5 Brent Social Services

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Victoria in Brent

The first referral

5.65

Esther Ackah, a distant relative of Kouao, made the first of two telephone calls to Brent Social Services from a telephone box on the afternoon of Friday 18 June 1999. She gave details about a child called ‘Anna’. She said she was aged about seven, her mother’s name was Marie-Therese Kouao, their address was Room 10, 8 Nicoll Road, Harlesden, London, and that they were French. She said she was worried about the unfit state of the accommodation that Kouao and ‘Anna’ were living in, the problems the child was having with incontinence, that she had a scar on her face which her mother had said was due to a fall from an escalator, and that others had expressed concerns about the well-being of ‘Anna’. Ms Ackah said at that stage she believed Victoria’s life was in danger, not because of physical harm, but due to the dangers posed by her living conditions. She said she made this clear to the person on the other end of the telephone. She wanted social services to make an urgent visit. As the coins for the telephone ran out, Ms Ackah was cut off before she could give, or was asked for, her own name as the referrer.

5.66

Samantha Hunt, a temporary customer services officer in the call centre at the One Stop Shop at Brent House, said she received an anonymous call from a lady concerning a child aged eight years. The caller gave the child's first name as 'Anna' but gave no surname. She described herself as a neighbour and wanted to report her concern about the child.

5.67

The caller said she had seen 'Anna' repeatedly wetting herself and that she had also previously seen her with cuts and bruises to her face, although the mother had said that this was caused when she fell down an escalator. Other neighbours had expressed their concern and had asked this neighbour to call social services. The caller said that as far as she was aware, 'Anna' was not attending school and was living in a home "surrounded by drug addicts". She did not think that 'Anna' was being treated by a doctor. The caller then hung up without giving any further information.

5.68

Ms Hunt believed she made a note of the conversation by hand and typed it up immediately after the telephone call. Although she could no longer remember the conversation, she was confident that if she had been given the child's surname or her place of origin she would have recorded those details. Similarly, if she had been told that the child's life was in danger, that also would have been recorded on the referral.

5.69

Notwithstanding these discrepancies in the detail of the concerns relayed to Brent Social Services about 'Anna', it is clear that the first telephone call made by Ms Ackah and the anonymous telephone referral received by Ms Hunt on 18 June 1999 were one and the same. Whether or not Ms Ackah told Ms Hunt that Victoria's life was in danger, the referral, as Ms Hunt recorded it, was clearly a child protection referral and should have been dealt with as such, even if it did not fully express the weight of Ms Ackah's concerns.

5.70

Ms Hunt responded promptly and did exactly what she was trained to do. She had been told to put all calls regarding children through to the children's social work department. However, at times this would prove impossible because all the lines were busy. In that situation the customer services officers, and she was one of two dealing mainly with social services, were expected to take down the referral details themselves and then pass them on. This is what Ms Hunt did on this occasion.

5.71

One can only speculate about what other potentially important details Ms Hunt might have found if she had had the time to question Ms Ackah further. What is clear is that social services should do as much as possible to access such information at the earliest opportunity, particularly in relation to child protection concerns where these have been relayed by members of the public whose chosen means of communication is by public telephone. I therefore make the following recommendation:

Recommendation

Local authorities with responsibility for safeguarding children should establish and advertise a 24-hour free telephone referral number for use by members of the public who wish to report concerns about a child. A pilot study should be undertaken to evaluate the feasibility of electronically recording calls to such a number.

5.72

Ms Hunt also checked the client database system for any previous referrals matching the name 'Anna' and the address of 8 Nicoll Road but drew a blank. At 4.21pm that same afternoon, Ms Hunt faxed the referral across to the children's social work department. According to Ms Hunt, all children's social work was deemed as urgent. She said, "It was not for us to ascertain the urgency, so all the children's social work referrals, from what I can remember, were faxed through." There was therefore no need in her mind to attach a cover sheet to Victoria's referral to signify that it was urgent, nor was it the practice to check whether anyone in the children's social work department had received the fax.

5.73

Sadly, nobody picked up Ms Ackah's referral that Friday afternoon and what actually happened to it was to prove the subject of some of the most bizarre and contradictory evidence this Inquiry was to hear.

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Logging the referral

5.74

The next agreed sighting of the 18 June referral was some three weeks later on 6 July 1999. Robert Smith, the group administrative officer, undertook the index check for Victoria that day. His team was responsible for completing checks for the duty intake and child protection teams on all new referrals. As the team supervisor, he had stepped out of his usual role on that occasion to assist his staff because the office was understaffed and busy with a backlog of work.

5.75

Notwithstanding these staff shortages, he said it was unusual for a delay of as much as three weeks before a case was logged, although other documentary evidence to the Inquiry clearly suggested the contrary. By way of explanation, Mr Smith thought it possible that if some work had already been done on the case before his office received it, the administrative staff might have only just seen the referral on 6 July 1999.

5.76

That, unfortunately, does not appear to have been the situation in relation to Ms Ackah's referral. Whether the fault lies with the administrative team or the duty team that failed to pass it on, a delay of three weeks in processing any child protection referral can never be acceptable and Brent accepted this. In Victoria's case, inquiries under section 47 of the Children Act 1989 should have begun immediately on 18 June 1999. The failure to do so constituted a significant missed opportunity to protect her.

5.77

To my surprise, Mr Smith and others confirmed that there was no system for ensuring that faxes that arrived in the building went to the people for whom they were intended. In a case such as this, the fax from Ms Hunt should have gone to the duty manager or duty senior social worker, who would log it in the referrals log book and complete the necessary paperwork. They, in turn, would pass it to the administration team who would log it onto the database and complete index checks to find out whether the child was known to Brent. Referrals marked as 'child protection' were usually passed to one particular administrative officer, Mr Punch, for processing.

5.78

Mr Smith entered the details of Ms Hunt's referral onto the database, creating a new, 'unique' record reference number: 1009966. This reference number was important. It contributed the crucial evidence to show that while the social workers involved with Victoria's case may not have made a link between the 18 June 1999 referral and the later referral by the Central Middlesex Hospital, the computer certainly did.

5.79

Mr Smith summarised onto the computer the details of the case as:

"Sees the child constantly wetting herself and has seen her previously with cuts and bruises around the face. Others have expressed concerns. As far as the referrer knows the child is not attending school."

