6 Haringey Social Services

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Analysis of practice

6.550

It is worthwhile at this point to step back from the chronology of events in Haringey to analyse in more detail what that chronology shows to have been the particular deficiencies in the practice of Haringey Social Services in the period with which I am concerned. The value of such an analysis lies in identifying the steps necessary to avoid the same problems arising elsewhere.

6.551

Quite apart from the vast amount of documentation that was provided on the subject, I heard over 20 days of oral evidence concerning the manner in which Haringey discharged its responsibility to safeguard and promote Victoria's welfare. Before commencing a detailed analysis of particular deficiencies in the service offered to Victoria by Haringey Social Services, it is useful to highlight four simple facts which do much to explain how it came to be that Victoria's plight was so disastrously overlooked for so long.

1

During the 211 days that Victoria's case was held by an allocated social worker employed by Haringey Social Services, she was seen by that social worker on only four separate occasions.

2

On none of those occasions did the social worker spend any more than 30 minutes with Victoria.

3

On none of those occasions did the conversation between the social worker and Victoria extend much further than "hello, how are you?"

4

The amount of time that the social worker spent discussing Victoria's case with those who were responsible for supervising her work amounted to no more than 30 minutes in total.

6.552

One's instinctive reaction on hearing the details of a case such as Victoria's, where the most extreme ill-treatment has gone undetected over a substantial period of time, is one of disbelief that nobody would seem to have noticed. The incredulity is increased in those cases in which there has been extensive involvement on the part of professionals whose job it is to protect vulnerable children.

6.553

Victoria's case, for the vast majority of the time that she was known to Haringey, was allocated to a qualified social worker based in an office containing a number of experienced managers. In view of this, it seems inconceivable that so little was done to help her. However, if one bears in mind the four facts listed above, it becomes a little easier to see how important information could have been missed or ignored.

6.554

However, what these facts do not do is explain why the attention that Victoria's case did receive from the staff of Haringey Social Services was so limited and ineffectual. The answer to that question involves looking more closely at a number of specific elements of the practice of the staff concerned. That is the purpose of the section which follows.

6.555

Before turning to consider those particular areas of practice, I wish to make two points.

6.556

The first is that some of what follows may be thought by some to be self-evident or to amount to little more than a call for social workers to do the job they have been trained to do and are paid to carry out. I have some sympathy with this sentiment, as I was often struck during the course of the evidence to this Inquiry by the basic nature of the failures illustrated by Victoria's case.

6.557

I make no apology for labouring these basic points during the analysis that follows. Victoria's case, like several others which have prompted Inquiries of this nature, is one that is characterised by a consistent failure to do basic things properly. In an environment in which time and resources may well be limited, it is of vital importance that sight is not lost of the fundamental aspects of sound social work practice.

6.558

The second point I wish to make at the beginning is that by focusing on specific elements of the practice of those who had direct dealings with Victoria's case, I would not wish to give the impression that I regard those front-line workers as wholly responsible for the deficiencies revealed.

6.559

It is plainly the case that when any member of staff in any organisation fails adequately to carry out a basic element of his or her job, then he or she must shoulder responsibility for that failure. However, where the poor practice concerned is found to be indicative of generally poor standards across the organisation as a whole, or where it is contributed to by the front-line staff being inadequately supported in their roles, then the senior members of that organisation must also accept their share of the blame.

6.560

The evidence I have heard leads me to the view that the manner in which a number of senior managers and elected councillors within Haringey discharged their statutory responsibilities to safeguard and promote the welfare of children living in the borough was an important contributory factor in the mishandling of Victoria's case. As such, the failure to adequately protect Victoria should be seen as a collective failure on the part of those involved with the provision of services to children and families in Haringey to ensure that adequate systems and practices were in place at the time, both to ensure that front-line staff carried out their duties adequately and to detect when they did not.

6.561

Given my views in this regard, I was left unimpressed by the manner in which a number of senior officers and councillors from Haringey sought to distance themselves from the poor practice apparent in Victoria's case. A good illustration of this attitude was provided by the former chief executive of the council, Gurbux Singh, who said:

"I have personally thought long and hard about what I could have done differently, which could have actually led to a situation where the tragedy of Victoria could not have actually happened. I have thought long and hard about that. I have thought about the sorts of procedures we could have put in place beyond that. But I end up thinking I am not sure that there was a great deal else more that we could have actually done."

6.562

Mr Singh went on to say that, despite it being absolutely clear that Haringey had failed adequately to discharge its duty to safeguard and promote Victoria's welfare, he was not clear in his own mind where the "line of responsibility" for that failure lay.

6.563

As I have already made clear, I do not share his uncertainty. As an organisation charged with the vital task of safeguarding children, Haringey council had a responsibility to ensure that its front-line staff were providing a proper and safe service to vulnerable children in the borough. As chief officer of the organisation, Mr Singh and his senior colleagues had a duty to ensure that such a service was provided.

6.564

A succession of senior managers and councillors from Haringey gave evidence before me and expressed their complete surprise at the state of the council's front- line services as revealed by the evidence given to this Inquiry by social workers and their immediate managers. It is the job of the leaders of any organisation to be aware of conditions on the 'shop floor' and the standard of service provided to its customers. It is their job to identify deficiencies in that service and put them right. Ignorance cannot, in my view, be a legitimate defence. Therefore, I make it clear at the outset that the criticisms of practice, below, are directed not just at the front-line staff concerned but at the senior managers and councillors whose role it was to ensure that Victoria, together with other vulnerable children in the borough, received an adequate service.

6.565

I have set out previously in this section a detailed description of the manner in which Victoria's case was handled by Haringey Social Services during the seven months or so that she was known to them. The occasions on which those involved failed to act in an appropriate and timely manner were numerous and varied. However, there are a number of particular aspects of Haringey Social Services' practice, as illustrated by Victoria's case, which merit more detailed analysis. They are:

•

The manner in which the strategy meetings were conducted.

•

The way in which the case was allocated to the social worker.

•

The decision to authorise Victoria's discharge from hospital.

