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Paragraphs: 13.1 - 13.12
| 13.13 - 13.24 | 13.25 -
13.37 | 13.38 - 13.46 | 13.47
- 13.61 | 13.62 - 13.71
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13.1
|
Between 4.30pm and 5.15pm on 14 July 1999, PC Rachel Dewar received
a telephone call from Michelle Hines, a social worker from Brent
Social Services. According to PC Dewar, Ms Hines told her that Victoria
was in the Central Middlesex Hospital suffering from bruised feet,
arms, legs and buttocks, infected bruises on her fingers, and bloodshot
eyes. PC Dewar was told that the medical staff at the hospital considered
these to be "serious non-accidental injuries". PC Dewar was also
told that Victoria had been taken to hospital by a childminder who
had become concerned as to the cause of her injuries.
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13.2
|
PC Dewar happened to pick up the phone when Ms Hines rang, and
so it seems this is why she became the officer in the case. There
was no formal system within Brent Child Protection Team (CPT) for
incoming referrals to be screened and assessed by a supervisor before
being allocated to officers. Although Sergeant (Sgt) David Smith
said he and Sgt John Gorry checked entries on the crime-recording
computer database, CRIS, on a daily basis, an investigation could
be well under way before a supervisor became aware of it. It also
seemed to be the case that whoever happened to take the initial
referral would end up dealing with the case.
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13.3
|
In my view, such a practice carries with it two important disadvantages.
First, it may lead to an already overloaded officer taking on more
work when a colleague may be better placed to give the referral
the required attention. Second, it deprives the team of a mechanism
for filtering referrals to make sure valuable police time is not
wasted dealing with matters that are not serious enough for police
attention.
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|
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13.4
|
At the time it came to deal with Victoria's case, Brent CPT was
housed in rather scruffy accommodation in Edgware police station,
which it shared with Harrow CPT. The accommodation and the facilities
provided for the teams were, like those for many CPTs in London,
of a poor standard. Detective Inspector (DI) Michael Anderson, the
officer in charge of the team, thought the accommodation was "distinctly
bad" when compared with the Metropolitan Police Service (MPS) as
a whole, but average for CPTs across the capital. However, I heard
no evidence to suggest that the standard of the team's accommodation
affected the way Victoria's case was dealt with, and DI Anderson
expressly stated that, in his view, it was not responsible for the
failings in Victoria's case.
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13.5
|
I heard a great deal of evidence from the MPS witnesses about the
training of individual officers and their career profiles before
joining the CPTs. I am satisfied that it is highly desirable for
officers engaged in child protection investigation work to have
some experience in, or knowledge of, criminal investigation. Experience
or knowledge would normally be gained by a period of time as a detective
in a CID office, but uniformed officers who have worked in, for
example, street crime units may also gain the necessary experience.
Therefore, it is useful to consider the training and experience
of the Brent CPT officers who were directly involved in Victoria's
case.
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13.6
|
Brent CPT was made up of one detective inspector, two sergeants
and six police constables. The training and career profile of the
officers directly involved in Victoria's case are as follows.
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|
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13.7
|
DI Anderson joined the force in 1971. By the time he gave evidence
he had retired, but during the relevant period he had 28 years'
police service, of which 25 years were spent in various CID roles.
He was therefore a 'career detective' and he had been the DI in
charge of Brent CPT since 1996. He had received no training specifically
in child protection work, but clearly he was a very experienced
crime investigator and had attended the CID foundation course. DI
Anderson considered Detective Chief Inspector (DCI) Philip Wheeler
to be his immediate line manager, even though they rarely saw each
other. At the time with which I am concerned, DI Anderson was also
the officer in charge of Harrow CPT, also based in Edgware police
station.
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13.8
|
Sgt Gorry joined the police service in 1975. He has never been
a detective but has worked as a uniformed constable in local crime
squads and the MPS clubs and vice squad. These roles would have
given him some experience of criminal investigation. He said he
felt adequately equipped to carry out the role of supervisor, but
felt hampered by his lack of training. In particular, the fact he
had received little child protection training and no CID training
led him to feel ill- equipped to supervise some of the more involved
criminal investigations.