5.80

Importantly, one printout of the computer record created by Mr Smith as it appears on the case file, and as it might well have been seen by those social workers involved with Victoria, shows no more than the first line of case detail and reads, "Sees the child constantly wetting herself and has seen her." Social workers should, however, also have had access to other records with the complete referral information.

5.81

It is clear that the information inputted by Mr Smith was edited from the details of Ms Hunt's referral. There can therefore be no doubt that it was this referral that was seen by Mr Smith on 6 July 1999. Mr Smith also had sight of a duty manager's action sheet, which enabled him to fill in on the same day and as part of the status section of the same computer record the following facts:

•

the initial action date as 21 June 1999

•

the duty manager's name as Eddie Armstrong

•

the action to be taken as a home visit on 14 July

•

the social worker's name as Lori Hobbs

•

the decision - 'open on duty'.

5.82

The duty manager's action sheet also asked for the details to be logged in and checked. The box marked 'other advice and assistance' was ticked but not the child protection box. Mr Smith therefore logged in the referral under what he understood to be the default classification of a child in need. He did this despite the detailed references to cuts and bruises.

The team manager

5.83

Edward Armstrong was the team manager of the intake duty team at the time Victoria's case was handled by Brent Social Services, and his involvement is of central importance to an understanding of this part of Victoria's story. His evidence merits particular close scrutiny, not least because it is out of line with that of other Brent witnesses on almost every count, and the quality of it leaves much to be desired. Mr Armstrong's memory proved to be highly selective about events of seemingly equal importance and his insistence on how things appeared to be could rarely be substantiated by any rational explanation of why they should be so.

5.84

It was Mr Armstrong's view that there was another referral on 21 June 1999 and that it was this referral, not the 18 June referral taken down by Ms Hunt, that he handled and for which he completed a duty manager's action sheet. This later referral was not a child protection referral. It is Mr Armstrong's evidence that all the papers for this 21 June referral, except the duty manager's action sheet, have gone missing. But he said that a social worker in his team, whom he could no longer identify, did receive a telephone call in relation to a child named 'Anna' in temporary accommodation who was wetting herself. He said the child in this referral was about eight years old. By an extraordinary coincidence, Mr Armstrong claimed that this less serious referral was also not logged onto the system until 6 or 8 July 1999.

5.85

Given that, by his own admission, the papers for the 21 June 1999 referral went missing some time after July 1999, it is almost impossible to accept that Mr Armstrong could have pinpointed so precisely the date of this second referral as well as the date on which it was logged onto the system. Victoria was one of many 'child in need' cases. Indeed, Mr Armstrong stated that his team would hold around 300 cases open. Not surprisingly, Mr Armstrong had no real answer to this point in evidence. Nor did he make any mention of a referral on 21 June in his interview for Brent's Part 8 management review of Victoria's case, nor as part of his own disciplinary process. More importantly, there is no evidence whatsoever that any referral received on 21 June was ever logged onto Brent's client-based system.

5.86

Despite giving vivid accounts of an office in chaos where files went missing and faxes spilled out regularly onto the floor, Mr Armstrong was adamant that the 18 June 1999 referral taken by Ms Hunt was never received in his office. He said that there were three floors in children’s social work and that the fax from Ms Hunt could have gone to any of these floors. He said that if he had received that referral he would have discussed it immediately with the child protection team. When asked whether the fact that the fax came through late on Friday afternoon meant that it would have been left to the following Monday 21 June to be dealt with, Mr Armstrong replied that the referral would have been dealt with by his team unless it was received after 5pm, in which case it would have been referred to the out-of-office-hours team. Out-of-office-hours teams are not necessarily staffed by people with expertise in services for children. Since children are not exposed to risk only during normal office hours or at times of administrative convenience, the timing of a referral should not determine the quality of the service provided. I return to the organisation of out-of-office-hours social services at paragraph 6.172.

5.87

To add to the confused picture, Ms Ackah said in evidence that a few days after she spoke to Ms Hunt - she thought less than a week later - she rang Brent Social Services again on exactly the same telephone number. Her reason for doing so was to make "absolutely sure" that social services had taken some action following her earlier call. She spoke to a different person, briefly repeated her story about 'Anna' and was asked to hold on while they went to check. When the person on the other end of the telephone eventually came back to Ms Ackah, she told her that she "thought the first call was received, and probably they [social services] had done something about it". In my view this was no way to respond to a member of the public who had behaved responsibly in contacting the authorities about her concerns for a child.

5.88

I cannot be certain when Ms Ackah made her second telephone call. It could have been on 21 June 1999 and it might have been this second call which was dealt with by someone in Mr Armstrong's team. What is clear is that the call did not trigger a new referral by whoever picked up the telephone in the One Stop Shop and no separate referral was ever logged onto the computer system.

5.89

According to Mr Armstrong, the social worker who took the referral found out that the family had moved from Ealing to Brent and it was Brent's housing department that revealed that Nicoll Road was used by Ealing to place temporary residents. Yet the case file evidence presented to the Inquiry suggests that Brent knew nothing about Ealing's involvement until 14 July 1999. As a result of this referral, Mr Armstrong claimed he made a telephone call to Ealing Social Services to establish whether they had placed a child called 'Anna' in Nicoll Road. Surprisingly, neither he nor anyone else thought to ask Ealing for 'Anna's' surname or, if he did, no surname was recorded at the time. There is no record of this telephone conversation in the Ealing case file for Victoria to support Mr Armstrong's claim.

5.90

Mr Armstrong also said he decided that inquiries should be made to Brent council's housing and health departments, and to the General Medical Practitioner's Board. Those instructions, he said, were put in written form and attached to the case papers, which he claims have now gone missing. Mr Armstrong's initial assessment, based on the information he said he had that the child was wetting herself, was that Victoria was a 'child in need'. As a result, he authorised two unannounced home visits by social workers he could now no longer identify. No records exist of any of these steps being taken, nor of their outcome. The only available recorded instruction by Mr Armstrong are the words "home visit" on the duty manager's action sheet, as noted by Mr Smith when he inputted the details of Ms Hunt's 18 June 1999 referral.