•

The manner in which the home visits were carried out.

•

The approach taken to Kouao's credibility.

•

The use that was made of Victoria's case file.

•

The supervision received by the social worker.

•

The manner in which the case was closed.

•

The way in which the allegations of sexual harm were dealt with.

I deal with each in turn.

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Strategy meetings

6.566

The 1999 version of Working Together provides the following guidance as to the circumstances in which it is appropriate to hold a strategy meeting: "Whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer significant harm, there should be a strategy discussion involving the social services department and the police, and other agencies as appropriate (for example, education and health), in particular any referring agency." As to the format that such discussions should take, the guidance avoids being prescriptive, stating simply, "A strategy discussion may take place at a meeting or by other means (for example, by telephone)."

6.567

The guidance clearly allows for a degree of flexibility as to the precise form that strategy discussions should take. In my view, such flexibility is entirely appropriate because the circumstances in which harm to a child may come to light may be many and varied. In some cases, formal meetings involving all the involved parties may be inappropriate in view of the urgency of the situation.

6.568

An inevitable consequence of the flexibility permitted by the national guidance, however, is that local arrangements and protocols can differ widely. All four sets of strategy meeting guidelines submitted by the social services departments involved in Victoria's case were materially different from each other. In the case of Haringey, I was told that there was even inconsistency between the local ACPC procedures, in this respect, and the custom and practice adopted by front-line staff.

6.569

In my view, Victoria's case demonstrates that the need for flexibility in this area must be balanced against the danger of confusion arising between the partner agencies involved as to the proper manner in which to proceed when first faced with a case of possible deliberate harm. In other words, while circumstances will inevitably dictate the precise procedure to be adopted in any given case, minimum and consistent standards, clearly understood by all the agencies involved, are vital.

6.570

Turning first to the strategy meeting held on 28 July 1999, shortly after Victoria's admission to the North Middlesex Hospital, there are a number of respects in which the perfectly proper decision to have a discussion at this point was undermined by defects in the procedure adopted. The following are clear examples of this:

•

The meeting should have been held in the North Middlesex Hospital, as required by the local ACPC procedures. The referral, it will be recalled, had come from the hospital in the first place and, in the four days that Victoria had spent there, a significant amount of relevant information had been collected. It should have been obvious to all concerned that Dr Rossiter's attendance at the meeting was absolutely essential. Her commitments at the hospital meant that she did not have the time to travel to Haringey Social Services offices.

•

The meeting was chaired by a senior practitioner, Ms Kozinos, rather than by a team manager. This, again, was contrary to local ACPC procedures. While the competency of the chairmanship is, of course, more important than the identity of the chairman, in my view it is preferable to adopt a clear and consistent approach in this regard. The effective chairing of a strategy meeting can be a challenging task. It is best performed by a manager who is experienced in the work and aware of the responsibilities it carries. Meetings of this nature are a valuable resource which use up a substantial amount of the limited time available to busy professionals. The ad hoc allocation of the chairmanship to whichever manager happens to be free at the time can seriously undermine their effectiveness.

•

The danger of inexperienced or inefficient chairmanship is well illustrated by Victoria's case. The 18 action points identified during the course of the meeting were, for the most part, sound. However, the lack of clarity as to precisely who was responsible for what, the absence of any timescales for the completion of the various actions identified, and the failure to circulate copies of the minutes of the meeting to those with responsibility for taking the strategy forward meant that the practical impact of those 18 action points was seriously diminished. Again, this is a defect which adherence to a basic set of procedures could easily have avoided.

•

However, of all the deficiencies in the conduct of the strategy meeting, it is the failure to arrange for a review meeting to monitor the progress of the agreed strategy which causes me the greatest concern. The ACPC procedures make reference to the need to "consider" holding such a meeting following a strategy discussion, but no reference at all is made to the practice in the procedures drawn up by Ms Mairs for use in the NTDO. In my view, such meetings are absolutely essential. If one takes Victoria's case as an example, 18 different actions were identified as being necessary and were assigned to a variety of people from a number of different agencies without any specified timescales. To simply assume that all the tasks would be satisfactorily completed, and that it was therefore unnecessary to check, was optimistic to say the least.

6.571

That the deficiencies in the manner in which this first strategy meeting was conducted was not an isolated example of poor practice would seem to be confirmed by the fact that many of the same faults are apparent in the second strategy meeting conducted a little over three months later.

6.572

In particular, a list of 15 generally sensible action points was produced, which, if carried out, may have gone a long to way to establishing the danger that Victoria was in. None of those action points is allocated to a particular individual and none of them has a specified timescale for completion. In view of this, the repeated failure to put in place any form of review mechanism is nothing short of disastrous in the context of Victoria's case.

6.573

The fact that the two strategy meetings in which her case was discussed were so ineffective in safeguarding Victoria's welfare is not explained by any lack of specialist judgement or expertise on the part of the professionals involved. As I have made clear above, the lists of recommended action points produced after each one were detailed, thorough and generally sound. The explanation lies, in my view, in the basic failure to implement simple procedures that would have ensured that the strategies agreed upon at the meetings were put into effect.

6.574

The flexibility afforded by the Working Together guidelines would appear to have led, in the case of Haringey at least, to strategy discussions being organised and conducted in a haphazard and ad hoc manner, with the inevitable result that important points were missed.

6.575

Victoria's case leads me to the view that while professionals must be allowed the freedom to tailor their response to individual situations as they see fit, and that it is impossible to lay down a detailed and prescriptive procedure for the conduct of strategy meetings, the time has come for the introduction of a few basic minimum standards. By making the recommendation, I aim to ensure that full value is extracted from strategy meetings and discussions, and that the crucial role they play in the protection of children is not undermined for want of a few basic procedures. Therefore, I make the following recommendation:

Recommendation

Directors of social services must ensure that all strategy meetings and discussions involve the following three basic steps:

• A list of action points must be drawn up, each with an agreed timescale and the identity of the person responsible for carrying it out.

