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Paragraphs: 7.1 - 7.13
| 7.14 - 7.20 | 7.21 - 7.27
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7.1
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In drafting this section of the Report I was greatly helped by
the closing submissions made by Counsel to the Inquiry. They seem
to me to summarise accurately the material evidence, and I have
drawn on them heavily in the paragraphs that follow.
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7.2
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The Tottenham Child and Family Centre was situated in Moira Close,
Tottenham, and was one of two centres established under a partnership
agreement between Haringey council, Haringey Health Care NHS Trust
and the NSPCC.
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7.3
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The managers of the centres were employees of either the council
or the health authority, but they reported to Catriona Scott who
was employed by the NSPCC and was responsible for the day-to-day
management of the centres. According to Ms Scott, "The main function
of the family centres was to provide planned family services relating
to health and welfare."
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7.4
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On 5 August 1999, Victoria's case was referred to the Tottenham
Child and Family Centre by Barry Almeida, a practice manager at
the North Tottenham District Office of Haringey Social Services.
He had no independent recollection of having made the referral,
basing his evidence instead on the handwritten notes he made on
the case file, the relevant part of which reads: "Referred to Moira
Close Family Centre. They have taken referral but say will take
up to two months for assessment."
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7.5
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Mr Almeida's note also indicates that the family centre was, in
fact, the third organisation that he had contacted in an effort
to persuade someone to visit Victoria's accommodation. His first
port of call would seem to have been the health visiting service
that, according to the notes, informed him that they would "not
be involved in hygiene assessment of this nature. It would be the
school nurse". As Mr Almeida correctly recorded in his notes, this
posed something of a problem given the fact that Victoria was not
attending school.
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7.6
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There is nothing to suggest that the point was pushed with the
health visiting service. Instead, Mr Almeida tried the environmental
health service. His notes indicate that the response he got from
them was to be told that people are "allowed to be as squalid as
they like in their own home, as long as they do not cause a public
health hazard". For this reason, it would seem, they also were not
prepared to undertake a visit.
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7.7
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Having drawn a blank with both the health visiting service and
the environmental health service, Mr Almeida decided to try the
family centre. In addition to the notes he made on Victoria's case
file, the fact that it was indeed Mr Almeida who made the call would
seem to be confirmed both by the written evidence of Anna Ieronimou,
the family centre officer who took the referral, and by the family
centre's own referral sheet, which names Mr Almeida as the referrer.
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7.8
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However, what is less clear is what Mr Almeida hoped to achieve
by making the referral. There would seem to be two possibilities.
He initially stated in his oral evidence that the purpose of his
call was to obtain advice from the family centre as to what precautions
Lisa Arthurworrey should take when visiting Victoria's home in light
of the fact that Victoria had previously been diagnosed with scabies.
This would appear to contradict the impression given by his statement,
which was that he telephoned the family centre because of its ability
to carry out parenting assessments and provide family support.
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7.9
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The discrepancy is plainly an important one. There is a very significant
difference between social services telephoning another agency in
order to obtain advice as to how to proceed themselves, and seeking
to transfer to that other agency some responsibility for the provision
of support services to the family concerned.
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7.10
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Unfortunately, however, when this discrepancy was put to him, Mr
Almeida was unable to provide me with much assistance. Instead,
he introduced a third possibility by suggesting that his reasons
for calling the family centre were in fact a combination of both.
In other words, he was concerned both to obtain advice for Ms Arthurworrey
and to prompt some form of action by the family centre directed
at Victoria's welfare. However, he was unclear as to what action
he expected the family centre to take.
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7.11
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The confusion as to exactly why he telephoned the centre is illustrated
by Mr Almeida's admission during the course of his evidence that
he did not really think about the referral or whether or not it
was appropriate at the time. He accepted that the referral should
not have been made until the reasons for it had been carefully thought
through, and that the lack of clarity from him probably led to the
family centre staff being confused as to what exactly they were
supposed to do.
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7.12
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Despite the confusion on the part of the referrer as to precisely
what he hoped to achieve, the family centre did pick up the referral
and log it on their system.
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7.13
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The 'system' was described by Sylvia Henry, the practice manager,
in her evidence. It would seem to have consisted of the recording
of the name of the child and the basis for the referral on a sheet
of paper. The sheet was then placed into the 'referrals box', the
contents of which were checked every Friday at a managers' meeting.