5.91

Asked why it was that a child wetting herself would have of itself justified a 'child in need' label, two unannounced home visits and many inquiries with other agencies, Mr Armstrong replied, "Because a child is wetting herself, and secondly because the culture in Brent at the time was that people who were in temporary accommodation, and came to the borough, we just tried to get them out of the borough for financial reasons."

5.92

This might be thought to be an unconvincing explanation. According to Mr Armstrong, Brent also knew Victoria had been placed by Ealing Social Services. Establishing that Ealing was funding the placement was only a telephone call away.

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Contact with Ealing Social Services

5.93

Mr Armstrong recounted a number of telephone conversations that were supposed to have taken place some time after 21 June 1999 between himself and members of his team and Ealing Social Services, all of which it seemed were aimed at shifting responsibility for Victoria's case back to Ealing.

5.94

The first was between Ms Viljoen, a social worker in Mr Armstrong's team, and Godfrey Victor, a social worker at Ealing Social Services, who reportedly said that as the family was living in Brent the case was Brent's responsibility. Mr Armstrong said in evidence that he then rang Mr Victor to press the case for Victoria being transferred back to Ealing but that he was unsuccessful.

Home visits

5.95

Mr Armstrong said that it was at this point he decided that his team should carry out an unannounced visit to the family, pending agreement by Ealing to retake responsibility for the case. He also said that he discussed the case with Ms Roper, the manager of the child protection team, or one of the two seniors in the team, though he could not recall with whom. It was agreed that the case properly belonged to Ealing and should be dealt with as a 'child in need'.

5.96

Within one or two weeks of 21 June 1999, Mr Armstrong said he spoke to John Skinner, assistant director for children's services at Ealing, who accepted that case responsibility rested with Ealing as the family was only temporarily resident in Brent. In the light of his conversation with Mr Skinner, Mr Armstrong said he then contacted Mr Victor again to inform him of the agreed decision. He also said he faxed across the information that Brent held, including details of the two home visits. Rather bizarrely, as Ealing had by now accepted case responsibility according to Mr Armstong's version of the events, Mr Armstrong said he told Mr Victor that Brent would make an appointment for a home visit to Nicoll Road and report back to him.

5.97

When asked why this was thought necessary when his team could barely cope with the pressures for which they did have responsibility, Mr Armstrong tried to explain his actions by saying, "It's something we do for other boroughs." It seems more than a passing coincidence that the two people Mr Armstrong said he had spoken to at Ealing Social Services were both known to him as former employees of Brent Social Services. Yet neither Mr Victor nor Mr Skinner, nor for that matter Ms Viljoen, Ms Roper or either of her two seniors could recall any of the conversations recounted by Mr Armstrong. There are no records of these conversations or of the fax that Mr Armstrong said he sent to Mr Victor in the Brent file, or more importantly, in the Ealing case file. In short, there is not a shred of written documentation to support any aspect of Mr Armstrong's version of events this far. If Mr Armstrong is to be believed, the implication must be, and Mr Armstrong asserted as much but was unable to point to any evidence to support his allegation, that the papers in both the Brent and Ealing case files relating to just the 21 June 1999 referral must have been tampered with or they were lost in both offices.

5.98

It remains Mr Armstrong's contention that he never saw Esther Ackah's referral of 18 June, but instead dealt with a less serious referral which he appropriately identified and responded to as a 'child in need' case. I find this version of events wholly unbelievable. I am left in no doubt that Mr Armstrong's evidence to this Inquiry in relation to a referral on 21 June 1999 - a referral that I conclude never existed - is an attempt to cover up his team's inept handling of a genuine child protection referral that slipped through the net. The duty manager's action sheet dated 21 July 1999 does not in my opinion support the existence of a new referral, but merely proves the delay in dealing with the referral recorded by Ms Hunt on 18 June. Inevitably, my conclusion as to Mr Armstrong's credibility in relation to this matter will have some impact on the weight to be attached to the rest of his evidence to the Inquiry.

5.99

On 7 July 1999, a computer-generated letter was sent from the duty manager to the occupant of Room 10, 8 Nicoll Road, arranging a home visit for 14 July 1999 at 3pm to discuss the referral about 'Anna'. Although it looked to an inexpert eye suspiciously like his writing, Mr Armstrong denied that he wrote the date 14 July 1999 next to the name "Lori" at the top of the duty manager's action sheet that he signed off on 21 June. Yet Mr Smith was equally clear that, although the administrative staff were responsible for making appointments for social worker visits and recording those on the system (hence the computer-generated letter), they would not have written these dates. Mr Smith assumed that either the duty manager or senior social workers had written the date of 14 July on the action sheet because that was when they wished the visit to take place.

5.100

According to Mr Armstrong, Lori Hobbs, the social worker who had been asked to visit Nicoll Road, went to the address twice on 14 July 1999. On his account, despite knowing that an appointment had been made for 3pm, he said Ms Hobbs inexplicably went to the premises ahead of the appointment time, found no one in and returned to the office. She later went back to Nicoll Road at 3pm in the company of Monica Bridgeman, one of the senior social workers in the duty team.

5.101

Ms Hobbs's recollection, though hazy some two years after the event, was that she made no other visit to Nicoll Road other than in the company of Ms Bridgeman for the 3pm appointment. She explained that she was with Ms Bridgeman only because she did not feel confident to do the visit scheduled immediately after Nicoll Road on her own.

5.102

Ms Hobbs said that the premises they came to looked like houses that had been converted into bedsits. There was no reception area, as Ms Hobbs might have expected of a bed and breakfast, and they found no one who appeared to be in charge. Ms Hobbs said, "There was nothing to indicate that it was anything other than bedsits."

5.103

Ms Bridgeman and Ms Hobbs spoke to a number of people hanging around outside the premises, some of whom were drinking. They asked where Room 10 was, if anybody knew who lived there, and if there was anyone upstairs. The people they spoke to informed them that the family had moved away about a week ago. This was of course true, as Kouao and Victoria had moved in with Manning on or about 6 July 1999. However, Ms Bridgeman agreed in evidence that she should not have relied on this information. They went upstairs to Room 10 and knocked on the door. There was no answer. They asked the people they had spoken to earlier if they had any concerns about the family, but none were raised.