• A clear record of the discussion or meeting must be circulated to all those present and all those with responsibility for an action point.

• A mechanism for reviewing completion of the agreed actions must be specified. The date upon which the first such review is to take place is to be agreed and documented.

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Case allocation

6.576

The proper and well-thought-out allocation of cases is a central component of the effective management of a social work team. As with any group of staff, there will be significant variations among a given group of social workers as to their respective levels of experience, training and expertise. Perhaps most important of all, some will have more available time than others by virtue of their current workloads. All of these factors are relevant to the decision of which social worker should be allocated a particular case.

6.577

It is clear that effective management of this nature involves a detailed knowledge on the part of the manager - both of the social workers on his or her team and the precise state of their current workloads. As was explained to me during the course of the evidence, the latter requirement cannot be met effectively by simply maintaining a list of the number of open cases currently held by each social worker on the team. Bare statistics of this sort can mask the fact that some cases require far more time and attention than others, and that a particular case, counted as one for the purposes of such statistics, may involve more than one child in the family.

6.578

It would appear that Victoria's case was allocated to Ms Arthurworrey by Ms Baptiste without any consideration of the sort of factors I have previously described. In the first place, there would seem to have been no assessment of whether Ms Arthurworrey had the requisite capabilities to handle the case. Ms Arthurworrey told me that at the time she found Victoria's case file lying on her desk, she had never completed a section 47 inquiry, never dealt with a child in hospital and never taken a case through to case conference. For present purposes, what concerns me is not whether Ms Arthurworrey was capable of handling Victoria's case in a competent manner, but that no assessment of her capabilities would seem to have been made by her manager before allocating the case to her.

6.579

Nor would there seem to have been any consideration as to whether Ms Arthurworrey's workload at the time allowed her to devote enough time to Victoria's case. The only system for the monitoring of the workload of individual social workers in operation in Ms Baptiste's team at the time was a crude list of the number of open cases held by each social worker, the more obvious limitations of which I have just described. Even on the basis of this unreliable information, Ms Arthurworrey, at the time that she was allocated Victoria's case, was holding more cases than virtually all of her colleagues and seven more than the recommended maximum specified in the office procedures. Again, the issue for present purposes is not whether Ms Arthurworrey had sufficient time to deal adequately with Victoria's case, but rather that no thought would seem to have been given as to whether or not she did.

6.580

Ensuring that a member of staff has the time and ability to undertake a particular task before asking them to do so amounts to no more than basic managerial competence. Therefore, I was greatly surprised to learn not only that this was not done in Victoria's case, but that there was no system in place in the office concerned that suggested it might have been done in respect of other cases. Ms Arthurworrey's experience of returning to the office one morning and finding a new case file sitting on her desk was not, I was concerned to hear, unique.

6.581

With a view to ensuring that such basic lapses in managerial practice are not repeated elsewhere, I make the following recommendation:

Recommendation

Directors of social services must ensure that no case is allocated to a social worker unless and until his or her manager ensures that he or she has the necessary training, experience and time to deal with it properly.

6.582

However, proper case allocation does not end with the simple identification of the right social worker for the job. It requires the manager to ensure that the social worker understands the work that he or she has been charged with doing. In practical terms, this would involve the manager and the social worker sitting down together with the case file and agreeing on the most appropriate manner in which to take the case forward.

6.583

Nothing of this sort was done in Victoria's case. The only explanation or guidance as to how to proceed with the case given to Ms Arthurworrey by Ms Baptiste would appear to have come in the form of a brief conversation between the two of them after Ms Arthurworrey had glanced through the file. When asked whether she found Ms Baptiste's input on this occasion to be helpful, Ms Arthurworrey replied, "Ms Baptiste just told me that this was a case about a child who was in hospital with scabies. No it was not helpful." Ms Baptiste, she went on to say, did no more than tell her "to implement the strategy meeting recommendations". No indication was given as to when she expected Ms Arthurworrey to have completed those tasks.

6.584

Apart from the factual inaccuracy concerning the reason why Victoria had been admitted to the North Middlesex Hospital (which may have influenced the way in which Ms Arthurworrey approached the case afterwards), there would appear to be a complete absence of any thought on the part of Ms Baptiste as to how best to approach Victoria's case. Consequently, she was unable to offer Ms Arthurworrey anything in the way of meaningful guidance or assistance in taking the case forward.

6.585

Nor would it seem as though manager and social worker read through Victoria's case file at the time of allocation. In addition to gaining a proper understanding of what needs to be done, and by when, this basic step can help to ensure that vital information is not missed at the outset of any investigation of the child's circumstances. An example of such information in Victoria's case is provided by the note on the CP1 form completed by Dr Forlee, which records that Kouao had previously been in contact with social services, who had apparently suggested that she and Victoria be separated. This potentially vital piece of information was never picked up Ms Arthurworrey, despite the inclusion of the document concerned in Victoria's case file.

6.586

I appreciate that in many social services departments up and down the country, the allocation of cases to social workers will routinely follow careful consideration as to who is best placed to handle the case and a thorough discussion between social worker and manager as to what needs to be done and by when. Prior to hearing the evidence to this Inquiry, I would have expected such procedures to be universal. In an effort to ensure that they become so, I make the following recommendation:

Recommendation

When allocating a case to a social worker, the manager must ensure that the social worker is clear as to what has been allocated, what action is required and how that action will be reviewed and supervised.

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6.587

The fact that Victoria had an allocated social worker for the vast majority of the time that she was known to Haringey Social Services meant that she was, in theory at least, better served that many other vulnerable children in the borough.

6.588

During the course of the evidence to this Inquiry there were many references to the problem of open cases which did not have an allocated social worker. By way of an example, my attention was drawn to a report written by Mr Duncan in January 2001 in which he made the worrying observation that there were 100 unallocated cases in the NTDO alone.

