Paragraphs: 4.47 - 4.58 | 4.59 - 4.72 | 4.73 - 4.85 | 4.86 - 4.105 | 4.106 - 4.115 | 4.116 - 4.126 | 4.127 - 4.141 | 4.142 - 4.153 | 4.154 - 4.163 | 4.164 - 4.179

Victoria in Ealing

4.47

On 26 April 1999, just two days after Kouao and Victoria arrived in the UK, they attended Ealing Homeless Persons' Unit. Kouao was seen by Julie Winter, a homeless persons' officer, to whom she spoke in English. She indicated that Victoria spoke only French. According to Ms Winter, Kouao preferred to conduct the interview in English because she did not want Victoria to listen in.

4.48

Ms Winter's impression of Kouao was that she appeared "tidy, clean, presentable, not a rough sleeper, not someone who was street homeless".

4.49

However, Ms Winter recalled nothing of Victoria's appearance other than the rather unusual fact that she was wearing a wig. But she made no note of this at the time.

The housing application form

4.50

Together, Kouao and Ms Winter completed a housing application form. Kouao gave her date of birth as 17 July 1956, her age as 43 years old and said that she had lived in France since birth. Initially she said she had three older children with her, but subsequently informed Ms Winter that they were in France, staying with a friend and were being educated there.

4.51

She told Ms Winter both she and Victoria were in good health, that neither of them were registered with a GP and that she was currently unemployed. Kouao said she did not intend to stay in the UK permanently. Her purpose in coming here was to spend a year improving her English. Kouao told Ms Winter that she had made some inquiries with an airline company in France and was advised that if she could communicate well in English, her chances of being offered a job were high. Ms Winter also recorded that while in France, Kouao had been a housewife, and that her husband had died in October 1998 following a road traffic accident. In fact, Kouao divorced her husband, the father of two of her children, in December 1978 and he died in June 1995. She had been evicted from her home because of rent arrears.

4.52

Rather than applying for assistance with rent in some less desirable accommodation in France, Kouao told Ms Winter that she had sought, and been given, assistance with the fare for her and Victoria to come to England. She had obtained seven nights' bed and breakfast accommodation as part of the flight package deal, but had no other accommodation once that period expired at the end of the week, on 30 April 1999.

4.53

Ms Winter did not question that the French authorities apparently had contributed to Kouao and Victoria's fare, although she thought it unusual. She told the Inquiry: "We have no knowledge of how the French authorities work. It seemed a reasonable situation, that she could either have money towards rent or a one- off payment to travel elsewhere ... I had not come across it before, but I had no reason to disbelieve that this was in fact the case.

4.54

Kouao's explanation for why Victoria was wearing a wig, which they discussed while completing the health section of the form, but which was never recorded, was that it was Victoria's choice. It was because she had "short or very short hair". Ms Winter had no concerns about this: "I accepted her reasons - she was a very plausible person." In fact, Ms Winter's overall impression was that Kouao was forthcoming with her answers, she did not appear to be withholding information and the material she provided seemed accurate.

4.55

Ms Winter, not surprisingly, concluded that Kouao was not habitually resident in the UK. Her ties at that stage were with France. She had no settled plans for staying in this country. Kouao had provided documentation to confirm her identification and proof of the date of her arrival into the UK. Although Ms Winter was shown both Kouao's travel documents and her passport, which included Victoria's 'details' and her 'photograph', she paid no further attention to them, believing Kouao's application to be ineligible on the grounds of habitual residence.

4.56

As it happens, it would have been helpful for social services to have sight of the passport, as they may have noted that the photograph was not that of Victoria, as did the police when conducting their murder inquiry following Victoria's death. Detective Inspector Keith Niven said in his statement to the Inquiry that the child on the passport was "clearly not Victoria" and he later confirmed in oral evidence that there "were distinct differences".

Housing application refused

4.57

Ms Winter confirmed her decision with her duty senior and then told Kouao she was not eligible for housing. It was a reasonable decision for the housing department to have come to in all the circumstances. Nevertheless, Kouao was clearly distressed and was emphatic to Ms Winter that she and Victoria would very soon have nowhere to live. It appears that Victoria understood the gist of that response because this was the first time she spoke and implored Ms Winter, in French and referring to her as "Madame" to find "une maison" for her. She was tearful, but Ms Winter did not think Victoria's behaviour was unusual. She said, "Often the children get distressed when they see their parent upset in the interviews.

4.58

Ms Winter advised Kouao that she might obtain assistance from social services under the National Assistance Act 1948, as someone who was destitute and responsible for a dependant child, and she noted in her interview record that an appointment had been arranged for Kouao to attend the social services office on 30 April 1999.

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The referral to social services

4.59

In the meantime, she quite properly telephoned the referral across to Ms Fortune, a social worker in Ealing's Acton office referral and assessment team. Although there were forms in use at the time for making such referrals, and Ms Winter 'imagined' there was guidance on how to complete them, she usually preferred not to put her trust on the internal post but to speak directly to an officer. Her lack of confidence in the internal mail is noteworthy. But the net effect was that no written or electronic referral to social services was ever made and no copy of the relevant documentation passed across when it should have. As a result, social services were not in a position to double check inconsistencies in the details Kouao gave about her and Victoria's life either here in England or in France. As a result, I make the following recommendation:

Recommendation

When a professional makes a referral to social services concerning the well-being of a child, the fact of that referral must be confirmed in writing by the referrer within 48 hours.

4.60

Ms Winter was clear in her evidence that her sole reason for making the referral to social services was that the family were going to become destitute in a matter of days. They had no income and were unlikely to have any in the immediate future. But she told the Inquiry, "She did not place any emphasis on the child's needs." After all, Victoria's circumstances were not unusual: "Cases that are found to be not eligible ... persons from abroad, they have no jobs lined up here, they have only the money they travel with, quite often they are refused benefits because again they are not habitually resident."

4.61

She acknowledged she was not familiar with the Children Act 1989. All she knew was that if the housing department could not assist a family with rehousing and the family was shortly to become 'roofless', then the authority had obligations towards the welfare of the child under the Act. Ms Winter said, "I took that to mean shelter and subsistence." This illustrates well the importance of social services being clear about the responsibilities they carry in law and ensuring other agencies understand this also.

4.62

In evidence, Ms Fortune conceded that from the very start she believed she was being asked to focus on Victoria's needs. On the first level assessment core form she noted, "Ms Winters would like S/S [social services] to undertake an assessment of Ms Kouao and her daughter's needs."

4.63

At the time she understood these centred on the family's housing needs. She also noted down the name of the solicitor that Kouao had already found to act on her behalf. She believed she had been told by Ms Winter that Kouao had enough money until 1 May 1999. But she did not record this on the referral form.

