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Paragraphs: 4.180 - 4.183 | 4.184
- 4.190
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4.180
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This first appearance by Kouao and Victoria at the childcare offices
was the start of a process which illustrates just how poorly organised
the 'front door' services in Ealing were. The case was passed from
worker to worker with differing assumptions being made about who
had done what and what remained to be done. The practice ensured
that no supervisory overview was given to Victoria, other than a
rather brief reactive analysis being offered by the duty senior
manager in passing.
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4.181
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The capacity of the team to keep track of each of the referrals
they were dealing with appears to have been dependent upon the memory
and diligence of the senior staff and a defective system involving
baskets, books, A-Z cabinets, pending trays, diaries and logs. The
case recording throughout was grossly inadequate and the likelihood
of cases drifting or being lost was high. Indeed, I wonder what
would have happened had Kouao not repeatedly been knocking at the
front door of social services? By Ealing's own admission, the threat
of legal action was the only reason the case was kept open. Ealing's
main intervention was to give money to Kouao for subsistence and
to finance her accommodation once she had been deemed ineligible
for housing by the housing department. Although this response was
under the Children Act 1989, the reality was that the needs of the
child, Victoria, were never considered. In fact it was said that
homeless families were dealt with administratively and not allocated
to a social worker. This is entirely unacceptable and is bad practice.
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4.182
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I found it hard to understand the evidence I heard from qualified
social workers about what they described as a lack of clarity on
how they should assess the needs of a child and its family. While
the National Assessment Framework was published more recently, and
welcomed, I would have expected qualified social workers at the
time Victoria needed protection to be capable of completing an assessment
of her needs. The Children Act 1989 had been implemented in 1991.
The forms for this purpose were available and senior managers accepted
that the tasks had been completed. In reality, however, the conversations
with Victoria were limited to little more than "hello, how are you?".
The only 'assessment' completed involved the writing down of limited
and sometimes contradictory information provided by Kouao.
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4.183
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The overall picture of what happened to Victoria while in Ealing
serves to illustrate well the effect of drift in social work. No
plan of action was ever devised and no sense of direction could
be identified. Little wonder that the information recorded on the
file in June 1999 was precisely that which was in the referral two
months earlier. This ineffective work was no doubt not helped by
the confusion in the managerial responsibilities and the ad hoc
weekly handover arrangements and irregular supervision between the
team manager and the senior practitioner. This is certainly something
which should have been sorted out by senior managers. The decision
was made to close Victoria's case without seeing or speaking to
Victoria, and without any indication of how her welfare was to be
safeguarded or promoted. Therefore, I make the following recommendation:
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Recommendation
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Directors of social services must ensure that no case involving
a vulnerable child is closed until the child and the child's carer
have been seen and spoken to, and a plan for the ongoing promotion
and safeguarding of the child's welfare has been agreed.
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Paragraphs: 4.180 - 4.183 | 4.184
- 4.190
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4.184
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It is useful to reflect on what Ealing knew, or suspected, about
Victoria despite their failure to undertake an assessment of her
needs. From the documentary evidence and other evidence put to this
Inquiry that did not always find its way onto the case records,
the following picture would have emerged under the four areas for
concern.
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4.185
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1: The credibility of the story as told by Kouao:
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•
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Kouao and Victoria arrived in London on a travel package, which
included seven days' bed and breakfast accommodation. (I suspect
an unusual route by a homeless family.)
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•
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Kouao had no means to support herself and Victoria for more than
a few days.
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•
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Within two days, Kouao had presented herself as a homeless person
with a young child.
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•
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Kouao said she had left three other children in France, a matter
which should have resulted in contact with the French authorities.
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•
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Kouao said the reason she came was to improve her English.
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•
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Kouao made it clear she had no immediate intention of returning
to France.
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•
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Kouao provided the Ealing duty team social worker with a French
social security number. Had the social worker contacted the authorities
in France, they may have heard about the quite serious concerns
the school had about the welfare of Victoria.
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•
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Kouao claimed she was given financial assistance by French social
security to travel to London with Victoria, which was never checked.
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•
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Kouao gave a different story to different members of staff in housing
and social services.
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4.186
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2: Concerns about Victoria's appearance:
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•
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Victoria was wearing a wig.
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•
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The photograph of Victoria on the passport was a questionable likeness
of her.
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•
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Kouao was very well dressed.
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•
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In contrast, Victoria was shabby and resembled one of the "adverts
you see for Action Aid".
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•
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Victoria was said to be small and of "stunted growth".
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Kouao and Victoria appeared to have a different skin colour.
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4.187
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3: Concerns about Victoria's behaviour:
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Kouao was "forceful" and "manipulative" and did not allow Victoria
to answer questions staff directed to her.
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•
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Social services believed that Victoria was being coached in her
reactions.
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•
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When Victoria cried it seemed to be "stage managed".
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In the office it was noted that Victoria stood silently and did
not play with the Wendy house or the toys like the other children.
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4.188
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4: The apparent lack of Kouao's concern for Victoria's welfare:
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There did not appear to be any parental warmth from Kouao toward
Victoria.
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•
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When a meeting was fixed to perform an assessment of Victoria's
needs, unusually Kouao attended without Victoria and she was less
than co-operative.
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•
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Despite being in this country for some two months, Victoria still
had not been registered with a school.
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4.189
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Each of the above is not of itself a determining factor, but together
they indicate that Victoria was probably in need of safeguarding.
I accept that in a busy office dealing with a high number and a
wide range of referrals, decisions have to be made about likelihood
of deliberate harm and urgency. The fact remains that the initial
reason for Victoria's referral was for an assessment of her needs
and in my view enough was known, or was observed about the family
during the months they spent in Ealing, to have triggered a full
assessment of those needs. It is a duty placed on social services
to assemble and analyse information about children who may need
to have their welfare safeguarded and promoted. This needs to be
done in a rigorous way, viewed, as far as possible, through the
eyes of the child. It certainly needs to be both tough-minded and
with an awareness of the ability of some adults to mislead and to
use children to satisfy their own needs. Had a proper assessment
been done at that point, it is possible that Victoria would have
received the necessary protection in Ealing and the other authorities
may never have been involved. That being so, I reject the implications
of a key conclusion of the Part 8 review, undertaken in response
to the death of Victoria, that "staff in Ealing were not aware of
any indicators suggesting that Victoria was at risk of serious abuse
or any indicators of serious deficits in Kouao's parenting". Ealing
were not aware because they undertook no proper assessment of Victoria
so that they could become aware of her needs.
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4.190
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Doing the basic things well saves lives. In my view, Ealing failed
to meet even the elementary standards of childcare practice, and
as a result Victoria went unprotected. It could have been so different.
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