6.589

The disadvantages inherent in a case being unallocated are obvious. If there is no particular individual charged with, and responsible for, ensuring that the needs of the child concerned are met, the likelihood of that child failing to receive the service he or she needs is increased enormously. While not of direct impact in Victoria's case, I heard enough evidence, from Haringey and elsewhere, to convince me that the problem of unallocated cases is one that needs urgent attention. I therefore make the following recommendation:

Recommendation

Directors of social services must ensure that all cases of children assessed as needing a service have an allocated social worker. In cases where this proves to be impossible, arrangements must be made to maintain contact with the child. The number, nature and reasons for such unallocated cases must be reported to the social services committee on a monthly basis.

6.590

However, the mere fact of allocation of a case is not enough to ensure that the child concerned receives the necessary services. The achievement of that objective requires the social worker concerned regularly to see, speak to and work with the child and the child's family. Unless this happens, the fact that the case is recorded as 'allocated' is meaningless. Therefore, in order to ensure that the above recommendation has the positive impact intended, I make the following additional recommendation:

Recommendation

Directors of social services must ensure that only those cases in which a social worker is actively engaged in work with a child and the child's family are deemed to be 'allocated'.

Discharge from hospital

6.591

The precise sequence of events surrounding Victoria's discharge from the North Middlesex Hospital remains unclear. However, there is no doubt that her discharge was approved by both Ms Arthurworrey and PC Jones following the brief interview of Victoria they conducted on 6 August 1999.

6.592

In my judgement, the decision that it was appropriate for Victoria to go home was taken without any proper consideration of whether it was safe for her to do so. Victoria's discharge from the North Middlesex Hospital is a key event in the story of her case. On the morning of 6 August, she was in a safe place and all her basic needs were being met. By that evening she had been returned to an environment that would eventually bring about her death a little over six months later.

6.593

Given the importance of the decision, the lack of investigation and analysis that preceded it is extremely disappointing. In my view, there were at least 10 important steps that were not taken when considering whether Victoria should have been allowed home. These are:

•

No adequate understanding was gained during the course of the interview with Victoria on 6 August of how she spent her days when she was living with Kouao and Manning.

•

No attempt was made to seek the views of any of the medical staff who had been involved in Victoria's care, other than Dr Rossiter and Nurse Quinn.

•

Victoria's notes were not carefully considered, and the concerns expressed in them were not explored.

•

No attempt was made to seek the views of Dr Forlee, the doctor who had made the initial referral.

•

No critical analysis was applied to Kouao's account of how Victoria had come by her injuries, and she was not challenged in any meaningful way on the matter.

•

No visit was made to the home to which it was proposed to return Victoria.

•

No effort was made to gain a proper understanding of the nature and causes of scabies and its links to possible neglect.

•

No structured discussion about the case took place between Ms Arthurworrey and her manager, during which the merits of the decision to discharge were properly considered.

•

No active consideration was given to convening a case conference, or any other form of multi-agency meeting, in order to explore whether discharge to Manning's flat was in Victoria's best interests.

•

No efforts were made to put any community support programme in place for Victoria. For example, the possibility of enrolling her in a summer play scheme was not explored, nor were any attempts made to secure community nursing surveillance.

6.594

In my view, all of the 10 steps should have been taken before deciding that Victoria could return home with Kouao. They are examples of the sort of rigorous consideration that must be undertaken before authorising the removal of a child about whom there have been child protection concerns from a safe place back to the environment in which the concerns first arose. In an effort to encourage the application of careful analysis to decisions of this nature, I make the following recommendation:

Recommendation

Directors of social services must ensure that no child known to social services who is an inpatient in a hospital and about whom there are child protection concerns is allowed to be taken home until it has been established by social services that the home environment is safe, the concerns of the medical staff have been fully addressed, and there is a social work plan in place for the ongoing promotion and safeguarding of that child's welfare.

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Home visits

6.595

Ms Arthurworrey candidly admitted that she was "totally set up" by Kouao and Manning during the two visits she made to Somerset Gardens. The picture of a happy and well-cared for Victoria playing contentedly on the floor with a doll was far removed from the reality of the situation, even at this early stage.

6.596

Although Ms Arthurworrey was by no means the only professional that Kouao deceived into thinking that she had Victoria's best interests at heart, she was the only one who had the opportunity to assess them in their home environment. Home visits of this nature can be extremely valuable sources of information in determining how well a child is cared for. That Ms Arthurworrey came away from both the visits she made to Somerset Gardens without any concern that Victoria might be in danger owes as much to defects in the approach taken to those visits as to any deceit on the part of Kouao or Manning.

6.597

In particular, I consider that the following essential components of a successful home visit were missing on both of the occasions that Ms Arthurworrey went to Victoria's home:

•

The proper planning of the visit in advance.

•

The maintenance by the social worker of an open mind.

•

The review of judgements and assumptions made during the course of the visit.

I consider each in turn.

Proper planning

6.598

There would appear to have been a complete absence of any planning or discussion between Ms Arthurworrey and Ms Baptiste in advance of either of the home visits. There was no consideration of the types of questions that should be asked, the background checks that were necessary before undertaking the visit, the things to look out for in the home, or the manner in which Victoria should be approached and spoken to. All of these, in my view, are matters that should be considered in advance of any home visit of this type.

6.599

The absence of any planning or preparation in advance of the visits also meant that the opportunity was lost to review and, if necessary, challenge the assumptions that Ms Arthurworrey had made about the case. Before the first visit, it will be recalled that she had effectively closed the child protection element of the case. The decision taken with PC Jones at the hospital on 6 August 1999 that Victoria was not a child at risk of significant harm had been reinforced by her interpretation of the material she later received from the Central Middlesex Hospital. Had there been any discussion of the case between Ms Arthurworrey and her manager before the home visit, the deficiencies in her analysis of the case at this point may have been exposed. As it was, she simply turned up at the home with a wholly mistaken view of the sort of case with which she was dealing.