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|
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13.9
|
Sgt Smith has been a police officer since 1980. He spent 10 years
as a uniformed constable in various stations, including three years
in a district crime squad in Camden. As a sergeant, he spent a period
of time in charge of a reactive team dealing with all crime in the
Harrow shopping centre. In these two posts he should have gained
a reasonable amount of expertise in dealing with and supervising
crime investigation. He had attended a two-week child protection
course in 1996 but had not undertaken the CID foundation course.
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13.10
|
PC Dewar was the officer from Brent CPT designated to investigate
the crimes against Victoria. She joined the MPS in 1993 and, after
serving for two and a half years as a uniformed beat constable,
she successfully applied for a posting with a domestic violence
unit. In July 1998, she transferred to Brent CPT. Therefore, by
the time she was dealing with Victoria, she had one year's CPT experience
and virtually no experience of criminal investigation. She had never
attended the CID foundation course and it would appear that her
only relevant training was a three- day child protection course
in December 1998.
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13.11
|
Despite her job description saying that she should carry out the
investigation of crime handed to her, I do not consider that PC
Dewar had sufficient training or experience to qualify her to deal
with a case of Grievous Bodily Harm (GBH). Her first-line supervisors
were slightly better qualified, but with an inexperienced case officer
it is vitally important to have first-line supervisors with plenty
of experience of the requirements of criminal investigation. This
was not the case in Brent CPT. The officer in charge, DI Anderson,
was undoubtedly qualified to manage officers engaged in serious
crime investigation, but he was expected to control two child protection
units, consisting of around 20 officers and support staff.
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13.12
|
When invited to comment on the lack of training received by the
officers in his team, Sgt Smith said, "I view it as a failure of
the Metropolitan Police to train its officers properly for the most
important task they could possibly do." I have considerable sympathy
with Sgt Smith's view on this matter, and I conclude that the MPS
had indeed failed to ensure that the team charged with the investigation
of Victoria's case had sufficient experience in the detection and
investigation of serious crime. As a result, Brent CPT was not able
to offer an adequate service to victims of child abuse in Brent.
|
|
Paragraphs: 13.1 -
13.12 | 13.13 - 13.24 | 13.25
- 13.37 | 13.38 - 13.46 | 13.47
- 13.61 | 13.62 - 13.71
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13.13
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After taking the referral, one of the first things that PC Dewar
did was to begin an entry on CRIS. In the box that asks for details
of the allegation, she entered "assault S.18". This is shorthand
for 'Wounding with intent to cause Grievous Bodily Harm', an offence
under section 18 of the Offences Against the Person Act 1861. Other
than homicide, this is the most serious assault there is, and it
is significant that PC Dewar believed it was an offence of this
importance that was being reported to her by social services. In
her oral evidence, PC Dewar stood by the classification of the offence
she made on the basis of the information given to her by Ms Hines.
PC Dewar also noted on CRIS that the mother was the likely suspect.
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13.14
|
Therefore, it is apparent that by just after 5pm, PC Dewar knew
she was the investigating officer for a serious crime, that the
victim was in hospital with multiple injuries, that there was an
important witness in the form of the childminder who had taken the
child to hospital, and that a suspect had been identified but not
accounted for.
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13.15
|
Apart from leaving a message with the police photographic department
asking them to take photographs of Victoria's injuries some time
in the future, and doing a police database check to see if the family
were known, PC Dewar did absolutely nothing to begin investigating
the crime before she went off duty at 7pm.
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13.16
|
As a result, vital hours were lost. When a crime comes to the attention
of the police, the period immediately afterwards can often be critical
to the effectiveness of the investigation. Unless prompt action
is taken, forensic evidence can disappear, tracks can be covered
and witnesses can be intimidated or coached. When dealing with a
possible serious assault against a child, it will never be appropriate,
in my view, simply to leave the matter until the following day.
