5 they recognise, on what they are told by their officers
6 about the services being delivered. They do not accept
7 that information unquestioningly nor are they naive and
8 gullible. Mr Meehan has told you they do not know what
9 more they can do to check up on what they are told. If
10 the Inquiry is able to suggest that there are other ways
11 to make sure that their Children's Services are
12 delivered, the members will try to do it, but we
13 question whether creating a climate of suspicion and
14 mistrust between members and officers is helpful in this
15 endeavour.
16 Haringey has also set out in its written submissions
17 and you heard very recently from Ms Bristow about the
18 improvements and lessons which it has learned. It has
19 improved the staffing position and we set out details of
20 that. It has made arrangements to improve the training
21 for all its staff including the relatively inexperienced
22 workers coming in. It has a full social worker
23 development programme. It has also been working
24 extremely hard on improving the working relationships
25 with other agencies and it is Haringey that has taken
71
1 a lead in strengthening the role of the ACPC in the
2 manner in which we detail in those submissions. It is
3 also the primary contributor towards its funds. It is
4 a role which the present Director has adopted and has
5 worked extremely hard, both personally and on behalf of
6 Haringey, to do better.
7 Haringey recognises that it is not enough just to
8 say that it is sorry for its part in a system which
9 failed Victoria. Out of the reflection and heart
10 searching which has followed Victoria's death has come
11 a renewed determination to improve Children's Services
12 to all the children in Haringey and a hope that this
13 Inquiry can assist it in that task.
14 I am reminded that I said in referring to the period
15 of the terms of reference that it was October 1999, it
16 should of course have been March 1999.
17 THE CHAIRMAN: Thank you Miss Lawson. Ladies and gentlemen,
18 we will now adjourn for a quarter of an hour. We will
19 resume at 12 o'clock with Ms Boye.
20 (11.45 am)
21 (A short break)
22 (12 noon)
23 THE CHAIRMAN: Ms Boye.
24 MS BOYE: Sir, I think my interpreter has picked
25 a convenient moment to go AWOL.
72
1 THE CHAIRMAN: Let us wait.
2 Closing submissions by MS BOYE
3 MS BOYE: Thank you sir. Sir, I should say first of all
4 that we filed lengthy submissions because Mr and
5 Mrs Climbie wanted to comment on all parts of the
6 evidence to this Inquiry. Rather than speed read I am
7 just going to go through the matters which they have
8 asked me to raise today but they want me to make it very
9 clear that they wish their submission to be taken in its
10 entirety.
11 There are several issues as well that they feel very
12 strongly about which they would like raised at the
13 outset. Firstly that there seems to be to them
14 a misunderstanding that Victoria was actually French.
15 She was French and she spoke French and disclosure is
16 a difficult thing for any child at any time but they
17 feel that there is a fundamental misunderstanding that
18 Victoria could have talked easily in a language she
19 hardly spoke to professionals about very difficult
20 matters.
21 Secondly, the issue of Kouao. It is right that my
22 clients were also taken in by Kouao as well but what
23 they say about that is they were first of all
24 unsophisticated, they had no knowledge of these sort of
25 systems, they are not trained in any way and they had no
73
1 insight into any of those issues and also that they did
2 the checks that they could do, which to be honest were
3 financial. Their main concern with Kouao at the time
4 was would she have enough money to support Victoria in
5 this education, and this was a woman who was
6 ostentatiously wealthy, had credit cards, and as far as
7 they were concerned had money.
8 Thirdly, it has been an overwhelming concern of
9 theirs throughout this Inquiry that there has been
10 something of an issue of responsibility. Mr Climbie
11 said that maybe it is because we have had too many child
12 abuse inquiries in this country that there are days when
13 he and Mrs Climbie have sat listening to witness after
14 witness saying "my manager" or "the system" and that it
15 seems to them that the higher people get up the ladder
16 and the more they are paid, the less they admit, and
17 they also feel that there are times when people have
18 forgotten that this Inquiry is about the death of
19 a child in such terrible circumstances.
20 Mr and Mrs Climbie arrived in the UK shortly before
21 the opening of this Inquiry with no knowledge about the
22 work of most of the agencies involved. They were
23 immediately upset by the opening statements of some of
24 the parties, most notably the comment by the London
25 Borough of Haringey that Victoria was given away by them
74
1 without so much as a forwarding address. This caused
2 them great distress. Such comments have concerned them
3 not simply because they were insensitive and showed
4 disrespect to bereaved parents but because they suggest
5 a lack of knowledge of a practice which they understand
6 to be common in the black community as a whole.