4.64

She recorded the nature of the concern to be assessed by the duty social worker as a "mother and child who were (pending) homeless" and a "child in need". An appointment was made for Kouao to attend social services on 29 April 1999 - not 30 April as noted by Ms Winter - and this information was given to Ms Winter over the phone to pass to Kouao. Nothing else on the first level assessment core form - including the recommendations and management decisions arising from the assessment - was recorded by Ms Fortune that day. She placed the referral form in the duty basket for the duty senior to allocate to a duty social worker on 29 April. Her expectation was that the duty social worker on the day would complete the assessment and record the management decisions on the form. In fact, no such assessment was undertaken on 29 April, or any day thereafter. Ms Fortune, who ultimately became Victoria's allocated case worker, was to have no further contact with Kouao or Victoria until 1 June 1999.

Kouao returns to Ealing Homeless Persons' Unit

4.65

Early in the evening of the following day, 27 April 1999, Kouao and Victoria returned to Ealing Homeless Persons' Unit. Kouao requested money for food and essential items. She was referred to William Martin, an approved social worker under the Mental Health Act 1989, who was working in the out-of-office-hours team. At that time, this team covered both the London boroughs of Ealing and Hounslow. Kouao gave Mr Martin her French social security number and he telephoned the out-of-hours Department of Social Security (DSS) number to request a payment for her, as his team held no funds. The usual procedure, which Mr Martin followed that evening, was to leave Kouao's details, including her telephone contact number and his own, on a recorded message to the DSS. If the DSS had any further queries they would contact Mr Martin in the first instance. No such call was received that evening and Mr Martin assumed that the DSS responded to Kouao's request by contacting her directly.

4.66

Mr Martin also advised Kouao to attend Ealing Social Services the following day, describing Victoria on the out-of-office-hours team referral report as a "child in need".

4.67

When asked why he did this Mr Martin replied, "I used the term as a precautionary measure, more of an alerting mechanism, to ensure that there was some follow up on the following day. I thought that was good practice really. I had no particular concerns at that time."

4.68

Indeed Mr Martin knew very little about Kouao and Victoria. He had been told by Kouao that she needed money to buy food and essential items and she and Victoria were living in temporary accommodation. He said it was not his role to ask Kouao why she was in this position - Mr Martin believed his task as an out-of-office-hours team worker was to deal with the emergency, to "hold things together until the day services can take over". The typical response to an urgent request for cash was via the DSS, and this he pursued. This may well be established practice for out- of-office-hours teams. However, it raises a number of questions about access to services which I return to in Phase Two of this Inquiry.

Kouao returns to Acton area office

4.69

Kouao did as she was advised and returned with Victoria to the social services office the next day on 28 April 1999. She spoke to Godfrey Victor, a social worker on duty in the Acton area office. He recalled that Victoria seemed rather small for her age and described her as "stunted in growth", though he made no record of this in his notes. He could not be sure, but he did not think Victoria was wearing a wig at the time though he remembered that her hair was very short.

4.70

This is the first of numerous observations disclosed as evidence to this Inquiry but not at any time recorded on Victoria's case file. The importance of accurately recording observations about children cannot be over-emphasised. The importance of accurate case recording will form a recommendation for general application later in this Report.

4.71

The interview with Mr Victor lasted 15 to 20 minutes. Mr Victor found on the computer the earlier referral made to Ms Fortune on 26 April 1999 - a hard copy was also in the duty manager's basket. But he did not know about the family's contact with the out-of-office-hours team. This is alarming given Mr Martin's evidence that the role of the out-of-office-hours team was "to hold things together until the day services can take over". Nor did Mr Victor do any other statutory checks because the family had just arrived from France and he presumed such checks would reveal nothing. It is clearly never safe to make such assumptions. Checks against Ealing's own housing department files, as the referrer, may have led to a trail which, if vigorously pursued in France, as it would likely have been if Victoria had come from another part of the UK, may have resulted in information coming to light. Such information did come to light after Victoria's death - she was known to French social services and Victoria's school in Paris had registered a Child at Risk Emergency Notification with the French education authorities on 9 February 1999, because of Victoria's repeated absences from school.

4.72

Kouao again requested financial assistance for food and other essentials for Victoria. She spoke reasonable English. She told Mr Victor that the DSS had refused her benefits because she had failed the habitual residency test. Mr Victor was aware that Kouao had other children in France but she refused to provide any details about them. This did not cause him to be suspicious and he assumed this would be probed further when Kouao returned for a fuller family assessment. His only anxiety was to ensure that Victoria was provided with a service that day.

Paragraphs: 4.47 - 4.58 | 4.59 - 4.72 | 4.73 - 4.85 | 4.86 - 4.105 | 4.106 - 4.115 | 4.116 - 4.126 | 4.127 - 4.141 | 4.142 - 4.153 | 4.154 - 4.163 | 4.164 - 4.179

Accommodation arranged

4.73

Mr Victor spoke to his manager, Ms Stollard, who agreed the provision of short- term financial assistance, amounting to £10 for food for Victoria, until Kouao could return to the office for an assessment on 30 April 1999. In the meantime, bed and breakfast accommodation for the family was arranged at 6-8 Nicoll Road, Harlesden. Mr Victor said he had no reason to believe Nicoll Road was unsuitable for Kouao and Victoria, but he made no checks to find out, and he was not aware of any complaints about the premises. It would seem that Mr Victor was also entirely unaware that Ms Fortune had already arranged for Kouao and Victoria to be assessed just one day earlier, despite the information recorded on the first level assessment core form.

4.74

Ms Stollard's perception of the case from the outset was that Victoria was in need only in so far as she needed food and accommodation. Nothing was brought to her attention at the time to suggest that Victoria might be in need of any other assistance. As no inquiries had been made it is understandable that there was nothing more to share. As a result, neither she, nor any of the six social workers in her team who were to come into contact with Victoria during her time in Ealing, did more than respond at this superficial level. Ms Stollard stated:

"[Victoria] did not present with injuries, she did not present as a child that other agencies were concerned about, it was an accommodation issue and a finance issue and that was how it presented at the time. We did not go looking for child protection issues."

4.75

This ignores the important fact that the only justification for the involvement of social services was Victoria's needs, which were not being assessed.

4.76

Kouao next returned to the office on 30 April 1999. Again Mr Victor saw Kouao and Victoria and he admitted that once again he did not speak to Victoria: "I attempted to speak to her, but mum was always talking to me."