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13.17
|
Having decided against investigating the possible crime committed
against Victoria that evening, PC Dewar instead agreed with Ms Hines
to place Victoria under police protection. This course of action
was taken before Victoria had been seen and before any assessment
of her circumstances had been made. In my view, this is a wholly
inappropriate way to proceed. Taking a child into police protection
is a serious step. It is unthinkable that a proper assessment of
the need for protection could be made before the child concerned
has been seen and his or her circumstances have been assessed. I
therefore make the following recommendation:
|
|
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Recommendation
|
|
|
Save in exceptional circumstances, no child is to be taken into
police protection until he or she has been seen and an assessment
of his or her circumstances has been undertaken.
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13.18
|
One of the requirements of section 46 of the Children Act 1989
is that when a child is taken into police protection, both the child
and parent are informed of the reasons why this course of action
has been taken. It also requires a 'designated officer' to investigate
the circumstances of the case in order to determine whether police
protection is appropriate. Neither of these steps would appear to
have been taken in Victoria's case. Instead, the hospital was simply
informed by means of a faxed 'Form 72' that Victoria was now in
police protection and must remain in the hospital as an inpatient.
This was an inadequate way of dealing with such a serious matter.
It was done without any discussion with a doctor to find out if
there was a medical need for her to stay in hospital, or for how
long she could stay.
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13.19
|
The use of police protection and the lack of procedures followed
in its application in Victoria's case are considered in detail at
paragraph 13.67.
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|
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13.20
|
It is worth spending time to examine what would have happened if
the victim of this possible GBH had been an adult, rather than a
seven-year-old child. It was clear from listening to the evidence
of the MPS senior officers that they believed there should be no
difference in the quality or timeliness of a serious crime investigation,
just because of the victim's age. Detective Chief Superintendent
(DCS) David Cox, head of the North West Crime Operational Command
Unit (OCU), was expressly asked what, if any, difference there should
be between the investigation of a suspected GBH or serious assault
on a child and a similar offence on an adult. He replied, "The police
investigations side of it is largely the same. The only other factors
would be that it would be a memorandum interview, it would be a
joint interview with social services and I believe it would be the
child protection plan issues, or those issues that are CPT related.
But the actual mechanics of gathering the evidence, preserving the
scene, arresting the suspect, getting the forensic evidence, would
be much the same."
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13.21
|
His view was echoed by Deputy Assistant Commissioner (DAC) William
Griffiths who said, "The basic ingredients of assault are very easy
and straightforward to deal with. You want the victim, the victim's
account, you want the medical evidence that supports the account,
you want to visit the scene and retrieve evidence there and then
you move on to suspects, and so on. These are basic steps that are
probably taught in lesson two at recruit school: first steps at
the report of a crime."
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13.22
|
Finally, DAC Carole Howlett, the current head of SO5 (the new Child
Protection Command Unit established in 2000), agreed with her colleagues
that there should be no difference in the quality of the investigation
of an assault against a child compared with that of an adult. In
particular, when asked how quickly she would expect a victim of
an assault to be seen by police, she replied, "Within hours, within
a couple of hours or whenever. As soon as possible. As soon as practically
possible to get there."
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13.23
|
I share the view of the senior officers that a young victim of
crime should receive the same prompt and professional service from
the police as an adult. It is plainly a cause of serious concern
that this does not appear to have been the case with regard to Victoria.
On the evening of 14 July 1999, there was every reason to believe
that Victoria was a victim of serious crime. Even so, PC Dewar not
only went off duty without carrying out a proper investigation,
but she also decided to continue with plans to attend a seminar
the following day. I find it difficult to believe that this approach
would have been adopted if it had been an adult victim of GBH lying
in hospital with multiple injuries. Indeed, I was expressly told
by PC Dewar that, had she received a referral concerning a case
of GBH in the street during her time as a beat officer, she would
have visited the hospital to see the victim.
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13.24
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Such discrepancies in the standards of service provided by the
police are, in my view, obviously unacceptable. Crimes against children
are every bit as serious as crimes against adults, and they demand
the same prompt and efficient response. To address this worrying
state of affairs, I make the following recommendation:
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|
|
Recommendation
|
|
|
Chief constables must ensure that crimes involving a child victim
are dealt with promptly and efficiently, and to the same standard
as equivalent crimes against adults.