During the course of that meeting, each new referral was logged
in a book and allocated to a practice manager. The practice manager
would then decide whether to deal with the case him or herself,
or to pass it on to a family centre officer. Once that decision
had been made, the name of the manager or officer to whom the case
has been allocated was noted down in the logbook together with an
indication of the action required.
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Paragraphs: 7.1 - 7.13
| 7.14 - 7.20 | 7.21 - 7.27
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7.14
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According to Ernell Watson, a practice manager at the family centre,
Victoria's case came up for allocation at the managers' meeting
on 13 August 1999. Why it was not considered at the first meeting
after it had been received, namely Friday 6 August, is unclear.
I had originally been led to believe that the reason no meeting
took place that day was due to the family centre hosting a party
for a group of its users. However, it would appear that there was
a meeting, as evidenced by a document that appeared to be the minutes
of the 6 August meeting. Ms Watson amended her statement, in light
of this document, to remove the reference to the cancellation of
the 6 August meeting. She was unable to provide me with any further
assistance with the matter, however, due to the fact that, as the
minutes confirm, she was not present at that meeting. I am unable
to form any conclusion, therefore, as to why Victoria's referral
stayed in the family centre's referral box until the following week.
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7.15
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On 13 August 1999, Victoria's referral was allocated to Ms Henry,
a qualified social worker. Ms Henry confirmed in her evidence that,
at the time that it was allocated to her, Victoria's case was marked
as 'urgent'. There would seem to be little doubt as to whether or
not this was the case in view of the fact that Ms Watson made the
following note on the family centre's contacts sheet on 13 August
1999: "Case needs to be actioned ASAP."
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7.16
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Ms Henry explained that, on receipt of a new case, the first thing
that she would do would be to determine whether further information
was needed from the referrer or whether she could proceed directly
to an initial assessment. In Victoria's case she decided that further
information from the referrer was needed. She asserted that it would
be her usual practice when dealing with urgent cases to make such
inquiries as may be necessary within a short time. She could not
envisage circumstances where she would have been unable to follow
up an urgent referral during the course of the week following its
allocation.
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7.17
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Up to this point, it seems as though the sequence of events can
be followed fairly easily. Mr Almeida made a referral to the family
centre on 5 August. The family centre had agreed to accept the referral.
It was taken by Ms Ieronimou and was placed in the referrals box
pending allocation. At the managers' meeting on 13 August the referral
was taken out of the referrals box and allocated to Sylvia Henry
for urgent action. Ms Henry accepted responsibility for the referral.
Having considered the information available at that stage, she decided
(unsurprisingly, given Mr Almeida's vagueness as to what he expected
the family centre to do) that more information was required from
the referrer. She was aware of the need, therefore, to contact Mr
Almeida at the earliest available opportunity during the following
week.
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7.18
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It is at this stage, however, that the evidence becomes slightly
opaque. The source of the difficulty is the next note which appears
on the family centre's contact sheet. It reads: "T/C Barry Almeida.
Family now moved out of the borough and case closed." The note is
not signed but Ms Henry did not seek to dispute the fact that she
made it. Neither, unfortunately, is it dated. This latter omission
is significant.
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7.19
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Ms Henry stated in evidence that her departure from her usual practice
of signing and dating all entries on the file can only be explained
by her being interrupted at the critical moment. Unfortunately,
she seemed to have no recollection of when her conversation with
Mr Almeida, in which she was told that the 'family' had moved out
of the borough, took place. Mr Almeida was clear in his evidence
that the only phone call that he made to the family centre was on
5 August 1999 when he made the initial referral. No written reference
to any other telephone call either to or from the family centre
can be found in Haringey's case file.