4.77

It was agreed, a decision authorised by senior commissioning manager Judith Finlay, that accommodation costs would be met by social services funding, and that the bed and breakfast accommodation at Nicoll Road, Harlesden would continue until Kouao's habitual residency appeal had been determined. Ms Finlay said she assumed the accommodation was satisfactory because it had been used previously. However, at no stage did she investigate or question whether the accommodation was in fact suitable for Victoria. She accepted that Ealing's approach to determining the suitability of Nicoll Road was not adequate. Therefore, I make the following recommendation:

Recommendation

If social services place a child in temporary accommodation, an assessment must be made of the suitability of that accommodation and the results of that assessment must be recorded on the child's case file. If the accommodation is unsuitable, this should be reported to a senior officer.

4.78

Although Nicoll Road is not far from Ealing's offices, it does in fact fall under Brent council - a fact Mr Victor knew all too well because he had come across the premises when he had been employed by Brent in the early 1990s. Yet it appears that none of the relevant Brent agencies were informed of this placement. This is despite the spirit of a pan-London agreement of social services directors, clearly set out in Ealing's own child protection procedures manual, that states:

"With families placed in bed and breakfast, it is considered good practice for the placing borough to provide social services support immediately following the placement, until and unless such support is specifically assumed by the receiving borough."

4.79

That was an obligation that Brent, of course, could not possibly have assumed if Ealing decided to cease supporting Kouao and Victoria (which ultimately they did), unless Brent were first made aware of the family's presence within their area.

4.80

However, Mr Victor saw no reason for him to notify Brent because:

"The child was not at risk, the child was not under child protection. The child was not being looked after. The child was not under a supervision order. It was a case of just placing the family within Brent."

4.81

Ms Finlay believed (wrongly) that the continuing support obligations applied only to children on the child protection register, and while senior managers thought the principle "admirable", they believed it would be impossible to implement. Mr Tutt shared this view and voiced concerns about the sheer quantity of information that would need to be exchanged and the systems needed to support and maintain that process.

4.82

The problem, however, may well get worse as the supply of affordable housing shrinks in parts of London. Unless greater weight is attached to such agreements, the risk of 'losing' vulnerable children somewhere in the system may well increase too. Therefore, I make the following recommendation:

Recommendation

If social services place a child in accommodation in another local authority area, they must notify that local authority's social services department of the placement. Unless specifically agreed in writing at team manager level by both authorities or above, the placing authority must retain responsibility for the child concerned.

4.83

Mr Victor did not manage to complete an assessment of Victoria and Kouao on 30 April 1999. Kouao told him that Victoria had not eaten that day. He said in evidence that "because the department was child centred, we allowed her to go in the belief that she would be back". Kouao and Victoria left, but not before collecting £17.50 subsistence, which was to last until the following Thursday - 6 May 1999.

4.84

It seems probable that Kouao and Victoria moved into Nicoll Road on 1 May 1999 immediately after their bed and breakfast booking at Twyford Crescent in Acton expired.

4.85

Kouao's next two visits to Ealing Social Services were on 7 May 1999, to collect a further payment of £17.50, and again on 11 May. On that second occasion, Ms Stollard agreed further subsistence funding of £64.44 per week - an amount equivalent to 90 per cent of the DSS rate for a mother and child. This appears to have been local policy at the time.

Paragraphs: 4.47 - 4.58 | 4.59 - 4.72 | 4.73 - 4.85 | 4.86 - 4.105 | 4.106 - 4.115 | 4.116 - 4.126 | 4.127 - 4.141 | 4.142 - 4.153 | 4.154 - 4.163 | 4.164 - 4.179

Social services record keeping

4.86

Some time before 24 May 1999, but after Kouao's visit to the area office on 11 May, Ms Lawrence, the duty senior that week, made the following, undated, entry on Victoria's case file. It reads:

"i)

This lady came to England to learn English

ii)

she has no connection with this country and has been found not habitually resident so is entitled to no benefits

iii)

she has a 17yr/16yr and 7yr and she intends to return to France for 2 other children in June

iv)

She has no skills and has made clear she has a 2 yr plan to be in this country

v)

she has not even sought assistance from a solicitor yet ... I advised her to do so yesterday [although had Ms Lawrence taken the trouble to read the First Level Core Assessment form she would have noticed that Ms Fortune had already noted down the details of Kouao's solicitor]

vi)

what do we do with this case, there will inevitably be a long-term financial implication for this department if she remains."

4.87

Ms Lawrence wrote a note to herself to speak to Ms Finlay, the senior commissioning manager, or Mr Skinner, assistant director of children's services, for their view of this case.

4.88

As stated in paragraph 4.21, Ms Fortune thought 60 to 70 per cent of the cases they were seeing on duty at the time were housing type cases. Families coming from abroad and who were ineligible for benefits were not uncommon. Despite this, when asked why this case should have prompted a discussion with senior management, Ms Lawrence said, "There was no specific guidance around how we approached cases or referrals where the presenting issue was homelessness or destitution and there was no particular assessment framework for approaching the case."

4.89

Asked if Victoria's case stood out in any way from the average, she replied, "[Kouao] ... did come from France and she did have a family or part of a family in France." Ms Lawrence thought that needed exploring but was unclear as to how to go about it. She thought an assessment was called for, yet Ms Winter's recorded referral on 26 April 1999 had already requested that social services do an assessment of Victoria's need so there was no progress in decision making here. Ms Lawrence "supposed" the assessment ought to be a full family assessment. In fact, Ms Lawrence could no longer clearly recall whether that was what she meant or whether she intended a short assessment in accordance with a format that the team had devised for dealing with this particular type of case. Nor could she recall whether she in fact spoke to either Ms Finlay or Mr Skinner. There is no record of a conversation with either, though she expected she would only have gone to them directly if Ms Stollard had not been available. According to Ms Lawrence, all cases with long-term financial implications for the department would have necessitated discussion with senior managers.

4.90

In the event, whatever assessment Ms Lawrence thought might have been appropriate, according to her statement to the Inquiry, her discussions with senior managers were heading in a completely opposite direction and were to culminate in a "final decision of the social services department ... to withdraw financial support".

Kouao complains about accommodation

4.91

On 24 May 1999, Kouao and Victoria came to the Acton area office without an appointment. They were interviewed by Ms Gaunt, one of the duty social workers, who had been in post in Ealing for just four months. She admitted that she knew very little about the family other than Kouao had failed the habitual residency test, that she and Victoria were living in Nicoll Road and that they had come from France. She was not aware that Ealing housing services had already referred the family for an assessment to be made of Victoria's needs.

4.92

The interview lasted about 20 minutes and was conducted in English, although Ms Gaunt thought there were sufficient lapses in understanding to have required an interpreter.