5.104

Ms Hobbs and Ms Bridgeman learned nothing from their abortive visit and they carried out no further investigation while on the premises. The premises did not look like a hostel, so they made no attempts to find out what sort of premises they were in or whether any of the occupants had been placed there by local authorities. Nor did they knock on any other door. It did not occur to them to try to find a manager of the property who would have been the most obvious source of the information they were seeking. Had they pursued any one of these lines of inquiry it might have opened up a fresh trail to Victoria's whereabouts.

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5.105

In fact, Ms Bridgeman and Ms Hobbs had come to Nicoll Road with only the haziest idea of the nature of the referral they were supposed to be investigating, a referral which was at least three weeks old judging by the duty manager's action sheet, and without having done any background checks first. They did not even know whether the family was being accommodated by Brent. Ms Bridgeman said she was sure that Ms Hobbs would have done the necessary checks on the address beforehand. She should have checked rather than presumed. Ms Hobbs said in evidence:

"I do not recall doing any checks prior to the visit, mainly due to the lack of information that was on the form. I probably would have made the decision that it would be more fruitful and economic with my time to do that afterwards, to see if the visit itself brought some light."

5.106

Ms Hobbs thought that before the visit she would have seen the duty manager's action sheet with the instruction to do a home visit, as well as the administrative checks form. There would also have been the referral itself plus anything else that was documented on the computer. But she admitted that she had little to go on. She recalled knowing that the referral was about an eight-year-old girl, she had an address but no surname, no date of birth, no referrer's details and the substance of the referral was about the suitability of the girl's accommodation. This was indeed exactly the issue that Ms Ackah was so keen to stress in her referral to Ms Hunt almost a month earlier. She had no specific memory of a child wetting herself.

5.107

Ms Bridgeman could not assist with any clearer recollection of what she knew when she went to Nicoll Road. However, despite the passage of time, she was "definite" that she knew nothing about a child wetting herself, or references to cuts and bruises or being told the child was not at school. She was clear: "If I was taking a referral like that, the referral details, that would have not gone to Child in Need." If she had seen Ms Hunt's referral sheet she said, "There is no way that I would have taken that on." Like Ms Hobbs, she was not aware of any earlier visits to Nicoll Road by any other social worker. If there had been any unannounced visits she expected they would have come to her attention and they had not.

5.108

If, as seems likely, Ms Hobbs and Ms Bridgeman were in fact responding to the 18 June 1999 referral, then it is deeply troubling that they believed they were dealing with accommodation issues rather then responding to concerns about a child who had been seen with cuts and bruises. It is possible that they are now seeking to minimise the nature of the concerns they were responding to, that they have forgotten, or they were sent out with incomplete information. Nothing on the file allows me to trace what information they had at the time of the visit. What is clear, and admitted by Brent, is that the home visit lacked any sort of social work focus and the inquiries made, such as they were, fell far short of an adequate investigation of a child in need, let alone a child in need of protection. Therefore, I make the following recommendation:

Recommendation

Social workers must not undertake home visits without being clear about the purpose of the visit, the information to be gathered during the course of it, and the steps to be taken if no one is at home. No visits should be undertaken without the social worker concerned checking the information known about the child by other agencies. All visits must be written up on the case file.

5.109

By the time Ms Hobbs returned to the office after completing the second of the visits scheduled for that afternoon, it was too late to do any further checks. She said that she intended to make some inquiries of the housing department as well as write up a note of her visit the following morning.

5.110

When asked what form her report would take, she replied that it would have been a running case note. She said, "I would have just outlined that a visit was completed with Monica [Bridgeman], that the child was no longer at the address according to the information we received, and that is all I really remember about it."

5.111

She thought she would have passed her note directly to either Ms Bridgeman or Mr Armstrong.

5.112

If indeed such a report of her findings or of any notes of follow-up discussions with her manager existed, they are now all missing. All that is left on the file annotated on the bottom of the 7 July 1999 appointment letter are Ms Hobbs's handwritten notes stating no more than "Not at this address. Have moved." Ms Hobbs disputed that this was the sum total of her recorded note of the visit on 14 July 1999 and Ms Bridgeman agreed. Ms Bridgeman was adamant that she had seen the report prepared by her colleague. The lack of any corroborating evidence, however, suggests the contrary. I am of the opinion that no such report ever existed and that the 'write-up' contained in Ms Hobbs's annotated 7 July appointment letter is all that might have been anticipated, given the vagueness of the referral she and Ms Bridgeman say they were responding to. It is an appalling reflection of Brent's children's social work team that from 18 June to 14 July 1999, the only information additional to the referral was, "Not at this address. Have moved." This was a dreadfully inadequate response to the serious concerns expressed by Ms Ackah and to the needs of Victoria.

The referral from the Central Middlesex Hospital

5.113

Events were then to overtake both Ms Bridgeman and Ms Hobbs. At the time they were making their unsuccessful visit to Nicoll Road, Victoria was admitted to the Central Middlesex Hospital. At 4pm that same day, according to the form she completed at the time, Ms Thrift, a duty social worker in Mr Armstrong's team, received a referral from the Central Middlesex Hospital in respect of a child named 'Anna', about whom the hospital had serious child protection concerns. 'Anna' had been brought to the Central Middlesex Hospital by Avril Cameron, the daughter of 'Anna's' childminder, Priscilla Cameron. 'Anna's' address was said to be 6 or 8 Nicoll Road. Ms Thrift marked the referral as 'child protection' and took down the following details:

"Anna is a recent arrival in the UK. Her mother lives in a bed and breakfast in Nicoll Road (believed to be housed by Ealing Council - to be checked.) For five weeks Anna has been cared for during the day by a lady named [Priscilla] Cameron (aged 63) ... Avril hadn't seen the child since last Wednesday then mother dropped her off yesterday evening due to problems at the B&B. This morning mother dropped off some items for Anna and said she would return at 7pm today."

Avril noticed bruising on the feet (2-3 days old), arms, legs, buttocks and infected bruises on the fingers. Also noticed Anna's eyes were bloodshot. She took her to the CMH. (Please see fax)"

Child currently at the CMH with carer. Will await contact from Brent CSW [children's social work]."