7 Victoria's parents were therefore fearful that like
8 their daughter they too would be judged by people who
9 clearly had no awareness of or regard to the cultural
10 background from whence she came and it would seem the
11 wider practice of the extended family bringing up and
12 educating relatives. To label those sir is to label all
13 of us who have been brought to this country to be
14 educated, and it is important to remember that Mr and
15 Mrs Climbie themselves were brought up by their
16 relatives.
17 To that end they have asked me to thank today the
18 very many black professionals who have attended this
19 Inquiry and the public gallery to support them and to
20 tell them first of all they are not unique in this
21 country and that it is not an unknown practice, and
22 secondly that they are not to blame.
23 If it needs to be said, sir, Victoria was extremely
24 precious to them and all they wanted for her is what we
25 all want for our children, which is a better life than
75
1 they had. She was an extremely bright child and the
2 chance of an education in Europe was akin to winning the
3 Lottery for them. It would have guaranteed her far
4 greater opportunity than they could ever have provided.
5 Having now reached the end of Part I, they are though
6 saddened and disappointed by the failure of so many of
7 the witnesses to acknowledge responsibility for their
8 part, their failings, or to show that they have learned
9 from the many mistakes.
10 As I said, the following really deals only with
11 those matters that seemed most significant to Victoria's
12 parents and the conclusions they have reached, and
13 I refer you to our lengthier submissions.
14 First of all, London Borough of Ealing. It was
15 accepted by Ealing yesterday that Victoria was not
16 assessed by them and it is only the result of that
17 failure which we dispute. It was seen as a housing case
18 in which Kouao was the client and Ealing's priority was
19 to get Victoria and Kouao out of the borough and back to
20 France as soon as possible. Victoria's needs were
21 completely overlooked despite the fact that she was the
22 subject of observations and discussion amongst staff in
23 the Acton office. Kouao was noted to be manipulative
24 and it was suspected that Victoria was coached.
25 For Victoria's parents one of the most disturbing
76
1 comments in this Inquiry was made by the social worker
2 Deborah Gaunt who said that Victoria looked like an
3 Action Aid poster.
4 THE CHAIRMAN: I appreciate there is a time limit and I do
5 not mean to interrupt but if you can slow down a bit, it
6 is important we get all of this.
7 MS BOYE: This was a statement which to most people screams
8 child in need without the necessity of any social work
9 assessment.
10 The Team Manager Sarah Stollard told us in evidence
11 that had she known of these discussions she would have
12 investigated further and possibly even separated Kouao
13 and Victoria. It is important that this statement is
14 noted at this early stage of Victoria's life in Britain.
15 As a manager we say she ought to have been aware of such
16 discussions of such potential significance. It means
17 that had the information been discussed amongst staff
18 and properly gathered and recorded, Victoria could have
19 been protected then. Ealing were also aware that she
20 was with an unregistered child minder, not at school,
21 and did not have a GP, so much of the material for an
22 assessment was already available to them, and we know
23 that seven days after they closed her case she was
24 admitted to Central Middlesex.
25 Ealing's thinking we believe was dominated by the
77
1 fact that they believed Kouao not to be habitually
2 resident and really trying to prove that. The allocated
3 social worker Pamela Fortune said in her evidence that
4 the team at that stage assessed people generally on
5 housing needs rather than being child focused. It is
6 therefore ironic that Kouao and Victoria were
7 subsequently found to be habitually resident.
8 London Borough of Brent. Victoria first came to the
9 attention of Brent via Esther Akers' referral of
10 18th June which it has been said was treated with no
11 urgency despite its content. It was therefore a matter
12 of chance that a Section 47 investigation was triggered
13 by the referral from Central Middlesex and, as we know,
14 dealt with by Michelle Hines. Victoria's parent are
15 troubled however by the knowledge that had the referral
16 been made earlier in the day things would have turned
17 out differently.
18 It is also interesting to note sir that too late in
19 the day in the London Borough of Brent appears to be
20 four in the afternoon rather than four in the morning.
21 Hines contacted PC Rachel Dewar and a decision was
22 taken to place Victoria in police protection and take no
23 further action that evening. This was at 5.20. Mr and
24 Mrs Climbie do not understand why Victoria,
25 Avril Cameron and possibly even Kouao could not have
78
1 been seen that evening. They feel strongly that the
2 timing of a referral should not affect the impact on the
3 quality of the subsequent investigation.