4.93

Kouao voiced a number of complaints about her accommodation in Nicoll Road which Ms Gaunt recorded. Kouao complained that the rooms were being burgled and the police were often involved. She complained of the noise, drinking and "weed smoking", the violence in the corridors and the toilets that were often vomited in. If true, Nicoll Road could hardly be described as accommodation suitable for a mother and seven-year-old child, yet Ms Gaunt never alluded to Victoria in her record of the interview nor to the fact that Victoria was resident in the hostel.

4.94

Ms Gaunt explained to Kouao that the department would pursue her concerns and decide whether the bed and breakfast accommodation was indeed suitable for women and children. She arranged for Kouao to return to the office that afternoon to collect her subsistence money.

4.95

In the meantime, she telephoned Peter Pandelli of Star Lettings, the letting agency, to pass on Kouao's complaints in the confident expectation that he would investigate them with the manager of the accommodation and report back to the duty team. Although this was the first complaint about temporary accommodation that Ms Gaunt had dealt with, it did not occur to her that there was anything inappropriate in leaving the checks for the letting agency to follow up. They clearly had an interest in maximising the take up of hostel places and ensuring that those places were suitable for as wide a range of local authority client groups as possible.

4.96

It is, of course, questionable whether social services should be involved in the management of temporary accommodation. I suggest they should confine their activities to supporting vulnerable families placed in such accommodation.

4.97

Before leaving the office, Ms Gaunt discussed Victoria's case with Ms Stollard and a decision was made to provide Kouao and Victoria with subsistence and accommodation for one more week, after which they would be invited to return to France. The decision was relayed to Kouao and it was this, according to Ms Gaunt, that prompted Victoria to start crying. She stopped when Kouao gave her some sugar.

4.98

To Ms Gaunt, the whole episode appeared to have been "stage-managed". It seemed odd to her that the prospect of returning to France - where Victoria had other siblings and where life by Kouao's account had been reasonable - should have provoked such a response.

4.99

Sadly, Ms Gaunt made no record of Victoria's reaction, or of her own observations about it, but she was clear that the incident had happened and that she had not, in hindsight, confused this with a similar incident recorded by Bernadette Wilkin later that same day.

4.100

In her evidence, Ms Gaunt made some other observations as to Victoria's appearance and her relationship to Kouao. Had these observations been recorded at the time they might well have prompted closer scrutiny of their true relationship. Ms Gaunt told the Inquiry that there was a marked difference between Kouao's appearance and that of Victoria. Whereas Kouao's hair was well styled, Victoria's was dull, short, unhealthy and generally less well groomed. Victoria's skin colour was also darker than Kouao's and was noticeably blotchy. She vividly described Victoria as looking like one of the "adverts you see for Action Aid".

4.101

To Ms Gaunt's eye there seemed to be no obvious mother/daughter relationship between them. When asked what she thought was lacking specifically, Ms Gaunt replied, "When Victoria began to cry I may have expected a mother to comfort her child in some way and that did not occur.

4.102

This, coupled with the differences in skin colour, led her to doubt whether the two were indeed mother and daughter. But she made no record of any of these observations, nor did they prompt her to initiate any further assessment of Victoria's needs. She said, "I can see in hindsight that it may well have been a truly important piece of assessment, but nevertheless at the time it was not. It did not raise concerns. It did not make me concerned.

4.103

Ms Gaunt said she was sufficiently concerned to raise her doubts with colleagues on her return to the duty room. But she could no longer remember with whom she raised the possibility that Kouao and Victoria were unrelated or what responses she received.

4.104

Unlike some of her colleagues, Ms Gaunt seemed to have a clearer understanding that Victoria was a "child in need" within the meaning of the Children Act 1989, and she knew that the local authority had a duty to complete a full assessment of the family. Ms Gaunt said, "She had no roof over her head, unless we were providing it for her at the time. She had no recourse to public funds, and therefore her health or well-being would have been hampered had we not provided those things.

4.105

Nonetheless she allowed Kouao to leave the office that day knowing that no such assessment had yet been completed, an assessment that she now conceded would "have made the management of the case clearer, earlier".

Paragraphs: 4.47 - 4.58 | 4.59 - 4.72 | 4.73 - 4.85 | 4.86 - 4.105 | 4.106 - 4.115 | 4.116 - 4.126 | 4.127 - 4.141 | 4.142 - 4.153 | 4.154 - 4.163 | 4.164 - 4.179

Kouao continues to collect subsistence

4.106

As instructed, Kouao returned with Victoria to the Acton area office later the same day to collect her subsistence monies. On this occasion she was dealt with by Ms Wilkin, a support assistant in the referral and assessment team. This was not the first time that Kouao had had her subsistence cash paid out in the reception area by Ms Wilkin. The two women first met on 28 April 1999 when Kouao collected the first of her weekly payments. Ms Wilkin, who had a daughter the same age as Victoria, had also observed the differences between Kouao and Victoria. She told the Inquiry that Kouao "was a very pretty lady with clear shiny skin and well dressed. Victoria was petite with really short hair".

4.107

She observed Victoria a few times wearing little short dresses and a leather jacket which seemed "a bit old fashioned for a little girl. It was burgundy, it was gathered at the waist and it had lapels on it". She also noticed that Victoria always stood very close to Kouao. Ms Wilkin recalled saying "hello" to Victoria but "she just smiled and that was it".

4.108

Ms Wilkin repeated to Kouao what Ms Gaunt had already told her, that this would be her last payment and that the council would pay only for her accommodation until Monday 31 May 1999. It was the first time that Ms Wilkin had had to convey such information to a client. According to her file note, Kouao asked her what she should do. Ms Wilkin explained that it was a management decision and that perhaps she should take legal advice. Kouao proceeded to say something to Victoria at which, for the second time that day, Victoria began to cry. Unlike Ms Gaunt, Ms Wilkin did record this reaction in her file note. She said she also relayed it back to a social worker but she could no longer remember to whom.

Accommodation complaint investigated

4.109

In a late additional statement to the Inquiry, Ms Gaunt recalled another material event that she failed to record at the time and omitted to mention in her original statement for the Inquiry. This concerned her visit to the Nicoll Road premises, which she believed she made some time after Kouao had lodged her complaints on 24 May 1999. It is Ms Gaunt's hazy recollection that she volunteered to do the visit in response to a suggestion by Ms Stollard that she lived in that direction and could pass the address on her way home. The visit, according to Ms Gaunt, was only partly in response to Kouao's complaints. She believed other complaints may have been made about the same premises and she said it was for this reason that no write up of her visit appeared on Victoria's file.