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|
Paragraphs: 13.1 -
13.12 | 13.13 - 13.24 | 13.25
- 13.37 | 13.38 - 13.46 | 13.47
- 13.61 | 13.62 - 13.71
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13.25
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The fact that PC Dewar decided to attend the seminar, even though
Victoria's case had yet to be investigated, presumably meant that
PC Dewar did not anticipate starting the investigation until the
following day - nearly 48 hours after Avril Cameron had first raised
her concerns at the hospital.
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13.26
|
In fact, an investigation should have begun straight away. Interviews
with Ms Cameron, Kouao and Victoria should have been essential elements
of the investigation. I deal with each in turn.
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|
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13.27
|
When she was asked why she did not urgently seek out and speak
to Ms Cameron, PC Dewar replied, "Because I did not think there
was anything I needed to urgently speak to Avril Cameron about from
the information I had in the referral." When pressed further on
the issue, she went on to say, "Well, we would have done but I felt,
on the information I had, that Avril Cameron had communicated to
the medical staff, that there was nothing in that referral, she
did not say who the perpetrator was."
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13.28
|
I have to say that I detect little sense in either of those two
answers. When it was pointed out to PC Dewar that perhaps nobody
had asked Ms Cameron who the perpetrator of the assaults against
Victoria was, she blamed the medical staff at the hospital. She
said she would have expected them to have obtained such information
from Ms Cameron if it had been available.
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13.29
|
Later, in her evidence to the Inquiry, PC Dewar said she was aware
that social services were going to speak to Ms Cameron. If this
was indeed her reason for not interviewing Ms Cameron herself, PC
Dewar would appear to have been happy to leave the interviewing
of the most important witness (other than the victim herself) to
hospital staff and social workers, none of whom were trained to
ask the right questions in a criminal investigation. This was, in
my view, a crucial error of judgement on the part of PC Dewar. Had
Ms Cameron been asked the right questions, the police could have
obtained the following valuable information, all of which was within
Ms Cameron's knowledge:
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•
|
Victoria was not attending school.
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•
|
Kouao often became very angry towards Victoria and acted aggressively
towards her.
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•
|
Victoria would regularly wet herself when taking a nap at Priscilla
Cameron's house.
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|
•
|
Ms Cameron had asked Kouao about the cuts on Victoria's hands and
Kouao had told her that Victoria cut herself with razor blades.
|
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•
|
Kouao had asked Priscilla Cameron to look after Victoria permanently
because the man she was staying with did not want Victoria around.
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•
|
On the night Kouao dropped Victoria off at the Camerons' house,
Ms Cameron noticed that Victoria had a cut above her eye, a healing
wound on her cheek, and two bloodshot eyes.
|
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•
|
Ms Cameron had also noticed Victoria's fingers were oozing pus
and her face had swollen up.
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•
|
Marie Cader told Ms Cameron that Victoria chatted happily about
other things, but when asked about her injuries she "went into auto
pilot" and became withdrawn.
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•
|
While at the hospital, Ms Cameron had seen marks on Victoria's
legs, back and arms. She also noticed that Victoria's nails were
short and that she held her hand in a half-clenched manner.
|
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•
|
Ms Cameron had seen small circular marks on Victoria which the
doctor had told her might have been caused by cigarette burns.
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•
|
Ms Cameron had never seen Victoria scratch herself.
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•
|
Ms Cameron had taken Victoria to the hospital because she was concerned
about the seriousness of the injuries and the possible cause of
them.
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13.30
|
If PC Dewar had made proper inquiries, she would probably also
have been told of a conversation with somebody called "Nigerian
Mary", to the effect that she had asked Mrs Cameron, "What is it
you say to Kouao that makes her beat the child each night?"
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13.31
|
In summary, the police would have quickly gained a clear indication
that child abuse may have been taking place, and that Kouao was
the perpetrator.