4 The Section 47 investigation which should have
5 followed was never concluded. It was abandoned
6 following Dr Schwartz's scabies diagnosis. At this
7 stage Brent Social Services were completely led and
8 directed by Central Middlesex, abdicating their own duty
9 to investigate.
10 Mr and Mrs Climbie also feel particularly strongly
11 that the Camerons were an untapped source of vital
12 information about Kouao, her behaviour and the many
13 inconsistencies of her life which we say are available
14 to professionals throughout this case. Had Hines spoken
15 to Avril Cameron she would at least have discovered that
16 Victoria had also had cuts, poor hygiene and that Kouao
17 had tried to effectively abandon her with them
18 permanently.
19 Much has also been said about the deference paid to
20 consultant paediatricians. We say sir that
21 Dr Schwartz's diagnosis would clearly have been
22 influential but it should not have been decisive.
23 Social workers have a duty to make their own independent
24 assessments, otherwise what is the purpose?
25 Hines never raised with any doctor the discrepancy
79
1 between the information that she had been given, namely
2 bruising to feet, arms, legs, buttocks and fingers and
3 Dr Schwartz's diagnosis. In contrast, Avril Cameron's
4 common sense response was to immediately ring up and
5 query the diagnosis and ask Hines for an explanation.
6 Effectively the child protection investigation was
7 abandoned without Michelle Hines ever meeting Victoria
8 at all, and the focus for Brent then became, ironically,
9 shifting the responsibility back to Ealing as soon as
10 possible.
11 Lastly on Brent Social Services, as any good
12 department knows, the public is the most valuable
13 resource to them because they can alert them to children
14 at risk. It is therefore unfortunate that neither
15 Mimi Konigsberg nor Jenny Goodall, despite heavy hints
16 from you sir, could bring themselves to apologise to
17 Esther Ackah. Victoria's parents believe that it is
18 vital that members of the public are not deterred from
19 making referrals to social services by the possible
20 consequences for them if they are proved to be right.
21 Central Middlesex Hospital. Dr Schwartz in her
22 evidence admitted making a series of mistakes in
23 Victoria's case. These included not speaking to her
24 alone, not taking her own notes or checking Dr Modi's
25 and also not asking Kouao to account for Victoria's
80
1 injuries. She knew that she was overturning the initial
2 view of colleagues but she neither discussed this with
3 them or another consultant.
4 Victoria's parents are particularly concerned about
5 Dr Schwartz's assumptions about the marks on Victoria's
6 body. Not only did she pass up the opportunity to speak
7 to either Victoria or Kouao about the cause of these
8 marks but significantly having decided that they were
9 insect bites or marks from abroad, she did not go back
10 to Dr Ajayi-Obe, who is of West African origin herself,
11 and had presumably dismissed such ideas.
12 Schwartz now states that Dr Dempster's letter to
13 Hines is a poor reflection of her own views. Like
14 Dr Rossiter subsequently, she too relied on social
15 services to undertake a much fuller investigation and
16 stated that she was incredibly surprised and puzzled
17 that her view was taken as final. Whilst we agree with
18 her as to subsequent investigations, we think that her
19 comment shows a dangerous lack of awareness as to the
20 deference that will be afforded to her as a consultant.
21 Such a position we say places a greater responsibility
22 on you to communicate with the utmost clarity and
23 discuss fully with junior staff and ensure that your
24 concerns, all of them, reach social services.
25 Victoria's parents were further disturbed to hear
81
1 from the evidence of Dr Riordan that even though
2 Schwartz made significant errors in this case, he only
3 spoke to her about Victoria's case after the death when
4 she and the hospital were criticised at the trial.
5 Police. It has been accepted by senior officers in
6 the Metropolitan Police that the investigations by
7 PC Rachel Dewar and Karen Jones were simply poor
8 coppering. The agency that we most associate with
9 investigation did very little in Victoria's case. What
10 they did do was led by social services who in turn were
11 led by Health. So effectively officers in both child
12 protection teams were being directed by at best
13 second-hand unverified information.