4.110

In the absence of any record, it is difficult to pinpoint exactly when this visit occurred. Ms Stollard told those who conducted Ealing's Part 8 management review following Victoria's death that the visit to Nicoll Road had taken place before Kouao made her complaints. But in evidence to this Inquiry she thought it must have taken place at around the same time. The Part 8 review also noted that Ms Stollard asked "two social workers to make an unannounced visit to the accommodation and inspect it all". In fact, Ms Stollard could only recall with any conviction that an unannounced visit did take place at Nicoll Road and that it happened while Kouao was living there. She thought it was "regrettable" that there was no record of the visit on the case file. When pressed, she could not deny that the only response to Kouao's complaints may well have been the phone call to Mr Pandelli at Star Lettings, as recorded by Ms Gaunt at the time.

4.111

In fact, unbeknown to Ms Gaunt, it appears that another visit was made to Nicoll Road by Ealing Social Services. On this occasion the visit was announced and conducted by two social workers - Ms Fortune and Cecilia Schreuder. I shall return to this later and its implications in the evidence given by Ms Stollard and Ms Gaunt in respect of the visit to Nicoll Road.

4.112

Ms Gaunt said that when she visited the premises she asked the manager whether Kouao and Victoria were in their room but was told they were not. As a result, it was not possible for her to assess the suitability of Room 13 for Victoria. She proceeded, nonetheless, to check out the common parts of the house - the corridors, toilets and bathroom - those areas that Kouao had mentioned specifically. Ms Gaunt found nothing to cause her concern. She came away with the general impression that the accommodation was adequate and she conveyed this to Ms Stollard.

4.113

On 28 May 1999, four days after Kouao had been told that her board and lodging would be paid up until 31 May, Ms Stollard reviewed Victoria's case. She said she may have read through the file but she probably would have been influenced more by the decisions made by the senior practitioner than by what was on the file. Ms Stollard decided to close the case one week later pending any further contact. When asked if she was satisfied that there had been a proper assessment of Victoria's needs she said,

"I was satisfied we had looked at the accommodation issues ... I have to say that I did not make any of the management decisions on this case. Sharmain [Lawrence] made the decisions [yet it was Ms Stollard who closed the case], and she made them with Judith [Finlay] so the details of the discussion and the assessment did not actually involve me."

4.114

The 'assessment' would not, it would seem, have involved Victoria either. Ms Stollard wrote a brief description of the case on her review note: "French woman homeless over here learning English. Has been told to go back to France."

4.115

Victoria, ostensibly Ealing Social Services' client, did not get a single mention. Nor is it clear from the case file that it was Ms Lawrence who had made the decisions in Victoria's case. Her last recorded, but undated, entry showed that she was anything but certain as to what to do next and needed to discuss the case with senior managers. By contrast, Ms Gaunt's case note for 24 May 1999 shows quite clearly that the decision to offer Kouao board and accommodation for one more week followed from "discussion and decisions with Sarah Stollard".

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The involvement of solicitors

4.116

Kouao, in the meantime, had instructed her solicitors and they wrote to Ealing on 27 May 1999. They pointed out that their client had come to the UK in March 1999, although Ealing housing department already knew from Kouao's flight tickets that she had arrived in England in April 1999. They also claimed that Kouao had exhausted her savings as she was required to pay £166 per week for a room for herself and daughter - again an assertion that Ealing could have questioned as they had been funding Kouao's accommodation since the beginning of May. The solicitor restated Kouao's position that she would have nowhere to live from 31 May 1999 as she had been asked to leave the hostel accommodation provided by Ealing. Nor did their client have any money to feed herself and Victoria. They reminded Ealing of their duty under sections 17 and 20 of the Children Act 1989, seeking on Kouao's behalf financial assistance and help with accommodation and care for "her child".

4.117

The letter came to Ms Fortune while on duty on 1 June 1999. She said she was brought up to date on the case in the duty team discussion and knew that Ealing's funding of Kouao's stay at Nicoll Road had come to an end the day before. On reading the solicitor's letter, Ms Fortune said she was anxious to discuss this with her duty manager, Ms Lawrence, and to seek legal advice. If there had been a clear strategy previously to close Victoria's case the solicitor's letter appears to have turned that on its head. Ms Lawrence's unsigned and undated instruction on the case record contact sheet, was to extend the accommodation booking at Nicoll Road and for the case to be allocated for assessment as "no thorough assessment has been carried out as yet". Ms Lawrence also raised the possibility that Ealing could consider paying for return tickets to France.

4.118

Ms Lawrence accepted it was unusual for housing cases to be allocated at all, particularly in the light of Ms Stollard's 'decision' the previous week that Kouao be given one more week's assistance before going back to France. But on this occasion Ms Lawrence said:

"There appeared to have been some drift in that although there was a process of information gathering and there was information recorded on the file, the assessment format that we were using at the time had not been used, and I felt that it needed to come off the duty system and be given to one worker to carry out the task."

4.119

However, by "thorough assessment", Ms Lawrence said she meant no more than completing the three-sided assessment template for families who have failed the habitual residence test. This is an assessment which she admitted with hindsight could not be described as "thorough". The solicitor's letter, it seems, had merely been the prompt for her to review the case file and ensure that the paperwork was up to date.

4.120

Despite being told that Kouao had no money for food - the last subsistence cheque for £64.44 had been paid on 24 May 1999, just over a week previously, though Ms Fortune did not know this because she did not check - Ms Fortune said she had no concerns as to where Victoria's next meal was to come from because Ms Lawrence had also instructed that the subsistence money should continue for another week. The monies were not paid out, however, until the next day, though nothing was done by Ms Fortune on 1 June 1999 to ensure that Victoria did not go without food.

4.121

Ms Fortune also had the impression that Kouao and Victoria looked very dissimilar:

"Kouao always dressed immaculately. Her clothing and jewellery seemed expensive and her hair was very well done. She did not in any way look destitute, contrary to what she always claimed. In contrast, Victoria was poorly dressed. I cannot recall exactly what she wore but there were times when she did not seem to be dressed appropriately. She always appeared to look as if she was in hand-me-down clothes. I thought she looked shabbily dressed. I also thought she looked very small for her age. She was very slim and very dark skinned. She had very short dark hair."

4.122

Yet again, none of these observations were recorded by Ms Fortune on the case file. It serves to support the general recommendation I make on the importance of case recording.

4.123

By chance, Kouao's solicitor spoke to Ms Fortune the same day, 1 June, that she received their letter. Apart from reiterating what was in the letter, they told Ms Fortune that Kouao was destitute and that she had asked Brent Social Services for assistance. Brent Social Services asked her to return to the Acton area office.

4.124

Ms Fortune told Kouao's solicitor that "social services had been given variations of her [Kouao's] circumstances" and that social services had a duty to undertake a "thorough" assessment of their client.