6.600

The same is true of the later visit at the end of October. As the scope of the discussion between Ms Arthurworrey and Kouao illustrates, the prevailing view at this stage would seem to have been that the only issue that needed to be addressed was Kouao's accommodation difficulties. The child protection referral concerning Victoria that had been received three months earlier had turned into a case about an adult with a child who needed better accommodation. Again, had there been any proper planning of this home visit involving a discussion between Ms Arthurworrey and her manager, the point may have been made that it was, in fact, Victoria who was the client in the case. Perhaps then Ms Arthurworrey would have taken the trouble to talk either to or about her during the course of the visit.

Keeping an open mind

6.601

Turning now to the visits themselves, it was suggested to Ms Arthurworrey during the course of her evidence that she showed a "lack of inquisitiveness" during the course of the visits she made in August. Her reply was interesting: "I am a social worker and I work with the facts as they are presented to me. As I have said to you, I was more trusting of Kouao when I went on that visit. I am not a detective. I had no reason to question what I saw and what I was being told at that point."

6.602

While I accept that social workers are not detectives, I do not consider that they should simply serve as the passive recipients of information, unquestioningly accepting all that they are told by the carers of children about whom there are concerns. The concept of "respectful uncertainty" should lie at the heart of the relationship between the social worker and the family. It does not require social workers constantly to interrogate their clients, but it does involve the critical evaluation of information that they are given. People who abuse their children are unlikely to inform social workers of the fact. For this reason at least, social workers must keep an open mind.

6.603

Their managers must also keep an open mind. I have already highlighted the value of discussion between social worker and manager before a home visit takes place so as to test assumptions made about the case thus far. I regard it as equally important for discussion to take place after a visit for the same purpose.

Reviewing judgements and assumptions

6.604

By the time that she had returned to the NTDO after the home visit on 16 August 1999, Ms Arthurworrey had formed the view that Kouao was "a respectful adult who was child focused". This view had been reached without her questioning Victoria about her well-being, establishing how she spent her days or following up any of the concerns expressed by the hospital such as Victoria's unusually large appetite. The second home visit would seem to have served only to reinforce Ms Arthurworrey's view of Kouao, despite the fact that, once again, no attempt was made to establish how Victoria spent her days or how she felt about her current living arrangements.

6.605

These assumptions were never tested in discussion between Ms Arthurworrey and her manager and so, again, the opportunity was lost to discover the lack of analysis that had preceded the assumption being made. Even such simple questions as "How was Victoria?", "What did she say?", or "How does she spend her days?" might have revealed Ms Arthurworrey's failure to focus on the needs of her client. In fact, Ms Baptiste would appear to have restricted herself to being the passive recipient of information given to her by Ms Arthurworrey in the same way that Ms Arthurworrey had been with respect to Kouao.

6.606

The net effect of these deficiencies in practice is that the valuable opportunities to gain an insight into Victoria's situation provided by Ms Arthurworrey's two home visits were completely wasted. That the same deficiencies were apparent in each of the two home visits, and that they were not identified until after Victoria's death, would seem to indicate that bad practice of this nature was not unusual in Haringey at the time. In an effort to ensure that it is not replicated elsewhere, 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 child protection agencies. All visits must be written up on the case file.

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Working with deceitful people

6.607

One aspect of the manner in which Ms Arthurworrey approached the home visits crops up on numerous occasions during the course of Haringey's handling of Victoria's case and merits further consideration. I refer to the extent to which Ms Arthurworrey was prepared to accept at face value that which she was told by Kouao.

6.608

As recorded earlier, Ms Arthurworrey encouraged me to bear in mind that she was not "a detective" when considering how inquisitive she should have been during the course of her home visits. This point was echoed in Haringey's closing submissions to the Inquiry, in which I was told that social workers "are not used to dealing with wholesale deception" of the type perpetrated by Kouao in this case.

6.609

While I accept that both of these points have some validity, I was struck by the extent to which the information held by Haringey Social Services during the course of their dealings with Victoria revealed clear inconsistencies in Kouao's story, of which the following are some examples:

•

The case file records Kouao's date of birth as being "18/07/66", whereas the age of her eldest child is recorded on the CP1 form as being 24. This would have meant that Kouao had her first child at the age of nine or 10. This discrepancy was never explored.

•

Kouao's country of birth varies between Zaire, France and the Ivory Coast depending upon which document in the case file one looks at. Similar confusion applied to Victoria. On the record of the 5 November 1999 strategy meeting she is recorded as being a Zairean Catholic.

•

The length of time that Kouao intended to spend in the UK is variously recorded as a one-year "leave of absence", "two years to learn English" and "permanent".

•

Various dates between January and March are identified for Victoria and Kouao's arrival in the country.

•

Several references are made to Manning's "fiancée" but her identity is never established.

6.610

Much was made in the evidence of a number of witnesses to the plausibility of Kouao and how successful she could be at diverting suspicion. In addition to whatever natural talent she may have had in this respect, she would also seem to have used the fact that English was not her first language to good effect. Ms Arthurworrey recalled at one stage that Kouao's English would sometimes deteriorate when certain difficult subjects arose, a tendency that was repeated during the course of her evidence to this Inquiry.

6.611

Nonetheless, it seems to me that a careful review of the available information would have indicated that there were numerous discrepancies in the information that Kouao was giving to social services, which needed to be resolved if an accurate picture of Victoria's situation was to be established. These discrepancies were never properly explored.

6.612

Despite the absence of much in the way of investigation and critical analysis of the available information, it would appear that some of those involved in the case had their suspicions as to the reliability of Kouao's version of events. This is illustrated by the inclusion of the following in the list of 15 action points drawn up at the 5 November strategy meeting: "some proof that the child is hers".

6.613

This note demonstrates that, over three months after the initial referral had been made, there were still doubts as to whether Victoria was Kouao's real daughter. Unfortunately, there is no record of what prompted those suspicions. There are, however, plenty of possibilities including the discrepancy in their appearance and dress, the lack of warmth shown between them, or the infrequency of Kouao's visits to the hospital and failure to bring anything for Victoria when she did visit. Unfortunately, the point is academic in view of the fact that no proof that Victoria was Kouao's daughter was ever sought.