5.114

The referrer was Dr Ajayi-Obe. Ms Thrift was quite clear that all the information that she had taken down by telephone that day, including the suggestion that Kouao had been placed in Brent by Ealing council, must have come from Dr Ajayi- Obe. Minutes before 4pm, the hospital also faxed across Dr Ajayi- Obe's body map. The body map showed the distribution of marks on Victoria's body as well as her medical report on "a child thought to have suffered abuse".

5.115

At 4.20pm, Ms Thrift passed on the referral, most probably to Mr Armstrong or one of her seniors, who in turn passed it to Ms Hines, a senior social worker in the child protection team. In accordance with the Brent Child Protection Procedures Manual, Ms Hines should have consulted with her team manager and the assistant director of child protection on receipt of the referral. Ms Hines said that she attempted to do so, but that her manager, Ms Roper, was at a child protection conference on another case and Mr Charlett, the assistant director for child protection and duty service manager for the duty team and the child protection investigation and assessment team (CPIAT), was not in his office. Ms Roper was adamant that she had arranged for one of the assistant directors to cover her responsibilities, but could not remember whom. Quite clearly it was Ms Roper's job to ensure that proper cover arrangements were in place for her team and that her staff were aware of these, if only so that they could meet the requirements imposed on them by Brent's own child protection procedures. On 14 July 1999, Ms Hines was either unaware of what those cover arrangements were or none had effectively been put in place.

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Failure to spot previous referral

5.116

At this stage, or prior to passing the case to Ms Hines, administrative checks on the databases should have been made by a member of the administration team to ascertain whether 'Anna' was known to Brent. Martin Punch believed that he may have inputted the new child protection referral details from the Central Middlesex Hospital. He said, "I think the case came in directly as a child protection case, and I would have done that check." He could not confirm when he did the checks but said that he may have done them on 14 July 1999. Although I cannot rule this out completely, it is, however, more likely these checks were done at the same time as the case was logged onto the database, and a link with the previous referral was made electronically. Scrutiny of the computer printouts supplied by Brent show this in fact occurred the following day, on 15 July, and not on the day when the hospital referral was received. It was on 15 July that the computer system provided Victoria with a second 'unique' reference record number. In fact, during Victoria's brief involvement with Brent Social Services, and partly as a result of the children's social work department running both manual systems and a completely separate client-based computer system from the rest of Brent Social Services, Victoria acquired five different identifier numbers, creating ample scope for information loss and case mismanagement.

5.117

On this occasion, the computer records made on 15 July suggest that a link was made between the Central Middlesex Hospital referral and the 18 June referral taken by Ms Hunt. Against the child protection referral category and description Mr Punch had typed in, the computer printout displayed the following:

"See also URRN 1009966. Carer Avril Cameron noticed bruises on Anna Kouro's body & that she had bloodshot eyes."

5.118

The link was there for anyone who had access to these printouts to see, but it seems likely that as the administrative staff were struggling to cope with the backlog of work at the time, it was simply overlooked. As a result, the link was not at any time drawn to the attention of Ms Roper, the child protection team manager, or either of the seniors. The papers were never brought together and the link was never followed. This had serious consequences for Victoria.

5.119

Ms Hines therefore had to make decisions about Victoria's case without the benefit of information from the previous referral. As far as she was concerned, the family was not known to Brent Social Services at that time. Although she could not recall what happened, Ms Hines said that she could have seen a copy of the computer printout log that specifically said "See also URRN 1009966", but in evidence she confused this reference number as referring to the same Central Middlesex Hospital admission. In any event, she was clear that her attention was not specifically drawn to any earlier referral. Ms Hines accepted that if she had been aware of an earlier child protection referral it would have altered her approach to handling Victoria's case entirely.

5.120

The only witness who gave direct and first-hand evidence that a match was made and recognised between the telephone referral from the Central Middlesex Hospital and the unsuccessful home visit by Ms Hobbs and Ms Bridgeman, was Mr Armstrong. He said that later on 14 July 1999, after Ms Hobbs and Ms Bridgeman returned to the office to report there was nobody present at Nicoll Road, he took the paperwork to Mr Punch who made the match. As a result, Mr Armstrong said he was satisfied that 'Anna' had been identified and her whereabouts were known.

Contact with the Central Middlesex Hospital

5.121

Having received the referral, Ms Hines first telephoned Barnaby ward and was told by Dr Haviland that Victoria had been admitted for what was believed to be non- accidental injury. Although she should have had Dr Ajayi-Obe's body maps and medical report on the file, Ms Hines said in evidence that she never saw these. Despite the reference in Ms Thrift's referral form to "please see fax", Ms Hines never followed this up. Indeed, failure to follow up critical information faxed to Brent Social Services was fast becoming the hallmark of Brent's poor handling of Victoria's case.

5.122

The timing of the Central Middlesex Hospital referral, too, seems to have made a difference to Ms Hines's management of the case, though in practice it should not have done. It was late afternoon when Victoria's case found its way to Ms Hines's desk. She knew that for the moment at least, Victoria was safe in hospital having been taken there by her childminder's daughter. Ms Hines also knew that the hospital had serious child protection concerns but that the whereabouts of the 'mother', who at that stage must have been a prime suspect, was unknown. Ms Hines and her colleague Elzanne Smit then made a number of telephone calls.

Contact with Ealing Social Services

5.123

Ms Smit first made contact with Ealing Social Services at 4.55pm. It is not clear to whom she spoke on this occasion, though she recorded in her contact note a telling comment: "Case was never opened to them in a Social Services capacity." This would seem to illustrate the fact that Ealing viewed Victoria's case as concerning only the family's housing needs.

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Placing Victoria under police protection

5.124

In the meantime, at about 5.15pm, Ms Hines, promptly and quite appropriately, telephoned the Brent police child protection team and spoke to PC Rachel Dewar. The decisions taken following the conversation were, however, less than appropriate. Ms Hines told PC Dewar that Victoria’s injuries were felt to be serious enough for the hospital to admit her. Together they agreed to take Victoria into police protection, which they did at 5.20pm. Ms Hines colluded in this decision without seeing and speaking to Victoria or her childminder. She did so without making any sort of assessment as to the likelihood of Kouao removing her from the hospital. She did so without ever establishing that the grounds for taking a child into police protection were properly made out. She also did so without authorisation from her senior colleagues. In my view, placing Victoria in police protection was a serious step that could have been safely deferred until, or if, it became necessary. Mr Anderson, who was working that night in the emergency duty team, said he felt confident he could arrange police protection out of hours if it was required.