14 It has been said that police officers sometimes
15 consider the long-term interests of children. However,
16 we believe that you do not know the long-term interests
17 of a child unless you investigate and have all the
18 information at your disposal and that is the role that
19 we would suggest the police have. In Brent Social
20 Services the practice had developed of taking police
21 protection primarily because it was easier than
22 obtaining an emergency protection order and in Brent CPT
23 it was the practice to allow social services to do the
24 police job of informing the child that they were in
25 police protection.
82
1 As it was in Victoria's case, nobody, social worker
2 or police officer, informed her, and the police
3 investigation into this crime which we say should have
4 been done from the moment they were aware of the
5 referral got postponed until the following day.
6 On that day as we know Police Constable Dewar went
7 on a course when she had an urgent investigation to
8 conduct and waited for Michelle Hines to call her. We
9 say that Dewar should have been speaking to Kouao who
10 ought to have been the main suspect at that stage and
11 should have been proactive in influencing the process
12 once the police were involved. It appears strangely
13 that the police were quite literally absent from this
14 process for which they were responsible once they had
15 placed Victoria in police protection.
16 As far as we can see sir there is a complete failure
17 by Police Constable Dewar to exercise any independent
18 judgment at all. She did not speak to Victoria,
19 Avril Cameron or to Kouao. She had a duty under
20 Section 46 and should have made her own independent
21 inquiries before no criming this matter, and she should
22 have at least seen Victoria whilst she had got her
23 placed in protection.
24 Mr and Mrs Climbie were both disturbed and confused
25 by the evidence of Police Constable Karen Jones. She
83
1 told the Inquiry that child protection work was
2 completely different to ordinary policing. We simply
3 cannot accept that sir. It may involve extra skills but
4 there is no way that it should not involve good basic
5 police work. She was clear in her evidence that before
6 she could investigate she needed evidence that a crime
7 had been committed, but she did not identify the job of
8 collecting that evidence as at all hers. As with Police
9 Constable Dewar, Jones saw the doctors as the only
10 source of information and waited for them to confirm the
11 crime.
12 Rather than speak to the hospital staff herself, she
13 delegated what should have been her police function of
14 evidence gathering to the social worker Karen Johns. We
15 do not suggest sir that there should be any of the
16 duplication that has been suggested here, but what we
17 say is this is information that Police Constable Jones
18 asked for at the strategy meeting, Police Constable
19 Jones should have gone and got. A social worker is not
20 the appropriate person to interview people and
21 investigate suspected crime. They cannot possibly know
22 what is going to be needed by the police to prove the
23 allegation.
24 Jones also decided, as we know, against a visit to
25 Victoria's home for fear of catching scabies, but
84
1 strangely if her evidence of the hospital's advice is to
2 be believed then she risked catching it in Social
3 Services' office in any event. What is certainly clear,
4 and no slant on it can make it sound better, is that she
5 was prepared for Victoria to return to a home that she
6 would not even visit.
7 As with many professionals in this case Jones
8 overlooked Victoria in favour of undue deference to
9 Kouao. She explained her failure to treat Kouao as
10 a suspect by saying that she took her at face value.
11 She was careful to neither query nor verify any of
12 Kouao's account, yet she concluded that there were no
13 grounds for suspecting her of ill-treating Victoria.
14 Much has been said about the major subterfuge and
15 deception of Kouao. Certainly it is accepted that she
16 was a liar but we would hope that the police are used to
17 dealing with liars and untruth. If they are not then it
18 is a problem.
19 Jones did not speak to Victoria until after she
20 decided to close the investigation, and nor was an
21 interpreter present which would have put Victoria at her
22 ease. Mr and Mrs Climbie thought it extremely strange
23 that a child protection officer should expect a child of
24 eight to make a clear allegation to two strangers she
25 had never met in a language that she hardly spoke.
85
1 They were equally perturbed by the evidence of
2 a letter which took two months to translate in what
3 should have been an urgent investigation and that the
4 file was closed on what we understand as no more than
5 a rumour from social services that Victoria and Kouao
6 had returned to France.
7 It is all the more concerning that we know that
8 Karen Jones has been a police officer for 15 years, in
9 the CPT for at least six and has one of the most
10 impressive list of courses and training submitted to
11 this Inquiry we would say.
12 Mr and Mrs Climbie have nothing but praise for the
13 officers who conducted the murder investigation. They
14 have noted however the assistance given by Manning and
15 the role his diaries played in the conviction. On the
16 day that Manning believed he would be interviewed by
17 Police Constable Jones about the allegation of sexual
18 abuse, he wrote "judgment day" in his diary and he
19 stayed at home all day worried and waiting.