4.125

Kouao's solicitor promptly advised Kouao to return to social services and she arrived with Victoria at the Acton area office at about 4.45pm. Kouao was told that she could stay at Nicoll Road one more night and that she would be telephoned the next day and informed whether social services could continue to assist her. Although she agreed to stay at the hostel, according to Ms Fortune, she seemed unhappy at Nicoll Road. Kouao complained that for the last three days she and Victoria had been sleeping in the kitchen area because of water leaking through the ceiling. When she had complained to the manager he had been abusive to her and that had upset Victoria. It had also upset Kouao sufficiently that she took her complaint about the manager to Harlesden police station the next day. She also mentioned again that the place was dirty and the toilets were filled to the rim with vomit and excrement.

4.126

Those complaints notwithstanding, the very next day on 2 June 1999, Ealing Social Services extended Kouao's booking at Nicoll Road for another week until 9 June. An interpreter was also booked and an appointment was made for the assessment interview to take place on 7 June.

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Inspection of accommodation

4.127

Asked how she responded to Kouao's complaints about the premises, Ms Fortune said, "I know that there was a phone call made to Nicoll Road and that they said Kouao had ripped up the carpets." In fact, this was a reference to a telephone call received by Ms Wilkin on 4 June 1999 from the accommodation agency through which Kouao and Victoria had been placed in Nicoll Road. The member of staff at Star Lettings, Mr Pandelli, told Ms Wilkin that he had personally inspected the accommodation the previous day and found it adequate. However, he was angry because following Kouao's complaints, she had been moved to a new room the previous night but had removed all the carpets and put them outside her room.

4.128

Ms Fortune told the Inquiry that social services had checked out the premises. She recalled that she herself had made an earlier visit to Nicoll Road - her diary confirmed this visit on 1 March 1999 - and that she had made a second 'announced' visit with another social worker, Ms Schreuder. But, like Ms Gaunt, she could not remember when that was. She thought it was "somewhere between May and June". Ms Fortune stated that she could not remember whether the visit took place before or after her conversation with Kouao. Therefore it is not clear whether the visit was a direct response to Kouao's complaints or complaints by other residents. She made no mention of it in her witness statement and she did not record it on the case file. Asked why not, she said, "I was called to go out with another duty social worker to see another family. I presumed she would have written the information. She obviously presumed I would have."

4.129

She said that if she had recorded her visit she would have noted that the bedrooms and toilets that she saw had basic amenities and were reasonably clean.

4.130

Having heard their evidence and that of Ms Stollard, I am prepared to accept that Ms Fortune and Ms Gaunt probably did visit Nicoll Road on two separate occasions and may well have done so during the time that Kouao and Victoria lived there. However, their and Ms Stollard's recollection as to precisely when these visits occurred was vague and inconsistent. On neither occasion was any serious attempt made to see Kouao's accommodation, particularly in the light of Kouao's complaint on 1 June 1999 that she and Victoria had been forced to sleep in the kitchen area because of a water leak. There was also a failure to record anywhere on the case file the outcomes of these visits. Therefore it seems unlikely that either visit was a direct response to, or was designed to follow up specifically, Kouao's complaints. As a result, Ealing Social Services left unresolved the question of whether the accommodation they were providing at Nicoll Road was in any way suitable for Victoria to live in.

4.131

Kouao and Victoria paid another visit to Ealing Social Services on 4 June 1999 without an appointment. Kouao made further complaints about Nicoll Road to Louise Jones, another social worker in the referral and assessment team who was on duty that day. She complained that there were no carpets in her room and that she had not had a bath for a month because the place was so dirty.

4.132

Ms Jones said she knew that complaints had been made before about the state of Nicoll Road so she asked in the duty room whether anyone had visited. She was told - though she could not remember by whom - that the accommodation had been checked and approved by social workers recently, and she passed on this information to Kouao.

4.133

In her unsigned case file note, Ms Jones recorded that Kouao was due to attend a job interview and that if she was successful she would arrange childcare for Victoria.

4.134

She also noted that Victoria had some rough skin on her arm. Kouao explained that Victoria had eczema and that she was registered with a Dr Emias, but Kouao was unable to give any contact details for Victoria's GP. Ms Jones accepted and recorded these details without question.

4.135

In the meantime, Kouao had instructed her solicitors to write to Ealing a second time which they did on 2 June 1999. Their letter, received in the social services office two days later, noted that Kouao's room in Nicoll Road had flooded on 28 May 1999 as a result of a burst water pipe and that her mattress was sodden - a matter that the manager of the hostel had yet to resolve. They also advised Ealing that neither Kouao nor Victoria had eaten in the last couple of days because Kouao had run out of money. It is not evident that either Ms Jones or anyone else in the Acton area office referral and assessment team ever responded to, or sought to check out, this new information that Victoria was going for long periods of time without food.

4.136

Kouao did not attend her appointment for the assessment interview on 7 June 1999. Instead she turned up again unannounced with Victoria, on 8 June 1999 for her subsistence monies. She explained to Ms Jones that she had missed her appointment the previous day because she had gone for a job interview. She had been successful and was due to start work at Northwick Park Hospital that afternoon. She promised to telephone once she knew her shift rota so that she could fix up a new assessment interview date and an interpreter could be booked. In the meantime, she needed a letter from social services so that she could open a bank account - her first pay cheque was due at the end of the month. Kouao then collected another week's subsistence cheque for £64.44.

4.137

Altogether, Ms Jones's involvement with Kouao and Victoria while on duty amounted to no more than two unannounced office visits, each lasting between 10 and 15 minutes. Yet she too recalled noticing the differences in the appearance of 'mother and daughter', that Kouao "appeared to be well dressed and she had very nice make-up and very nicely presented and [Victoria] by comparison did not seem to be well presented in her clothes and appearance".

4.138

She observed that Victoria appeared to be a little short for her age and that she seemed "to stand quite quietly, a little behind Ms Kouao and to be extremely quiet and reserved". She did not play with the toys in the Wendy house like the other children did. On the second of the two visits, she described Victoria's posture as "submissive, very quiet and timid".

4.139

However, like her colleagues before her, Ms Jones recorded none of these observations about Kouao and Victoria's physical appearance. She told the Inquiry that in a busy duty system, the need to write down events and contacts as they happened did not allow time for proper reflection and evaluation. Nonetheless, she said she discussed what she had seen informally within the team shortly afterwards:

"We maybe had feelings - a gut feeling about the observations we had made but ... this was not a level of concern that would mean we would instigate child protection procedures, or any level of concern that we felt that we would follow up."

4.140

This cumulative failure to record basic information about Victoria over a period of weeks denied Ealing the benefit of assembling what was becoming a substantial body of information which could and should have been used to inform the assessment of Victoria's needs and future care. By not completing the simple task of assessing Victoria's needs, the original reason for the referral, two and a half months of limited reactive and ineffective social work followed. It was the start of a pattern of response Victoria was to receive in the months ahead. Ms Finlay's admission that less effort may well have been used in completing a basic assessment of Victoria's needs is correct, and it illustrates the degree of disorganisation in the Ealing office at the time and that poor work can waste scarce resources.