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|
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13.32
|
In addition to being content for nurses, doctors or social workers
to interview Ms Cameron, PC Dewar was prepared to allow social services
to speak to Kouao alone. She accepted that Kouao was the main suspect,
yet wanted a social worker to speak to Kouao in the first instance
in order to "obtain her account" - this being a woman who was suspected
of having caused GBH to her seven-year-old child. I find it extremely
surprising that PC Dewar should have felt this was an appropriate
manner in which to proceed with the investigation, especially given
the disadvantages of questioning a suspect in any way but with the
Codes of Practice set out in the Police and Criminal Evidence Act
1984.
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|
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13.33
|
I am firmly of the view that PC Dewar should have visited Victoria
during the evening of 14 July 1999. She was questioned at length
about her decision not to do so and gave various answers, of which
the following is representative: "I have been told that I should
not see the child before the memorandum interview. I knew that Ms
Hines would see the child the next day."
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13.34
|
PC Dewar explained that the usual sequence of events in child protection
investigations was, as far as she was aware, first to interview
the victim and then to carry out any further work depending upon
the outcome of the interview. In other words, the investigation
should not even start until the child had been spoken to. In order
for this approach to have anything other than a seriously damaging
effect on the usefulness of the investigation, it is plainly necessary
that children who are capable of giving evidence about what has
happened to them are seen as soon as possible. Therefore, PC Dewar's
suggestion that she would not necessarily have sought to interview
Victoria until she was discharged from hospital is extremely worrying.
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13.35
|
I also reject PC Dewar's claim that it would have been inappropriate
for her to see Victoria before a memorandum interview had taken
place. The established practice in 1999 was that the police, when
dealing with suspected crimes against children, would interview
the children concerned in a special video interview suite, in accordance
with the government guidelines called The Memorandum of Good
Practice. However, in cases where a child victim is in hospital,
a degree of flexibility is necessary. It may have been open to PC
Dewar to conclude it was inappropriate to conduct a full interview
with Victoria in a hospital setting. However, she should not have
made this decision without visiting Victoria and assessing her circumstances
with a view to deciding on the appropriate location and timing of
the interview. During the course of such an assessment, she should
also have considered the chances of recovering forensic evidence
from Victoria or from her clothing.
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13.36
|
The Police and Criminal Evidence Act 1984 Codes of Practice (Code
C, note 1B) expressly allows the police to speak to any person who
can help with their inquiries. However, the MPS Child Protection
Course Training Manual, dated 1995, advises that, except in
urgent cases, interviews with children can only take place with
the consent of a parent or guardian. Given this apparent confusion,
and assuming that PC Dewar was familiar with the requirements of
the manual, it is perhaps not surprising she formed the view that
it would be inappropriate for her to see Victoria until she had
been given the go ahead to do so by Ms Hines. However, there is
no excuse for her failure to interview, and take full statements
from, the medical staff involved.
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13.37
|
In addition to interviewing the key witnesses, PC Dewar should
also have visited the scene of the possible abuse. By the time Victoria
was admitted to the Central Middlesex Hospital, she was living in
Manning's flat at 267 Somerset Gardens. One can only guess at what
may have been found at the scene if it had been properly searched
and examined at this point. However, it is conceivable that some
evidence of deliberate harm may have been detected as early as mid
July, if the police had tried to look for it. If such evidence had
been found, then events may have followed a radically different
course.
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|
Paragraphs: 13.1 -
13.12 | 13.13 - 13.24 | 13.25
- 13.37 | 13.38 - 13.46 | 13.47
- 13.61 | 13.62 - 13.71
|
|
|
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13.38
|
I turn now to consider why Brent CPT's investigation, such as it
was, ended so abruptly.
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13.39
|
At around 10.30am on 15 July 1999, PC Dewar was at the training
seminar at Bushey. She said she was expecting a call from Ms Hines
to say that social services had spoken to the mother and obtained
her account of how Victoria had received her injuries and her permission
to speak to Victoria. Plainly, as far as PC Dewar was concerned,
the investigation at this stage was in the hands of social services.