6.614

What the point does illustrate, however, is how significant discrepancies in the account given by the carer can be. If, for example, the suspicion expressed at the strategy meeting on 5 November had been followed up, the first thing that might have been done would have been to look at Kouao's passport which, as the police later discovered, contained the photograph of a little girl who looked different to Victoria. Had such a discovery been made, the outcome of this case may have been different.

6.615

The same might be said in relation to the discrepancies in Kouao's account of her background in France. Quite apart from the inconsistencies set out above, Kouao's decision to leave a well-paid job in France and come to the UK, where she was unable to support herself or find satisfactory accommodation was, on the face of it, curious.

6.616

At the first strategy meeting on 28 July 1999, the need to carry out checks concerning Kouao's and Victoria's background in France was identified - action point 17 states: "complete checks in France - International services." Unfortunately, the notes of the strategy meeting do not specify what checks were necessary or how they should be undertaken.

6.617

This may explain why, by the time of the second strategy meeting over three months later, no such checks had been carried out. Again, the meeting identified the need to contact the French authorities and the following note was made: "s/w to complete a check with France if client is previously known. Find out more information re other children.

6.618

The investigation carried out by the police after Victoria's death revealed that a substantial amount of important information was held by the French authorities concerning Victoria and Kouao. In addition to the discovery that Kouao owed French social services a significant amount of money in respect of improperly claimed benefits, the fact that Victoria had experienced problems with absenteeism at school and had been subject to a child at risk emergency notification was also established. A French social worker had also become involved who had noted a "difficult mother daughter relationship" between Kouao and Victoria.

6.619

The fact that Haringey Social Services proved incapable of discovering this information while Victoria was alive may be attributable to a lack of awareness on the part of the staff concerned as to the proper avenues to explore and procedures to adopt. If that is the case then the situation needs to be addressed. Many social services departments around the country have to deal on a regular basis with children who have arrived in this country from abroad. Even in those cases in which the country of origin of the child concerned is without a developed welfare system, the child may well have passed through such a country on his or her way to the UK. The social services departments of those countries are a potentially valuable source of information. Social workers should be provided with clear guidance and procedures explaining how best to access such information. It is with this objective in mind that I make the following recommendation:

Recommendation

Directors of social services must ensure that social work staff are made aware of how to access effectively information concerning vulnerable children which may be held in other countries.

Paragraphs: 6.550 - 6.565 | 6.566 - 6.575 | 6.576 - 6.586 | 6.587 - 6.594 | 6.595 - 6.606 | 6.607 - 6.619 | 6.620 - 6.629 | 6.630 - 6.647 | 6.648 - 6.657

Case file management

6.620

During the course of one of his submissions to me, the representative appearing before the Inquiry on behalf of the NHS witnesses informed me that telling medical professionals that they should write better notes was like "pushing at an open door". In doing so, I expect that he intended to convey something of the wearying regularity with which this issue arises in the context of investigations of this nature. Numerous inquiries in the past have called for higher standards of case recording and the more thorough maintenance of case files by professionals from all agencies involved in the welfare of children.

6.621

In view of the regularity with which deficiencies in this regard have been identified, it is disappointing to find them repeated with such regularity throughout Victoria's case. One wonders why, if the problem is so universally acknowledged that to identify it amounts to "pushing at an open door", it has yet to be properly addressed.

6.622

I have dealt elsewhere in this Report with the importance of recording all relevant information concerning a child in his or her case file or notes and have made a general recommendation to this effect directed at all the agencies involved. I do not propose to repeat those matters here, particularly in view of the fact that my concerns regarding the management of Victoria's case file in Haringey are of a slightly different nature.

6.623

The case file is the single most important tool available to social workers and their managers when making decisions as to how best to safeguard the welfare of children under their care. It should clearly and accessibly record the available information concerning the child and the action that has been taken on the case to date. Reference to the case file should be made at every stage of the case and before any significant decision is made.

6.624

My concern regarding the Haringey case file is not that it contained glaring omissions, but rather that so little use would seem to have been made of it by those with responsibility for Victoria's case. As I have mentioned earlier, the case file would not appear to have been read by Ms Baptiste at the time she allocated Victoria's case to Ms Arthurworrey. Nor, it would seem, was any meaningful reference made to the file during the course of the supervision sessions in which Victoria's case was briefly discussed. Most remarkable of all, perhaps, is the fact that the second strategy meeting proceeded in the complete absence of Victoria's case file, despite the fact that it was sitting in the next room at the time.

6.625

The lack of reference to the case file at these and other stages in Victoria's case may go some way to explaining why so many important steps were missed. It is not difficult to envisage how, for example, the review during the course of supervision of the lengthy lists of action points produced after the two strategy meetings would have revealed that there was much outstanding work to be done. It is extremely frustrating to think how important a difference such a basic and self-evident element of good social work practice could have made in Victoria's case. The information contained in Victoria's case file should have been more than sufficient to prompt effective social work intervention in her case. That it was not read at key points is indicative of extremely poor practice and a matter much to be regretted.

6.626

It is impossible for me to form any judgement as to how easy it would have been for a reader of Victoria's case file to have gleaned from it the relevant information at various stages along the way. The reason for this is that by the time that it reached the Inquiry, the case file had been taken apart and copied on several occasions and was no longer in its original order.

6.627

However, it may be that a contributory factor in the failure of various professionals involved in Victoria's case to read the file was that the information was not presented in a sufficiently convenient and accessible way. If only a limited amount of time is available for supervision, for example, the manager concerned may feel it is not worth spending it trying to make sense of a jumble of papers in the file.

6.628

This is one of the reasons why I regard the inclusion in any case file of a clear, comprehensive and up-to-date chronology as absolutely essential. In addition to saving valuable time that would otherwise be spent trying to extract the relevant information from a number of documents, such a chronology would also help to identify actions ordered on the case which had yet to be completed. The discipline of preparing the initial chronology at the outset of the case is also valuable given that it would require the allocated social worker carefully to read the file before embarking upon the assessment.