20 Victoria's parents believe that had any officer
21 decided to interview Manning in these early days or even
22 speak to him it is likely that he would have cooperated
23 in the same way that he did later on. At the point that
24 Police Constable Dewar became involved Kouao had already
25 tried to leave Victoria at the Camerons saying that it
86
1 was Manning who wanted her out.
2 North Middlesex Hospital. Mr and Mrs Climbie have
3 been confused and asked the Inquiry to clarify the whole
4 issue around multiagency working. Mr Climbie commented
5 yesterday that this is not really multiagency working,
6 it is actually two agencies working for doctors.
7 Victoria's parents found the evidence given by the
8 NMH nurses particularly distressing to listen to because
9 in contrast to other witnesses, here were a group of
10 professionals who were saying that they actually
11 recognised the evidence of emotional and physical abuse
12 at the time that it happened. The collective view of
13 the nurses on Rainbow Ward was that Victoria was beaten,
14 neglected and was afraid of Kouao and Manning. They
15 wondered though why none of these nurses sought to raise
16 their serious concerns with Nurse Ryan who acknowledged
17 that she should have gone to Dr Rossiter to stop the
18 discharge. She also said in evidence though that no
19 ward nurse came to raise this issue with her or object.
20 Mr and Mrs Climbie believe that even on the few
21 occasions that Victoria was spoken to in hospital she
22 left many clues. This two-week period in Rainbow Ward
23 was a chance to talk to and befriend her. She told
24 Lucienne Taub that she liked living in the Ivory Coast
25 because she could play outside and it is clear to us
87
1 that given the opportunity to speak in French, Victoria
2 was willing and able to talk about her past and maybe
3 her present.
4 Miss Taub mentioned Victoria's use of the words
5 "enciente" meaning "pregnant" because she felt it was
6 a very adult word of a child of her age to use. She was
7 concerned enough to note this. When Victoria left home
8 she was very excited about her mother's pregnancy and
9 her parents believe that had she been questioned further
10 in the language she spoke, the true details of her
11 family background could have been revealed.
12 Finally it was said by the hospital staff and
13 Lisa Arthurworrey that Victoria wanted to go home.
14 I say sir that I heard Miss Hoyal's statement this
15 morning that this was not home to the Ivory Coast, but
16 I say about that that it is not my recollection that
17 that was ever said by Lisa Arthurworrey in evidence, nor
18 that it has been raised on her behalf before, and we
19 would say sir that our recollection is certainly that
20 the words used by Lisa Arthurworrey and the hospital
21 staff in relation to this incident were that Victoria
22 had been asked if she wanted to go home and answered
23 yes.
24 You recall that Mrs Climbie burst into tears when
25 she heard this evidence because to her it is completely
88
1 clear that Victoria's excitement was because the
2 believed she was returning to her family in the Ivory
3 Coast.
4 As regards NMH, Dr Rossiter took full responsibility
5 for the failings in her department saying that she did
6 not appreciate that social services did not comprehend
7 the full extent of her concerns. Dr Rossiter's
8 communications however were the very antithesis of
9 clarity. She was outraged to discover that Victoria had
10 been discharged but she accepts that she never told
11 anybody that this should be prevented. Such action as
12 she did take is not noted or even clearly recalled by
13 her now. When the response from Lisa Arthurworrey via
14 Petra Kitchman made it clear that there was
15 a misunderstanding, Dr Rossiter, who was the person at
16 the epicentre with the key knowledge, failed to clarify
17 this very serious mistake.
18 Victoria's parents find this incomprehensible and
19 they cannot match the actions to what they heard
20 Dr Rossiter say. In the multiagency system clearly the
21 consequences of poor record keeping for a consultant
22 paediatrician are far more serious than in any other
23 profession, as Victoria's case so vividly shows.
24 Equally Dr Rossiter said in evidence that her
25 relationship with Haringey at this time was not an easy
89
1 one and Mr and Mrs Climbie cannot then understand how
2 a person who appears to have spent her life chasing or
3 writing letters to Haringey could speak in terms of the
4 trust that she had in them to care for Victoria.
5 On the matter of Haringey, Mr and Mrs Climbie were
6 completely horrified by the descriptions of the team in
7 which Victoria's case was in North Tottenham at this
8 stage. This is truly bizarre, witchcraft in one corner
9 and, perhaps appropriately so, religious fanaticism in
10 the other, and in the middle absolutely nobody reading
11 a file.