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7.20
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The most curious aspect of Ms Henry's note, however, is not the
fact that it refers to a telephone call (the existence of which
is disputed by the other party), but that it records information
that is plainly incorrect - Kouao and Victoria never did leave the
borough. Therefore, it is surprising that this assertion should
have been made by anyone in Haringey Social Services. It is even
more surprising if one were to accept Ms Henry's assertion that
she would have followed up Victoria's referral promptly after it
was allocated to her on 13 August. It is conceivable that someone
at the North Tottenham District Office might have formed the view
that Victoria and Kouao had left the borough by December 1999 or
January 2000 - this was the period during which Lisa Arthurworrey
was trying unsuccessfully to contact them. Given that this is the
case, it is very hard to see how anyone could have reached this
conclusion at any point during the three months or so after Ms Henry
assumed responsibility for the case. Furthermore, it would have
been readily apparent to anyone in the North Tottenham District
Office who took the time to check, that Victoria's case was not
closed until 25 February 2000.
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Paragraphs: 7.1 - 7.13
| 7.14 - 7.20 | 7.21 - 7.27
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7.21
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In attempting to establish the accurate position in light of these
apparent inconsistencies, Counsel to the Inquiry identified four
possible versions of events, each of which was put to Ms Henry.
They were as follows:
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Ms Henry did not follow up Victoria's referral by calling the North
Tottenham District Office until some time after 1 December 1999,
the earliest date on which it could even have been suspected by
Haringey Social Services that Victoria and Kouao had left the borough.
(It was on this date that Kouao failed to attend the North Tottenham
District Office for an appointment, without explanation.) If this
were true, Ms Henry would have done nothing on this urgent case
for at least three and a half months.
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•
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Ms Henry did call the North Tottenham District Office promptly
after being allocated Victoria's referral and was given entirely
false information by whoever she spoke to at the office. This would
mean that despite the fact that Ms Arthurworrey had visited Kouao
and Victoria on 16 August 1999, someone at the North Tottenham District
Office decided to tell Ms Henry that the family had left the borough
and the case was closed.
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The note that Ms Henry made on the family centre's contact sheet
was not an accurate reflection of what she was told. In other words,
she misheard or misinterpreted what was said and somehow gained
the impression that the family had moved. This explanation provides
no assistance with the question of when the call was made - such
a mistake could have been made at any time up to the date of Victoria's
death.
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The entry made by Ms Henry on the contacts sheet was written in
after it emerged that Victoria had died, in an effort to explain
away the fact that nothing had been done by the family centre in
respect of the referral throughout the six months leading up to
Victoria's death.
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7.22
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Having given the matter careful consideration, I am unable to add
any further plausible alternatives to Counsel's list. Which of the
four scenarios is to be preferred is not an easy question to answer.
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7.23
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Ms Henry was unable to provide much assistance in respect of this
issue. She could not remember the telephone call and she could not
say for sure what she was told and when. This is unfortunate because
the matter is a significant one. If it is the case that Ms Henry
was told relatively soon after she assumed responsibility for Victoria's
referral that Victoria and Kouao had moved and their case was closed,
the fact that no action was taken on Victoria's case by the family
centre may be easily explained.
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7.24
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Ms Henry refuted the suggestion that she added the entry after
Victoria's death in order to attempt to explain her inactivity.
She also invited me to reject the conclusion that she did nothing
on the case until some time after 1 December 1999. She agreed that
there was a possibility that she did not correctly record what she
was told during the course of the conversation that she allegedly
had with Mr Almeida but invited me to conclude that she did make
a call to the North Tottenham District Office before February 2000,
during which Mr Almeida told her that the family had moved out of
the borough and the case had been closed.
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7.25
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In attempting to reach a view on this matter I also took into account
the fact that Victoria's case was closed on the family centre's
computerised information system on 15 March 2000. This may be significant
as I was told by Ms Henry that cases tended to be closed on the
system within a month or so of them being identified as requiring
no further action by family centre staff.
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7.26
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The fact that the case was closed on 15 March 2000 may indicate,
therefore, that Ms Henry was not told that Victoria and Kouao had
left the borough until some time in February. Were this to be the
case, it might provide an explanation for why she was told that
the family had left the borough, as there had been no contact between
Kouao and anyone at the North Tottenham District Office for approximately
three months. However, it would still not explain why nothing was
done in relation to Victoria's case until six months after the referral
had first been received by the family centre.
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7.27
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Having given this matter careful consideration, I am unable to
reach a conclusion in which I have any confidence. No satisfactory
account of how and when Ms Henry's entry on the contact sheet came
to be made has been provided, and I can do no more than speculate
as to the true position.
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