However, instead of receiving the expected message, PC Dewar was
told by Ms Hines that Dr Ruby Schwartz had examined Victoria and
concluded that all her injuries were due to scabies.
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13.40
|
However, it is likely that this was an incomplete summary of Dr
Schwartz's views, and that if PC Dewar had chosen to question Dr
Schwartz, she would have discovered that Dr Schwartz had some lingering
concerns about Victoria that she expected to be followed up by social
services. More importantly, if Dr Schwartz had been questioned more
closely, it would have become clear that she had not satisfactorily
accounted for all the marks that had been noted on Victoria's body,
so that physical harm remained a possibility.
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13.41
|
I find it remarkable that PC Dewar was prepared to accept, without
question, the reported diagnosis of scabies as an explanation for
all of Victoria's injuries, particularly because she had described
these injuries on CRIS the night before as including multiple bruising
on feet, arms, legs and buttocks, infected bruising on her fingers,
and bloodshot eyes. If she had applied her mind to the matter, it
seems highly likely she would have realised that a scabies diagnosis
left several of the reported injuries unexplained.
|
|
13.42
|
The evidence of PC Dewar, together with that of a number of her
colleagues, indicated a profound reluctance to challenge the diagnosis
of a consultant paediatrician. In order to test the extent of that
reluctance, Counsel to the Inquiry asked PC Dewar if she would have
accepted a diagnosis of scabies if the child had a broken arm. PC
Dewar replied that of course she would not. In re-examination, her
Counsel went as far as to say that the analogy was plainly absurd.
However, I found it useful because it demonstrated to me that a
police officer would feel able to challenge an improbable medical
diagnosis. The question raised by PC Dewar's handling of Victoria's
case is how improbable that diagnosis would have to be before an
officer might be prepared to exercise his or her own independent
judgement.
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13.43
|
In my view, social workers and child protection police officers
are specialists in child protection. Doctors specialise primarily
in dealing with the medical needs of sick children, so they are
often able to give child protection investigators opinions as to
the cause of injuries. However, the final analysis of the significance
and interpretation of those injuries must be made by the practitioners
who have the benefit of looking at the whole picture (including
the wider family circumstances), any forensic evidence and the experience
of the carers.
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|
13.44
|
It is wrong for social workers or police officers to blindly accept
everything they are told by doctors, no matter how important those
doctors are, and they must fit the medical evidence in with the
other information available before arriving at their own conclusion.
It was entirely inappropriate for PC Dewar to completely abandon
such a serious investigation because of a third-hand medical report
told to her over the telephone.
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|
13.45
|
Also, PC Dewar had written in the original CRIS entry, "Doctors
consider the injuries to be serious non-accidental injuries" and
so would have been aware that the reported diagnosis of Dr Schwartz
differed from that of the doctors who had examined Victoria the
day before. The fact that there was a divergence of medical opinion
as to the cause of Victoria's injuries should have led PC Dewar
to question Dr Schwartz about her differing opinion.
|
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13.46
|
However, having received the call from Ms Hines, PC Dewar immediately
lifted the police protection and later marked up the CRIS entry
as "no crime". Regrettably, she also cancelled the one positive
step she had taken the previous evening, which was to arrange for
police photographs to be taken of Victoria's injuries. This last
action may have been important, because if PC Dewar had kept an
open mind and obtained the photographs, then perhaps her supervisor,
or one of her social services colleagues, may have seen them and
felt suitably concerned to query Dr Schwartz's diagnosis. Certainly,
as events were to unfold, the photographs would have been extremely
useful a few days later, when a further set of injuries was being
pondered over.
|
|
Paragraphs: 13.1 -
13.12 | 13.13 - 13.24 | 13.25
- 13.37 | 13.38 - 13.46 | 13.47
- 13.61 | 13.62 - 13.71
|
|
|
|
13.47
|
Responsibility for failing to undertake any adequate investigation
into the possible crime committed against Victoria cannot rest with
PC Dewar alone. As I have already indicated, she was a junior officer
with very little experience in the investigation of serious crime.