6.629

If it is to be comprehensive, a chronology will, in many cases, have to take account of the information possessed by other agencies involved and the work they carry out on the case. As the agency best placed to co-ordinate the collection of the relevant information, I regard it as the responsibility of social services to maintain the chronology, seeking the input of other agencies as appropriate. In order to ensure that social services are clear as to their obligations in this regard, I make the following recommendation:

Recommendation

Directors of social services must ensure that every child's case file includes, on the inside of the front cover, a properly maintained chronology.

Paragraphs: 6.550 - 6.565 | 6.566 - 6.575 | 6.576 - 6.586 | 6.587 - 6.594 | 6.595 - 6.606 | 6.607 - 6.619 | 6.620 - 6.629 | 6.630 - 6.647 | 6.648 - 6.657

Supervision

6.630

There is now a good deal of consensus as to the key features of effective social work supervision. In particular, it is widely recognised that such supervision should be well documented and should include the discussion of individual cases. In addition, supervision provides an opportunity to challenge assumptions and judgements that have been made regarding particular cases and to agree plans of action. All of these elements are present in the supervision policies and guidance in use in Haringey Social Services at the time that they were dealing with Victoria's case.

6.631

Unfortunately, it is very difficult to see these principles reflected in the supervision that was offered to Ms Arthurworrey when she was dealing with Victoria's case.

6.632

The first formal supervision that Ms Arthurworrey received concerning her work on Victoria's case took place on 20 September 1999, some two months or so after the case had first been allocated to her. Although a delay of two months between allocation and first supervision in a case of this nature is unsatisfactory, it is the nature of the supervision when it was provided that causes me most concern.

6.633

As I have noted previously, Victoria's case file was not read by Ms Baptiste either before, during or after the supervision session. Her failure to do so meant that her knowledge of the case was entirely dependent upon what she was told by Ms Arthurworrey. The limitations of such a situation are obvious. If the manager knows only what she is told by the social worker, it will be virtually impossible for her to identify action points that had been missed or to challenge constructively the social worker's understanding. A prime example of the limitations of this approach to supervision provided by Victoria's case is the fact that Ms Baptiste would appear to have been unaware during this supervision session that the majority of the action points identified at the July strategy meeting had yet to be completed.

6.634

In addition to the lack of preparation that preceded it, the supervision session itself was characterised by a complete lack of thoroughness or analysis. The record of the session written by Ms Baptiste on the case file runs to a total of eight handwritten lines which, for the first supervision session in a case referred with child protection concerns, is wholly inadequate.

6.635

The brevity of the record merely reflects the lack of time spent discussing the case which, according to Ms Arthurworrey, did not extend much beyond five minutes. Supervision of this length in a case of the complexity and seriousness of Victoria's can amount to no more than the rubber-stamping of the decisions and judgements already made by the social worker. Overall, one is left with the clear impression that the objective of this first supervision session was simply to get through the cases as quickly as possible, with the manager acting as the passive recipient of whatever information the social worker decided to give her.

6.636

During the seven months or so that she had responsibility for Victoria's case, Ms Arthurworrey participated in a total of four supervision sessions in which it was discussed. The other three would seem to have followed a very similar pattern to the first session, in that the case file was never read and very little in the way of meaningful analysis took place. As a result, whatever mistakes or errors of judgement that Ms Arthurworrey may have made during the course of her handling of Victoria's case went undetected by her immediate managers.

6.637

The nature and extent of the supervision that Ms Arthurworrey received in Victoria's case would seem, from the evidence I heard, to have been typical of the practice in the NTDO at the time. Thorough supervision appears to have been one of the casualties of the inability of some staff to cope with the day-to-day pressures of work in the team. While it may have been possible to record supervision as occurring, and to report as much to senior managers, its quality was extremely poor.

6.638

Effective supervision is the cornerstone of safe social work practice. There is no substitute for it. In particular, the need for such supervision cannot be met by what were referred to as 'corridor conversations' between managers and staff. A number of such conversations regarding Victoria's case took place between Ms Baptiste and Ms Arthurworrey before the first formal supervision session that I have described earlier. A number of extremely important decisions about Victoria's case would seem to have been taken by Ms Baptiste during the course of informal, ad hoc discussions of this nature, of which the following are examples:

•

She agreed to the cancelling of the planned home visit prior to Victoria's discharge from hospital.

•

She endorsed Ms Arthurworrey's interpretation of the material received from the Central Middlesex Hospital that there were no longer any child protection concerns.

•

She accepted Ms Arthurworrey's interpretation of the information obtained during the October home visit that there were still no child protection concerns.

•

She decided that the concerns expressed by Dr Rossiter, as relayed via Ms Kitchman, required no further action.

6.639

All of these important decisions were made during the course of informal discussions and without reference to the case file. They illustrate the amateurish way in which the supervision of Victoria's case was approached. The significance of the inadequacy of the supervision given to Ms Arthurworrey cannot be overstated. As with so many aspects of Victoria's case, the faults would have been remedied by the straightforward observance of basic practice standards. In this instance, the outcome for Victoria might have been different if her case file had ever been read by those who were supposed to be supervising Ms Arthurworrey. The recommendation which addresses this is in paragraph 6.59.

Case closure

6.640

The need to thoroughly read the case file before taking any important decision on a case is never more vital than when consideration is being given to closing it. The mechanics of case closure are straightforward - all that is generally considered necessary is that a manager or senior practitioner endorses the view reached by the social worker in charge of the case that there is no reason to keep it open any longer. However, implicit in such a system is the requirement that the manager or senior practitioner concerned carefully reviews the case to ensure that there is not further work for social services still to do.

6.641

Ideally, therefore, a social worker, having carried out all the action identified as necessary on the case, would present that case to a manager who, having verified that this was indeed so, would endorse the decision to close the case. The sequence of events in Victoria's case was very different.

6.642

The strategy meeting held on 5 November added a further 15 action points to those that remained outstanding from the earlier strategy meeting in July. By this stage there were approximately 30 individual steps that had been identified as necessary in Victoria's case, but which had yet to be completed. Despite the fact that all this work remained outstanding, Victoria was never seen again by anyone from Haringey Social Services after 2 November, when she was brought to the NTDO to withdraw the allegation of sexual harm.