5.125

Ms Hines admitted that police protection on this occasion was no more than a holding measure designed to keep Victoria in a safe place. However, the practical consequence of this action appears to have been that neither the police nor social services felt they needed to begin their respective inquiries that evening. Instead, Ms Smit briefed Mr Anderson to alert him that Victoria was in police protection and should Kouao turn up at the hospital, she was to be told that Victoria was under police protection and could not be removed.

5.126

Ms Hines said in evidence that she fully intended seeing Victoria the next day. She said:

"The child was in a safe place, in hospital, all the safeguards had been put in place, we had phoned the emergency duty service ... the police had been informed ... the hospital had been informed that the child was in police protection, so the child was felt to be safe and it was late in the evening and our investigation would have started the following day."

5.127

Looking at the times of the telephone calls made by Ms Hines and Ms Smit that evening, it is doubtful that "late in the evening" could have meant any later than 6pm. Whatever Ms Hines's intentions may have been, the fact was that she failed to see Victoria either that evening or at any time thereafter. I regard prompt action in cases such as this to be vitally important and therefore make the following recommendation:

Recommendation

Directors of social services must ensure that children who are the subject of allegations of deliberate harm are seen and spoken to within 24 hours of the allegation being communicated to social services. If this timescale is not met, the reason for the failure must be recorded on the case file.

5.128

Ms Hines painted an entirely different picture of how she might have responded if she had received the referral at, for example, 10am. She said she would have tried to make contact with whoever had parental responsibility and seek their permission to speak to the child. If she could not track down that person, or permission to speak to the child was denied, she said she would have discussed the problem with her legal section and possibly sought an emergency protection order. However, Ms Hines did not consider an emergency protection order to be an option in this case because the legal services unit went into answer-phone mode at 5pm every day. Therefore, I make the following recommendation:

Recommendation

No emergency action on a case concerning an allegation of deliberate harm to a child should be taken without first obtaining legal advice. Local authorities must ensure that such legal advice is available 24 hours a day.

5.129

As well as speaking to PC Dewar, Ms Hines rang Priscilla Cameron. Her purpose in ringing was not to question her about what had happened to Victoria, but instead to ask her to act as a messenger to Kouao. Incredibly, she wanted Mrs Cameron to tell Kouao that Victoria was in police protection and that she was not to be removed from the hospital or the police would be called. In fact, it is a police responsibility to do this.

5.130

Ms Hines agreed that Mrs Cameron was an important source of information in any assessment of Victoria's circumstances and a person she would have interviewed if she had been carrying out inquiries under section 47. However, no such inquiries under section 47 were under way on the evening of 14 July 1999 because the matter had been put on hold until the next day. In the event, Brent never interviewed Mrs Cameron, either as part of the section 47 inquiries or any other inquiries. Indeed, Mrs Cameron was an unregistered childminder, and Brent did not make inquiries about this either.

5.131

As it happens, Kouao was with Mrs Cameron when Ms Hines telephoned, and they spoke over the telephone. Kouao explained to Ms Hines that Victoria's injuries were all self-inflicted. Ms Hines was surprised by this and thought that Kouao sounded "quite cold and matter-of-fact". However, she took the matter no further that evening. As with Victoria and the childminder, Ms Hines did not consider it necessary to interview Kouao there and then. Although Ms Hines agreed that time is of the essence in child protection cases, this was one child protection investigation where time seemed to be anything but of the essence. Instead she gave Kouao an appointment to attend the Brent Social Services office the next morning at 9.30am.

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Police protection lifted

5.132

Events were to overtake Ms Hines too, with the result that no section 47 inquiries were ever begun by Brent Social Services the next day, let alone completed. Furthermore, Victoria was placed in, and then taken out of, police protection in less than 24 hours, without ever being seen by either the police or social services. I comment further on the use of police protection in section 13.

5.133

When Kouao failed to turn up at the office on 15 July 1999, Ms Hines telephoned the hospital and spoke to Dr Charlotte Dempster, only to be informed that Kouao was at the hospital. This was her second visit to the ward since Victoria had been admitted and placed under police protection, giving her ample opportunity, if opportunity was needed, to coach Victoria as to how she should respond to questions from a police officer or social worker.

5.134

According to Ms Hines, Dr Dempster told her that Victoria's case "was not child protection at all, and more or less it was not to be seen as child protection, it was actually a child in need". It was for this reason that Ms Hines said she did not feel unduly concerned that Kouao had failed to turn up for her appointment. She presumed that the doctors had already passed this information on to Kouao and this was why Kouao had stayed at the hospital rather than attending the appointment. It was an assumption that she never checked, as she should have done.

5.135

In her contact note at the time, Ms Hines wrote:

"Dr Schwartz who has now seen the child does not feel that the injuries are non-accidental. Dr Dempster said that the child possibly has scabies and that they would like child protection to withdraw and treat this as a child in need because the family need urgent housing. I advised Dr Dempster that this would be dealt with by our duty team."

5.136

This was a medical diagnosis that was to have important consequences for Victoria, well beyond the confines of this single admission to the Central Middlesex Hospital. That it was Dr Ruby Schwartz who had made the diagnosis appears to have elevated Victoria's case beyond the realm for questioning by social services. As a result, an important opportunity was lost to verify directly Dr Schwartz's true concerns. Subsequently, Dr Schwartz acknowledged that although she had ruled out non-accidental injury, she believed that Victoria must be suffering "other forms" of deliberate harm.

5.137

Ms Hines did nothing to question what factors had been taken into account in the hospital's coming to its diagnosis. She did not speak to Dr Schwartz directly. She said in evidence, "I was told this child was seen by Dr Ruby Schwartz, who is a consultant paediatrician who is highly respected in Brent, she is a member of the ACPC ... I felt that if Dr Schwartz had seen the child, her diagnosis would have been correct, and I did not feel I could have disputed that.