In such circumstances, her handling of this referral should have
been closely supervised by more senior officers.
|
|
13.48
|
The officer best placed to do so was her first-line manager, Sgt
Gorry. Sgt Gorry said that he remembered hearing PC Dewar take the
referral concerning Victoria and that she told him it related to
a "serious assault, possibly a GBH, on a young girl". He said in
evidence, "I remember the call coming in. I remember Rachel's reaction
to the phone call and I can remember sort of reacting to it and
thinking this is something quite important, quite serious."
|
|
13.49
|
PC Dewar made no mention of any discussion with Sgt Gorry, although
she did state that Sgt Gorry gave her permission to work one hour's
overtime on the evening in question, perhaps because he knew she
had an important referral to deal with.
|
|
13.50
|
However, it would appear that Sgt Gorry took little interest in
Victoria's case and did not set down a plan of action for the investigating
officer to follow. He was aware that another officer, PC Karen Blackman,
was planning to assist PC Dewar with the referral, but despite being
on duty throughout the evening, he appears to have left them to
their own devices. When Sgt Gorry was asked what he did to satisfy
himself that these two junior officers were conducting a proper
investigation of this serious offence, he replied, "Other than the
fact that I had spoken to them at the initial stages and was aware
that they were carrying out the investigation what appeared to be
diligently and effectively, nothing more. The reasoning behind that
is that I have considerable confidence in the ability of both officers
to have come to the right decision."
|
|
13.51
|
Plainly, Sgt Gorry's confidence was misplaced. His explanation
for why he failed, the following day, to ask either of the officers
what progress they had made in the investigation of the referral
was that he was aware that PC Dewar had spoken directly to DI Anderson
in the meantime. Sgt Gorry explained, "When I was at the seminar
the following day, PC Dewar addressed Detective Inspector Anderson
about the matter and it was really not my position to intervene
and find out additionally what course of action she was going to
take because I assumed, quite reasonably I feel, that the issues
would have been covered, discussed and addressed in the conversation
that she would have had with Detective Inspector Anderson."
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13.52
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I am firmly of the view that any referrals of suspected child abuse
to the police from social services should be handled at a managerial
level, and that a manager from each agency should be involved in
discussing how best to take the investigation forward. The danger
of doing otherwise is that a junior officer would have to conduct
an investigation as he or she sees fit with minimal input from more
senior experienced officers. The inevitable risk would be that important
decisions are incorrectly taken, causing the whole investigation
to be seriously flawed. Such risks can, in my view, be reduced by
the involvement of experienced managers in the investigative process.
Therefore, I make the following recommendation:
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Recommendation
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Whenever a joint investigation by police and social services is
required into possible injury or harm to a child, a manager from
each agency should always be involved at the referral stage, and
in any further strategy discussion.
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13.53
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Sgt Gorry refused to accept that he should bear any blame for failing
to supervise any investigation of Victoria's case. I do not share
his view. It seems to me that one of the principal functions of
a sergeant in a child protection team is to supervise the investigation
of crime by more junior officers. I believe Sgt Gorry should have
taken a firm grip of this investigation as soon as the referral
was taken. He should have agreed with PC Dewar a plan of action
that had a clear timescale in which the work should have been carried
out. Indeed, it is difficult to see why Sgt Gorry did not take any
active part in the inquiry himself, perhaps by visiting the hospital
that evening with PC Dewar. He was on duty until l0pm that night,
and although he mentioned that he had to make a telephone call to
America during the evening, it is hard to imagine that this should
have taken precedence over ensuring that such a serious referral
was being properly investigated.
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13.54
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When Sgt Gorry was asked if an "S.18" assault should not have been
dealt with by someone more senior than a PC, he replied, "I think
in the scheme of the investigations that have been dealt with in
Brent, yes it is a serious assault. But initially I think it will
be fair to say that there were no complexities about it and, had
there been complexities within it, then obviously the supervisor
would have overseen it or taken over, but at that initial stage
it was something that I personally felt that the combined skills
and abilities of PC Dewar and Blackman were able to deal with the
initial investigation." I reject Sgt Gorry's assertion that Victoria's
case was neither serious or complex enough for him to have become
involved, and I was surprised to hear that he continues to think
so.