6.643

Instead, her case was allowed to limp listlessly towards the point at which those involved would seem simply to have lost interest in doing anything proactive on it. The chronology of what Ms Arthurworrey did in respect of Victoria's case during the four months or so between the November strategy meeting and the decision to close the case makes for depressing reading. A letter was written, a few telephone calls were made and three visits were made to the flat, none of which found anyone at home.

6.644

Therefore, when the case was passed to Ms Mairs for closure, the file should have revealed that, far from the thorough completion of all identified tasks, the preceding four months had witnessed nothing but sporadic and ineffectual attempts to get in contact with the family concerned.

6.645

The last time that this child had been seen she had been making and withdrawing allegations of sexual harm in a manner identified by all those involved at the time as suspicious. As a result, a strategy meeting had been called at which 15 action points had been identified, several of which involved seeing and speaking to Victoria. As even a brief reading of the case file would have revealed, virtually no progress had been made on any of those action points.

6.646

Even if the manager concerned was interested only in whether there were sufficient grounds for safely assuming that Kouao and Victoria had left the borough, the case file would have revealed that there were important steps that had yet to be taken. For example, no checks had been made with the health services to ascertain whether Victoria had received further treatment, no attempt had been made to speak to any of Manning's neighbours to establish who was living at the flat, and no contact had been made with the French authorities in an effort to establish whether Kouao and Victoria had indeed returned to France.

6.647

The closure of a case should be the result of a job well done, not the result of a desire to have one less case to worry about. Victoria's case file shows that there was much still to be done on her case at the time that it was closed. In those circumstances there would appear to be two possibilities. Either the case file was not read before it was signed off for closure, or it was read and the decision to close it was made in the knowledge that there were concerns that had yet to be resolved and important steps that had yet to be taken. Both would amount to very poor practice indeed.

Paragraphs: 6.550 - 6.565 | 6.566 - 6.575 | 6.576 - 6.586 | 6.587 - 6.594 | 6.595 - 6.606 | 6.607 - 6.619 | 6.620 - 6.629 | 6.630 - 6.647 | 6.648 - 6.657

Sexual harm allegation

6.648

Finally, I turn to consider the manner in which Haringey dealt with the allegation made on 1 November 1999 that Manning had sexually harmed Victoria.

6.649

In many respects, an allegation of specific harm done to a child by a named individual is easier to deal with from a social services point of view than a more vague referral of general suspicion. This is not least because of the wealth of procedures and guidance that have been produced in order to assist social workers in identifying the correct steps to take. It was somewhat surprising, therefore, to learn that Haringey's handling of the 1 November allegation was flawed in almost every material respect.

6.650

The crucial error, in my view, was the failure by social work staff, after they had been informed of the allegation and had invited Victoria and Kouao to attend the office, to arrange for a police officer to be present when they arrived. That police officer could then have assisted social services in interviewing both Kouao and Victoria at an early stage. The result of this failure was that when Kouao and Victoria did arrive, they were interviewed in an entirely inadequate manner.

6.651

First, Kouao was spoken to by two social workers - neither of whom had ever been trained in the conduct of interviews of this nature and neither of whom had, by that stage, completed a section 47 investigation. No notes of this interview were taken at the time, although Ms Arthurworrey was able to recall that she told Kouao that the police would be involved and that Manning would be arrested.

6.652

Secondly, Victoria was spoken to by the same inadequately trained social workers. Despite her apparent willingness to talk about what had happened to her she was discouraged from doing so, apparently due to the fact that the social workers realised by this stage that the police should be involved in that process. Had a properly trained child protection officer been involved from the outset, Victoria's account could have been obtained at the time that she seemed anxious to give it. The disadvantages of discouraging a child in Victoria's situation from telling social workers what has happened to her are obvious.

6.653

Only after they had interviewed both Kouao and Victoria did Haringey Social Services contact the police. By this time it was after 4pm and PC Jones, to whom the case was allocated, had gone home for the night. I comment elsewhere in this Report as to the adequacy of the police's response at this stage, but for present purposes it is sufficient to note that had the police been involved from the outset, this particular difficulty would not have arisen.

6.654

Victoria and Kouao were then allowed to leave the office supposedly to stay with the Kimbidimas, a family about which virtually nothing was known. No checks were made as to what the sleeping arrangements would be, how Victoria and Kouao would be fed and looked after or what, if any, connection the Kimbidimas had with Manning, the alleged perpetrator of the harm.

6.655

Thereafter, nothing of any value was done apart from scheduling a strategy meeting for 5 November 1999, some four days after the allegations had first been made. The timing of the strategy meeting is curious to say the least. While an immediate strategy meeting prior to the commencement of a joint investigation may have made sense (as for that matter would a strategy meeting at the end of the initial investigation when all the parties had been interviewed), I can see no logical basis for the decision to call the meeting in the middle of an investigation which had yet to yield any findings.

6.656

To summarise, my view is that when dealing with specific allegations of harm to children, such as the one with which Haringey were presented on 1 November 1999, there a number of steps which must be taken immediately. I set out a list of the immediate action which should have been taken on Victoria's case and which provide a practical template for use in such cases:

•

During the same day that the allegations were made, both Victoria and Kouao should have been seen and spoken to at a mutually agreed safe place by a properly trained police officer and social worker.

•

Kouao should have been spoken to first and a detailed note made of what she had to say at that time.

•

Victoria should then have been interviewed with the use of a video camera.

•

If, during the course of that interview, Victoria had made allegations about Manning, he should have been arrested and interviewed by the police. At that point consideration should have been given to obtaining medical and legal advice.

•

Social services should then have taken steps to find safe and secure accommodation for Kouao and Victoria. This would involve satisfying themselves that the sleeping arrangements would be adequate and that they would have sufficient means of supporting themselves. Emergency contact details should have been provided.

•

Social services and the police should then have reviewed the work they had done and agreed a set of next steps in the investigation.