5.138

Yet Ms Hines knew that at the time Victoria was admitted she had been observed to have suffered bruising over her feet, arms, legs and buttocks, to have infected bruises to the fingers and to have bloodshot eyes. All she knew about scabies was that it was some form of skin disease and that it could be caused by unhealthy living conditions. Faced with these glaring discrepancies, however, she was still content to rely completely on what she understood Dr Schwartz's diagnosis to be, as conveyed to her by a third party. She was also content to rely on Dr Schwartz's opinion that there were no longer any child protection issues. This was an opinion that no one in the hospital, including Dr Schwartz, acting on their own, was qualified to give. Social services are charged with the responsibility for investigating and assessing child protection concerns in conjunction with their partner agencies. Therefore, I make the following recommendation:

Recommendation

The training of social workers must equip them with the confidence to question the opinion of professionals in other agencies when conducting their own assessment of the needs of the child.

5.139

In evidence, Dr Dempster disputed that she had asked social services for the child protection order to be lifted. She said that she did no more than relay Dr Schwartz's diagnosis and outline some concerns about housing and other issues to the duty social worker and to Ms Hines. Ms Viljoen, who was working in the duty team, logged this as a separate 'child in need' referral on 15 July 1999. Dr Dempster was clear that she did not request that child protection be lifted for Victoria, although she kept no record of her conversation. While Ms Viljoen's referral summary makes no mention of child protection, Ms Hines's note completed at that time and the written confirmation subsequently faxed by Dr Dempster to social services, communicated only too clearly that the hospital had ruled out child protection concerns. Whether or not Dr Dempster had also expressly used the term 'child in need', in Ms Hines's mind there was now no longer any other track to pursue.

5.140

This was not the first or only occasion when there were conflicts in the evidence as to who said what between staff working on Victoria's case.

5.141

Ms Hines rang PC Dewar to tell her that the injuries were no longer thought to be non-accidental and the police protection could now be discharged. PC Dewar confirmed: "I was told that they were all as a result of scabies. It was very clear." Victoria was duly discharged from police protection, such as it was, at 10.40am that morning (15 July), without Victoria or her carer ever having been questioned and without any further explanation of the issues that had been deemed important enough, according to both the police and social services, to put Victoria into police protection in the first place.

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Communication with the hospital

5.142

Ms Hines spoke to her team manager, Ms Roper, when Ms Roper returned to the office at about midday on 15 July 1999. She fed back to Ms Roper the medical opinion that Victoria’s was no longer a child protection case but was now a case about a medical condition. Ms Roper agreed that the section 47 inquiries, which had never got off the ground, could be safely aborted. Although Dr Ajayi-Obe’s medical report and body maps had been faxed the day before, Ms Hines said she had not seen them and Ms Roper did not consider these in reaching her decision. Ms Roper said she was not aware of these documents at the time and their existence only came to her attention in 2001. She said she had had difficulty in reading them, but said that even if she had been able to read them, they contained nothing that would have caused her to rethink her decision. This is remarkable given the graphic representation of widespread injuries in Dr Ajayi-Obe’s notes. However, Ms Roper was clearly influenced by the information from Dr Dempster, as relayed by Ms Hines and subsequently confirmed in writing from the hospital, that the marks on Victoria’s body were caused by scabies. Ms Roper understood that the reportedly self-inflicted marks were the result of Victoria scratching the scabies. She did not query the inconsistency of these reports.

5.143

If the hospital had any other concerns, Ms Roper would have expected the examining doctor to have referred to those in his or her report and they had not, except to mention issues of housing and schooling - neither of which on their own would constitute grounds for continuing with child protection inquiries.

5.144

Ms Roper conceded, however, that it was social services' job, not that of the hospital, to pull together what information existed and ensure that it was properly evaluated as part of any such inquiries. The duty to assess the needs of children is clearly placed on social services. The paediatric assessment notes taken by Dr Rhys Beynon demonstrated that the hospital possessed information that would have been relevant to an assessment of Victoria's needs. Not unreasonably, Ms Roper said she would have expected the hospital to have faxed across a copy of those notes. However, what use she would have made of them had they been sent is questionable.

5.145

Ms Roper said if Brent Social Services had known - and to my mind there can be no doubt whatsoever that it was social services' job to find out - that Kouao had asked Mrs Cameron to look after Victoria for good or that she had suggested that Victoria had cut herself with razor blades, she would have expected her team to have continued with the section 47 inquiries that day. With hindsight, Ms Roper said that a joint visit by a child protection social worker and a duty social worker should have been undertaken before closing the section 47 inquiries. It was, however, her expectation at the time that all the key parties, including Victoria, Kouao and the childminder, would be interviewed as part of a 'child in need' assessment.

5.146

Instead, Ms Roper agreed with Ms Hines that Victoria's case should be re-labelled 'child in need'. The primary focus was once again housing and the case was transferred back to Mr Armstrong's duty team. This illustrates well the dangers which attend the premature classification of 'child in need' and 'child protection'. In my opinion, the correct application of the Children Act 1989 requires a proper assessment to be completed before such a decision is taken.

5.147

Ms Roper wanted to have the hospital's diagnosis in writing. Dr Dempster duly faxed a letter across to the duty team on 15 July 1999, the content of which Dr Schwartz was subsequently to describe as "very superficial". The key passage that was to have such an impact on how Victoria's case was handled not only by Brent Social Services but also by Haringey Social Services thereafter reads as follows:

"She [Victoria] was admitted to the ward last night with concerns re possible NAI [non-accidental injury]. She had however been assessed by the consultant Dr Schwarz and it has been decided that her scratch marks are all due to scabies. Thus it is no longer a child protection issue."

5.148

Dr Dempster went on to record several social welfare issues that needed to be sorted out urgently, including the fact that Kouao and Victoria were homeless and that Victoria was not attending school.

5.149

Dr Schwartz mentioned for the first time in evidence that she was "almost positive" that she had spoken to someone from social services that morning about her concerns for Victoria, and that possibly it was to Ms Hines. However, Ms Hines firmly denied this. She believed she faithfully recorded in her contact notes the names of all the doctors she had spoken to, together with a brief summary of the conversations. There is no record of any conversation with Dr Schwartz on the Brent case file, nor anything to support Dr Schwartz's claim in the hospital records. In these circumstances, it seems unlikely to me that any such conversation took place. As a result, Brent Social Services were left with Dr Dempster's letter and telephone conversation with Ms Hines, themselves an interpretation by one doctor of a second doctor's notes of Dr Schwartz's evaluation of Victoria, as the final summary of the hospital's concerns.