12 Ironically the most benign description we got was of
13 Lisa Arthurworrey's spiteful school. Managers
14 apparently knew that files were not being read in breach
15 of guidelines and supervision could therefore be no more
16 than a recital by a social worker of what they chose to
17 tell. There was no mechanism for assessing whether work
18 was being done or whether a client's circumstances had
19 changed or improved.
20 Strategy meetings as we know were in Victoria's case
21 chaired without reading the file, and after the meeting
22 there is a failure to follow through decisions taken to
23 send out minutes or ensure that future strategy meetings
24 did not repeat tasks. Guidance was either completely
25 unknown or custom and practice had developed to avoid
90
1 following it.
2 Whilst it appeared that Miss Lawson this morning was
3 suggesting -- it appeared to us anyway -- that this was
4 some sort of rogue team, Victoria's parents were also
5 shocked to hear that seven months before her death
6 management were warned that the restructuring proposals
7 in Haringey were potentially dangerous and detrimental
8 to those who offer a service. Whilst of course we
9 cannot know in detail what went on at this time,
10 Victoria's parents have noted that these warnings went
11 unheeded by those senior managers who now appear to have
12 been promoted to posts in other authorities.
13 Mr and Mrs Climbie always made it clear that their
14 concern was to see that Victoria's death was not in vain
15 and lessons have been learned. They were even more
16 troubled by Rose Kozinos's letter of June 2001 saying
17 that mirror conditions if not worse exist in Haringey
18 now.
19 There was a period sir when this Inquiry was
20 dominated by the disappearance of, search for and
21 obstruction by Carole Baptiste. Unfortunately, her
22 evidence, so long awaited, provided little information
23 but did raise serious concerns as to the state that she
24 must have been in when she supervised Victoria's case.
25 It was of great concern to Victoria's parents to
91
1 read in the press that Baptiste, a team manager in child
2 protection, had had her own child removed from her care.
3 To them sir this is akin to discovering that police
4 officers all have previous convictions. Whatever the
5 circumstances or support she required, it casts doubt
6 firstly on her ability to function during the time she
7 supervised Victoria's case and secondly on Haringey's
8 approach to working around her rather than facing up to
9 what was at the very least a serious problem of
10 availability.
11 Covering for such work as we say sir in management
12 posts sends out a clear message. These people act as
13 a buffer, a mark below which no one can fall, and
14 employees know that as long as they are not as bad as
15 this, their jobs are going to be safe. Consequently and
16 inevitably standards deteriorate. It is dangerous for
17 the clients and it is damaging for the morale of those
18 many staff who are committing to providing a proper and
19 professional service.
20 Turning now to Lisa Arthurworrey. Lisa Arthurworrey
21 first met Victoria when planning her discharge for
22 hospital. Again this meeting was attended with a child
23 who spoke French but an interpreter was not used.
24 Whilst we accept that Victoria spoke to
25 Lisa Arthurworrey we say that this interview can have
92
1 provided neither information for the social worker nor
2 reassurance for a child who would have struggled to
3 communicate in her broken English.
4 In her seven months as Victoria's social worker
5 Arthurworrey met her four times for a total of 30
6 minutes. Her conversations never got further than
7 "hello, how are you?" which is a record she accepts is
8 appalling. When he eventually visited Victoria at home
9 she ignored her client and focused on Kouao and her
10 housing application.
11 Much has been made of the inaccuracy of the medical
12 information received, with which of course we agree.
13 But we say that a social worker's job is not simply to
14 act on a direction of a doctor. It is actually to build
15 up your own social work assessment and independent view
16 of the information available. Arthurworrey told the
17 Inquiry that from the evidence received she had no
18 reason to believe that Victoria was at risk. The
19 impression given to Victoria's parents is of a social
20 worker waiting for information to land on her desk
21 rather than gathering it herself. This is particularly
22 true of the allegation of sexual abuse. Even if it
23 transpired that these allegations were invented, that in
24 itself would be important evidence of the way Kouao was
25 able to use, coach and control Victoria.
93
1 Victoria's parents feel that Lisa Arthurworrey made
2 no attempt literally to understand Victoria but in
3 contrast she made considerable efforts to understand
4 Kouao, placing favourable interpretations on her
5 incredible story. She told the Inquiry that she saw
6 Kouao as a proud woman struggling to find her feet in
7 a new country but she made no attempt to corroborate or
8 challenge anything that Kouao told her. She ignored the
9 observations of the NMH nurses, both black and white,
10 that Victoria was afraid of Kouao and dismissed these
11 observations as part of the Afro-Caribbean script.