4.141

Kouao's next contact with Ealing Social Services was not the telephone call she had promised to make but an early morning unannounced visit on 14 June 1999. She spoke to Ms Wilkin as soon as the office opened to ask whether the department would pay the £30 a week costs of a childminder she had found to look after Victoria while she was at work. It is not clear whether she was given an immediate answer to her question. She did, however, collect her weekly subsistence money and she was given a further assessment interview appointment for 1.30pm on 17 June 1999. She was told that failure to attend on that occasion would cost her her place at Nicoll Road and her financial support would stop.

Kouao turns up for assessment

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4.142

On 17 June 1999, Kouao attended Ealing's offices for the assessment. On that occasion, Victoria, who ought to have been the focus of the assessment, did not accompany her. Ms Fortune, as the duty social worker, saw Kouao and was told that Victoria was with a childminder. She was not particularly concerned by this, even though by this stage Victoria had been in the country almost two months and was still not at school. Kouao's explanation was that she wanted to bring over her other children from France, to settle the family's accommodation and then make arrangements for Victoria's schooling.

4.143

Ms Fortune did nothing to alert the education authorities to Victoria's presence in Ealing, nor did she ask any questions to establish whether Victoria was going to a registered childminder. Therefore, I make the following recommendation:

Recommendation

Where, during the course of an assessment, social services establish that a child of school age is not attending school, they must alert the education authorities and satisfy themselves that, in the interim, the child is subject to adequate daycare arrangements.

4.144

According to Ms Fortune, it was a difficult interview. Kouao seemed anxious and distressed and said that she had only a limited time as she had to be at work later in the afternoon. Kouao also refused to speak any English and would only talk to, and allow information to be written down by, the French-speaking interpreter, Ouafa Choufani. So Ms Choufani, rather than Ms Fortune, completed the assessment of families who have failed the habitual residence test form. This was the assessment form that Ms Lawrence had instructed to be completed by an 'allocated social worker'. It is questionable whether Ms Fortune learned anything new that day - certainly nothing about Victoria - and what she was told bore little relation to the information Kouao had given in the past.

4.145

Kouao described her previous employment as a "manager at Roissy Airport", yet she had told Ms Winter that she had been a housewife. She gave the name and contact details of Dr I Patel as her GP - the same name as she had given to Ms Winter. She had previously told Ms Jones that Victoria was registered with a Dr Emias whose address she did not know. In fact, none of these details relating to the registration of either Victoria or Kouao were entirely correct. When asked about Victoria's education, she gave details of her own, which included "A levels in science and three years study at a medical centre". When asked about the general health of the family, the recorded answer was "none". When asked about her reasons for coming to the country and staying here, Kouao again provided her French national insurance card details and repeated her intention to improve her English. Ms Fortune was able to complete the only remaining details on the form from information she already knew, namely the name of Kouao's solicitor and that she had been supported by Ealing Social Services with accommodation and funding.

4.146

Ms Fortune's assessment was limited by the fact that important sections of the form - her conclusion, assessment and management decisions - were left blank. Her assessment at best only partially considered Victoria's needs. Ms Fortune told the Inquiry that it was difficult to undertake an assessment if a person gives various accounts: "We can only work with the information that we have ... I asked Kouao to bring Victoria, she did not bring her at all. It was difficult."

4.147

Ms Fortune's case file note of the interview appears in two separate places. The first note, which appears in chronological date order on the contact sheets for 17 June 1999, outlines Ms Fortune's action points for the next day, 18 June, when she was away on leave. The action points were:

•

to contact Kouao's solicitor to find out when the result of Kouao's habitual residency test appeal would be known;

•

to write to Kouao and arrange a home visit so that the assessment could be completed;

•

to discuss with the duty team manager if financial assistance should continue pending the outcome of the assessment.

4.148

There is no record on the file to suggest that any manager endorsed Ms Fortune's action plan. Managers remained unaware that a visit to Victoria in Nicoll Road was ever made. Ms Fortune said that she later contacted Kouao's solicitor but she did not receive an answer to her question about Kouao's appeal.

4.149

Ms Fortune's second entry on the case file relating to her interview with Kouao on 17 June 1999 appears on the contact sheets after an entry by her duty manager, Ms Lawrence, for 30 June. Ms Lawrence's entry instructs Ms Fortune to "complete the assessment and write to Ms Kouao, invite her into the office to discuss the management decision". It is in this entry that Ms Fortune describes Kouao's anxious state and her insistence on only speaking through the interpreter. She also notes that she explained to Kouao that her financial support would probably cease as she was now in work - in effect pre-empting the management decision that Ms Lawrence referred to. When Kouao again repeated her request for help with childminding fees, Ms Fortune told her that social services would "probably not assist".

4.150

When asked if she could have written this entry on the case file after 30 June 1999, and indeed after Ms Lawrence's instruction to her, Ms Fortune replied, "It could be. I do not know." In my view, this is the most plausible explanation.

4.151

On 22 June 1999, Ms Fortune discussed the case with her duty manager who informed her that Kouao's accommodation would not be funded after 30 June 1999. The next day Ms Lawrence made an entry on the file to the effect that the duty social worker should contact Kouao's solicitors to check the outcome of what Ms Lawrence called "her housing appeal" (that is, her habitual residency test). That social services should consider paying her return fare to France, that they should withdraw funding once the outcome of the appeal was known and they should write to Kouao informing her of the outcome of the assessment.

4.152

Ms Lawrence said that she could not recall if she ever saw Ms Fortune's assessment. She believed the only reason she recorded "something on the file" was because Ms Fortune brought it to her attention for some direction. She said, "I did not see the assessment. I was given feedback, I was told the assessment had been completed; I did not check it." As a result, I make the following recommendation:

Recommendation

All social services assessments of children and families, and any action plans drawn up as a result, must be approved in writing by a manager. Before giving such approval, the manager must ensure that the child and the child's carer have been seen and spoken to.

4.153

When asked if it was her responsibility to read the file and to make sure that the case was properly directed, she replied, "Overall responsibility would have been with the team manager. However, I played a part in that I managed duty on a fortnightly basis."

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Case allocation

4.154

That same day, Ms Lawrence finally allocated Victoria's case to Ms Fortune, or so she thought. The process involved making the papers up into a file and logging the details on the computer - a task that was to take a week before Ms Fortune finally received the case papers. As a result, the case allocation date was subsequently changed to 30 June 1999 and Ms Fortune was instructed to "complete the assessment".