5.150

Ms Hines passed Victoria's file through to Ms Roper for her to sign off on the morning of 16 July 1999. Owing to a careless error, Ms Roper's own closure summary note would appear to have reduced still further what started out as serious child protection concerns to little more than a minor medical complaint. She wrote:

"This child has been examined by Dr Dempster and Dr Schwartz. It is not felt to be a child protection case as the marks on the child are noted to be eczema [my emphasis]. Dr Dempster has faxed a letter to that effect …"

Dr Schwartz wishes the case to be looked into for a child in need assessment particularly as the family are homeless."

Family were originally placed in Brent by Ealing."

Case passed back to duty in order to complete an assessment or agree transfer of case to Ealing."

The internal transfer of case responsibility

5.151

According to Mr Armstrong, Ms Roper had already discussed with him her recommendations to transfer the case back to the duty team the day before, and he had acted on that by telephoning Ealing to agree the transfer of the case to them. It seems an unlikely coincidence that Pamela Fortune at Ealing Social Services should have received a telephone call on the same day, also from a Mr Armstrong, whom she thought worked at the Acton Law Centre. It was her recollection, as recorded in the Ealing case file, that Mr Armstrong had expressed concerns about Kouao's case. However, she said she told him that Ealing had closed the case and that Brent Social Services were dealing with it because they had some concerns about Victoria.

5.152

In evidence, Mr Armstrong relied on Ealing’s record of the telephone conversation as support for his claim that he made the telephone call on about 15 July 1999, but his recollection of the outcome of that call was wholly different. It was his contention that Ealing accepted case responsibility, though this, he said, was by verbal agreement with Mr Victor. As a result, Mr Armstrong faxed over the papers to Ealing on 15 or 16 July. Although Brent’s duty manager action sheet purports to record that the case was transferred to Ealing on 16 July, there is no other documentation evident in either authority’s papers to suggest that a formal transfer of the case was properly executed and recorded. In my judgement, the likelihood is that it was not. If it wasn’t for Victoria’s later admission to the North Middlesex Hospital and the subsequent involvement of Enfield and Haringey Social Services, concerns about Victoria may well have been left unresolved with neither Brent nor Ealing taking any direct action. This leads me to make the following recommendation to ensure that local authority social services departments are absolutely clear as to who has case responsibility at any one time:

Recommendation

Directors of social services must ensure that the transfer of responsibility of a case between local authority social services departments is always recorded on the case file of each authority, and is confirmed in writing by the authority to which responsibility for the case has been transferred.

5.153

Quite by chance, Ms Hines saw Kouao and Victoria for the only time when they appeared in reception at social services on 15 or 16 July 1999. By that stage Ms Hines's involvement in the case had already ceased and the case had been, or was in the process of being, transferred back to the duty team. She saw a little girl who was sitting down while Kouao was making a bit of a scene. Ms Hines understood that she had asked for the taxi fare to take her back to Ealing but duty staff refused this. She saw enough of Kouao to observe, as others had done before and were to do again in the future, that she "was very well turned out, dressed up very nicely". Interestingly, Ms Hines could not really say what Victoria looked like, or comment on her demeanour or her clothes.

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Kouao's housing application

5.154

A housing application to Brent council was a two-step process, first involving an assessment of a person's eligibility for housing, and second an assessment of points to determine whether an offer of housing can be made.

5.155

Kouao attended Brent's One Stop Shop in Harlesden on 1 September 1999 and put in an application for housing in the borough. Two days later, Faithlyn Anderson, a senior officer in Brent's housing resource centre, received Kouao's application and made the initial assessment of Kouao's eligibility.

5.156

Kouao's application indicated that none of the family suffered from any medical condition, but was in fact accompanied by a nearly two-month-old letter from the Central Middlesex Hospital indicating that Victoria had been treated there for an infection. The letter also stated that Victoria and Kouao were homeless.

5.157

Kouao stated in one section of the form that the people to be included in the application were herself, Victoria, and her son Jean. However, later in the form, when describing her current housing conditions, she stated that only she and Victoria were living in Nicoll Road - an inconsistency that was later picked up by Rachael Green, a transfer and registration officer, when assigning points. Kouao stated on the form that the living conditions at Nicoll Road were very poor and that the family was occupying one room.

5.158

Kouao's application met the local eligibility criteria, but it was judged by Ms Anderson to be non-urgent for the following reasons. Although the letter from the Central Middlesex Hospital indicated that Victoria and Kouao were homeless, Kouao stated on her accompanying application form that she was not homeless and was not expecting to become homeless. Kouao had also waited nearly two months from the date of the letter from the Central Middlesex Hospital to make her application; to qualify for urgent treatment applicants must be threatened with homelessness with 28 days. Ms Anderson stated that applicants often say that they are homeless but are still in accommodation several months later.

5.159

Over the course of the next seven weeks Kouao's application was registered by the finance and systems section - a not unusual delay given the non-urgent nature of the application. Ms Green made the second-stage assessment on receipt of the application on 20 October 1999. She found that Kouao had insufficient points to qualify for housing. A letter to this effect was sent to Kouao on 28 October. At the same time, Ms Green sought clarification about the whereabouts of Kouao's son and about the condition of Nicoll Road. These two issues could potentially affect the number of points Kouao had already been awarded. The letter advised Kouao she would be informed about this at a later stage, presumably after she had provided Brent with the additional requested details. However, as no response to this was received, no further action was taken.

Closing the case

5.160

Brent Social Services closed Victoria's case on 3 September 1999. It might be thought odd that despite the agreed transfer to Ealing Social Services, Mr Armstrong should have marked the case as pending from mid July, a practice that he said was common, particularly if the cases were out of the borough. On his first day back from a month's annual leave, Mr Armstrong marked on the action sheet "Client referred to Ealing" and closed the case.

5.161

There were, in my view, strong grounds for believing that Victoria's needs could and should have been met in Ealing, and I have commented upon this earlier. That did not happen and an opportunity to safeguard and promote her welfare was clearly missed. A second opportunity arose in Brent but once again no assessment was made of Victoria's needs, despite the clear indications that her safety was at risk. Had Brent met their responsibilities to Victoria, it may be that Haringey would not have become involved.

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