12 Mr and Mrs Climbie were at first puzzled and then
13 angered by this term. They wondered how such obvious
14 descriptions of fear as "master and servant", "jumping
15 to attention" and "wetting yourself in your mother's
16 presence" could be dismissed on the pretext of cultural
17 respect, especially as Arthurworrey had no knowledge of
18 the country or culture from whence Victoria came.
19 For Victoria's parents her social worker can be
20 summed up by three statements, all equally disturbing.
21 Firstly, she said she believed what people told her;
22 secondly, she said she was not a detective; and thirdly,
23 her refrain in evidence that everything she did or did
24 not do was known, confirmed by her managers.
25 The effect of these statements are that she took
94
1 everything Kouao told her at face value without
2 verification or evaluation. She did not see her role as
3 a social worker as one of either investigating or
4 assembling any information but complained about the lack
5 of information available to her, and lastly as with many
6 witnesses she holds her managers responsible for conduct
7 that was hers.
8 Kouao. It has been said by social workers and many
9 other parties that there was nothing in their dealings
10 with Kouao or Manning that could have alerted social
11 workers. We completely disagree with this sir. It is
12 a feature of abusers that they often lie. That should
13 therefore be within the knowledge of anybody who does
14 child protection work. The inconsistencies in Kouao's
15 accounts were all there had anyone questioned the
16 information. Much of it was there by putting the
17 documentation together. The different explanations
18 given for the timing of the schooling, her choice of
19 hospitals, how the injuries were received, for instance,
20 were never pursued with her. Nor was clarity sought of
21 more basic information such as different dates of her
22 arrival in the UK, death of her husband, who she said
23 was Victoria's father, and how long she intended to stay
24 in this country and what she was actually doing.
25 Even if Kouao's account is accepted unchallenged,
95
1 Victoria was at the very least a child who had lost her
2 father, moved from her home in another country twice,
3 had two admissions to hospital, a serious scalding
4 injury, some sort of skin condition or other and was
5 incontinent at this late age. This information should
6 have been enough to alert any social worker. And it is
7 disturbing now that the London Borough of Haringey
8 should seek to pray in aid the support of Kouao and
9 Manning as references for lack of blame.
10 In the early days of this Inquiry sir you
11 complained -- little did you know -- of being drip fed
12 documents by Brent. Subsequently we have all been
13 drowned in a tidal wave of documentation from Haringey
14 right up until the last day. Victoria's parents have
15 said that they believe that the Inquiry has been
16 deliberately hindered by the withholding of documents
17 and they wonder what it is that Haringey is trying to
18 hide. In addition to their language difficulties they
19 have been greatly hampered and in recent times frankly
20 defeated, as has their counsel sir, by the plethora of
21 documents which they wish to read but simply cannot be
22 translated fast enough for them.
23 They were also disturbed by the disclosure of the
24 letter signed by six health managers which gave the
25 impression of a pact between Haringey and the NHS for
96
1 the purposes of this Inquiry. Whatever the meaning of
2 "joint and positive approach", it was concerning to
3 Mr and Mrs Climbie that there may at some stage have
4 been some sort of agreement and it is their view
5 obviously that such a pact would stand in the way of the
6 Inquiry's scrutiny of all matters relating to her death.
7 Finally, a theme that they believe is important has
8 been the deliberate denial of responsibility and the
9 lack of accountability at this Inquiry. It is
10 a function sir of a public inquiry that it is
11 a restoration of public confidence, but a pre-condition
12 to that restoration must be the acceptance of
13 responsibility by those who fail to protect.
14 A vague acknowledgment of corporate responsibility,
15 whilst suggesting that actually you were far too high up
16 the tree to really know what was going on and expected
17 people in the middle to tell you, is woefully
18 inadequate.
19 Victoria's parents have noted that social workers
20 blame doctors, front line staff blame management,
21 managers blame the council, the councils blame the
22 Government for lack of funding. Typical responses to
23 failings have been "I am poorly managed we did not have
24 the resources" or "it was not my job".
25 Victoria's parents have been left with the strong
97
1 impression that when giving evidence the primary
2 objective of certain witnesses was to avoid
3 acknowledging their personal responsibility at all
4 costs.