4.155

It might seem bizarre that the decision to allocate Victoria's case should have come more than two months after Victoria was first referred to Ealing and after an assessment had supposedly been completed which was to lead to Ealing Social Services discontinuing their support to Kouao and Victoria. Ms Lawrence's explanation was "for the assessment that Pamela [Fortune] said she had completed to be put down on paper ... to take it off the duty system, to ensure that that person got it done". It would seem that the process of allocation on this occasion was no more than a vehicle for ensuring that Ms Fortune, the person who conducted the assessment interview such as it was, also wrote it up.

4.156

By "completing the assessment" Ms Lawrence certainly meant no more than that Ms Fortune should write it up. Ms Fortune, on the other hand, believed she was being asked to "complete" the assessment. She said she told Ms Lawrence that she had found the assessment "difficult", which no doubt accounts for why Ms Fortune's account of her interview with Kouao appears after Ms Lawrence's file instruction for 30 June 1999. Ms Fortune also knew that a decision had been made "from quite early on that Mrs Kouao should go back to France or the child should be accommodated".

4.157

Ms Fortune was instructed to write to Kouao to invite her into the office to discuss the decisions that had been reached. The decisions, as they appear on the case file in Ms Lawrence's handwriting, unsigned and undated, were:

"i)

client has no connection with this country, has no significant family/friends

ii)

there has been no appropriate/adequate planning prior to coming to this country

iii)

reasons for coming are weak - to learn English

iv)

she has family/friends in France, has access to housing and state benefits in France

v)

she has children who she left back in France whom she intends to return to France to collect and bring back to this country, who will subsequently become dependent on social services funding

vi)

based on the above the department has decided that we can no longer fund Ms Kouao as it is apparent that she will need intermittent funding for a long period of time. Ms Kouao has left a stable lifestyle to come to this country where she has no recourse to public funds or accommodation and has therefore placed herself in a vulnerable situation. We are in a position to provide Ms Kouao with return tickets for herself and child to France."

4.158

What is extraordinary about these decisions was the basis for making them. As Ms Lawrence recorded, they reflected almost precisely the reasons Ms Winter gave back in April for Kouao failing the habitual residency test. All the emphasis was on Kouao's lack of significant ties in this country, the fact that she had left family and friends in France and that her stay in the country was intended to be short term. There is not a single mention of Victoria. Indeed, there can be no doubt that the "client" referred to was Kouao. Nothing more had been learnt about Kouao, let alone Victoria, in the two months since the case had been referred to Ealing Social Services.

4.159

Ms Lawrence said she fully accepted that the focus of the assessment was on the adult and the presenting issue, which was homelessness. She admitted that she did nothing to assure herself that the assessment was complete, let alone adequate. In fact, she never read Ms Fortune's account of what had happened on 17 June 1999:

"I was not the person who closed the case - perhaps if I had closed the case I would have referred back to the assessment before closing it as I had directed that it be done ... I had been informed by Pamela [Fortune] that it had been carried out and I informed Judith Finlay that it had. I accept that I should have actually looked at that form and signed it off and ensured that it was completed before I reported to Judith Finlay."

4.160

Her only concern, it appears, was that the form had not been properly completed. Asked if a different conclusion might have been reached if someone had read the file from start to finish, Ms Lawrence replied:

"I do not think there would have been a different approach. I think we could have come to the conclusions that we came to at an earlier point in our involvement with the family, but I am not convinced that the outcome would have been different."

4.161

In a telephone call with Ms Lawrence, Ms Finlay ratified the management decisions that had been made. She did not know at the time that Victoria had never been seen or spoken to. She was told that a comprehensive assessment had been undertaken: "My understanding of a comprehensive assessment is that the child is seen and spoken to."

4.162

But she also did nothing to check this was the case. On average, Ms Finlay said she was consulted about once a week on similar cases where the presenting issues were homelessness. Had she known the truth, she said she would not have endorsed the management decisions.

4.163

Kouao returned to the Ealing office on 30 June 1999, again without Victoria. She saw Ms Fortune and told her that Victoria was with the childminder. Ms Fortune gave her a letter setting out the reasons why social services would no longer fund her stay in England. Kouao was told that her accommodation would be paid for until 7 July 1999 and she and Ms Lawrence went through the letter with Kouao. Before leaving the office, Kouao made it clear that she did not want to return to France and that she would be contacting her solicitor. To Ms Lawrence's eye, Kouao appeared "forceful" and "manipulative" and that she seemed to understand only what was being said when it suited her. However, she never recorded these observations on the case file.

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Ealing council's legal department

4.164

On advice, Ms Fortune contacted Ealing council's legal department (interestingly the only authority to make use of its legal section) and spoke to Phillip Joseph. Mr Joseph told the Inquiry that he found the circumstances of Victoria's case "slightly bizarre". He said, "It just struck me as peculiar that a lady would come from France with a child and leave her other children in France merely to learn English.

4.165

Regrettably, this was not a perception shared by his social work colleagues, and in particular by Ms Fortune or her managers.

4.166

Mr Joseph was told by Ms Fortune that a section 17 assessment had been done of Victoria's needs. In his view it was perfectly reasonable to fund return tickets to France for Kouao and Victoria if the child's needs could best be met there. He thought there had been some preliminary inquiries as to Kouao's circumstances in France, though he was reliant on what Ms Fortune had told him, and she in turn had simply accepted at face value what Kouao had chosen to tell social services. At no stage had Ealing Social Services attempted to verify independently any aspect of Kouao's life before her arrival in England.

4.167

On 2 July 1999, Mr Joseph had a second telephone conversation with Ms Fortune. Kouao's solicitors had written another letter to Ealing Social Services expressing surprise at the decision to repatriate their "client", and asking them to review that decision or face judicial review proceedings. Mr Joseph repeated his earlier advice and suggested as an alternative to the family returning to France, that social services could offer to accommodate Victoria in their care until Kouao had found full-time work. Ms Fortune passed this on to Kouao's solicitors.

4.168

On 7 July 1999, Kouao again visited the offices alone. She was seen by Ms Fortune who confirmed that social services would no longer pay for her accommodation or continue to offer financial assistance. Kouao, who according to Ms Fortune was quite emotional at the time, was adamant that she would not return to France nor would she agree to Victoria being accommodated separately from her. Ms Fortune advised her to return to her solicitors but Kouao indicated that they were "no good". She also asked if she could have the money for the tickets, but Ms Fortune repeated her offer of purchasing the return tickets if Kouao would give her a travel date. Kouao did not respond and left the office.

The file is closed

4.169

That day, Ealing Social Services closed their files on Kouao and Victoria. They did so in the full knowledge that funding for their accommodation at Nicoll Road would cease the same day and that Kouao had no intention of returning to France. It was a poor decision