5 In this regard Mr and Mrs Climbie were particularly
6 shocked by what they perceived sitting where they are to
7 be the arrogance and indifference of the former Chief
8 Executive of Haringey Mr Gurbux Singh. When it was put
9 to him by Counsel for the Inquiry that there was a lack
10 of willingness to take responsibility, he replied,
11 "I have personally thought long and hard about what
12 I could have done differently but I end up thinking that
13 I am not sure there was a great deal more that we could
14 have actually done". This is a very disturbing and
15 disappointing statement from a former Chief Executive
16 after all that has emerged during the course of this
17 Inquiry especially concerning Haringey.
18 Mr Singh's evidence can be sharply contrasted sir
19 with the candour of the previous Chief Executive of
20 Brent Gareth Daniel.
21 The evidence given during this Inquiry revealed,
22 Victoria's parents feel, incompetence, indifference and
23 a complete absence of common sense on some occasions.
24 These are basic failings. There has been no
25 investigation by the police, no assessment by social
98
1 workers and a failure by doctors to be clear about what
2 they were trying to say.
3 Much has been said about resources and training but
4 Victoria's parents feel that a hell of a lot more should
5 have been said about responsibility because at the heart
6 of their case they feel that the key people charged with
7 the responsibility of ensuring Victoria's safety and
8 welfare simply did not do their jobs.
9 I flag up now sir some matters that Mr and
10 Mrs Climbie wish to draw to your concern and put in
11 their written submissions in relation to possibly
12 Part II but also your recommendations.
13 Firstly the role of the churches. Victoria's
14 parents have particular concerns about the Rainbow
15 Church which we have already heard has been brought to
16 the attention of Haringey as a result of child
17 protection concerns.
18 Having heard the evidence that emerged during the
19 course of the Inquiry from several churches, they are
20 concerned that it cannot be left up to churches who take
21 on a welfare and childcare, even in the form of
22 a creche, role to decide how best to act when they are
23 faced with issues concerning the welfare of children.
24 They are concerned that if some sort of statutory
25 regulation is not looked at there can be little doubt
99
1 that some churches and religious institutions will
2 continue to act in a manner that is totally at odds with
3 the child's welfare.
4 Secondly, speaking to children. Mr and Mrs Climbie
5 were very disturbed about the evidence we have heard
6 throughout the Inquiry sir of the failure to speak to
7 Victoria, and felt that it was important to provide
8 children with reassurance and also gather information.
9 It is their view that most of the witnesses who had the
10 opportunity to speak to Victoria did not take the time
11 to, but even more said that they would have done had it
12 not been for some perceived prohibition relating to the
13 tainting of evidence or the necessity to obtain the
14 parents' permission.
15 Victoria's parents would therefore like the Inquiry
16 to clarify the issue around the DOH guidance memorandum
17 procedures and practices so that there is no room for
18 variations in the interpretation of at least what the
19 guidance is to be before coming to a professional
20 judgment.
21 Funding for Children's Services. Victoria's parents
22 are also concerned, probably largely due to the ongoing
23 debate about the SSA, about funding for Children's
24 Services. It seems to them that if money for Children's
25 Services is not ringfenced in some way or given with
100
1 sanctions attached, that it will be spent in other areas
2 because other things will take priority.
3 Social workers' code. Mr and Mrs Climbie were very
4 surprised to find out that a code of conduct for social
5 workers is only now being introduced, especially as it
6 appears to them to amount to no more than a series of
7 very obvious ideas and ideal aspirations. Where
8 individuals fail, then the system goes wrong, there must
9 be full accountability, and this is all the more
10 important given the difficulties that exist in making
11 local authorities accountable before the courts.
12 As a result, they would like the Inquiry to consider
13 something along the lines of I think it is
14 Commander Kelleher's evidence, sir, looking at a PACE
15 code of sorts that was at least uniform for social
16 workers.
17 Finally, sir, a mention must go to those who Mr and
18 Mrs Climbie feel they owe the most, the Camerons and
19 Esther Ackah. It is regrettable that the most that was
20 done for Victoria was done by those who were not paid or
21 trained to protect her. These actions taken by
22 Avril Cameron, Priscilla Cameron and Esther Ackah are
23 not only deserving of the highest praise but are also
24 a model of what we all hope the public would do for
25 children suffering abuse in any society. It was they
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