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13.55
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My view is that the skill and judgement that an experienced officer
can bring to an investigation is of vital importance, particularly
in making sure that matters get off to a good start. I consider
that it should always be the case that such an officer is involved
from the outset in investigations involving serious crimes against
children. Therefore, I make the following recommendation:
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Recommendation
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In cases of serious crime against children, supervisory officers
must, from the beginning, take an active role in ensuring that a
proper investigation is carried out.
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13.56
|
PC Dewar spoke to DI Anderson, but could not remember if it was
before or after she received the message from Ms Hines concerning
the diagnosis from Dr Schwartz. For his part, DI Anderson was also
unable to remember. However, it would seem unlikely that he made
a considered assessment of the case before the telephone call from
Ms Hines, especially since he told me that, had he known Victoria
was in hospital and nothing had been arranged, he would have instructed
PC Dewar immediately to formulate a proper strategy with social
services and organise for a plan of action to be put in place. Therefore,
it is more likely that PC Dewar spoke to DI Anderson after her telephone
call with Ms Hines, and presented him with an open and shut case,
in as much as she already believed the diagnosis of Dr Schwartz
ended the need for a criminal investigation.
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13.57
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What emerges is a picture of blurred and confused management roles,
with nobody taking responsibility for ensuring that an investigation
takes place. Sgt Gorry was aware that the referral had come in,
but gave no directions as to what action he expected to be taken.
Once he knew DI Anderson had been consulted, he ceased to take any
active interest.
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13.58
|
When the case was mentioned to him the following day, DI Anderson
probably did not grasp how serious the case had been viewed the
evening before and, hearing about the scabies diagnosis, thought
it was a formality for PC Dewar to lift the police protection and
mark the investigation as complete on CRIS. Nonetheless, in my view,
DI Anderson should have taken much greater care to explore with
PC Dewar the extent to which she had properly investigated the case
before lifting police protection. He should also have directed that
a written medical opinion be obtained from Dr Schwartz.
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13.59
|
The last occasion on which a supervisor had anything to do with
the investigation was on 10 August 1999, when Sgt Smith checked
the CRIS report to see if it was ready to close. He said that, having
read the contents of the report, he was satisfied that it could
be closed. When asked what he understood his role to be in checking
the CRIS report before closure, he replied, "I wanted to make sure
that the matter had been investigated. I wanted to make sure that
the statutory checks had been carried out." When asked whether he
was satisfied this had been done after reading this particular report,
he replied, "I could see that it had come in initially as a quite
serious allegation, that the following day there had been discussions
that had taken place between the hospital, the social services,
between the officer of the case and the Detective Inspector and
that a decision had been made to - I do not want to use the word
downgrade - but to change the classification to 'no crime'. When
I saw that that had taken place and that there was no further explanation
required by police, when I saw that report then I closed it."
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13.60
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Clearly, Sgt Smith did no serious analysis of the case or any cross-checking
to see whether PC Dewar's understanding of the medical evidence
was correct. If he had, he would quickly have found out that Dr
Schwartz did have ongoing concerns for the child and that there
were injuries which could not have been accounted for by scabies.
It is also disturbing that a case that started off as being so serious
could be closed without a written, detailed, medical report being
examined by a supervisor.
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13.61
|
Also, in common with his colleague Sgt Gorry, Sgt Smith placed
a lot of importance on the fact that DI Anderson had apparently
agreed the decision to "no crime" the case. Therefore, Sgt Smith's
input amounted to no more than a 'rubberstamping' exercise, compounding
the poor decision-making and supervision of others. Ironically,
at the very time that Sgt Smith closed the CRIS entry in Brent,
Victoria was being discharged from a hospital in the neighbouring
borough, having suffered a further set of serious injuries.
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Paragraphs: 13.1 -
13.12 | 13.13 - 13.24 | 13.25
- 13.37 | 13.38 - 13.46 | 13.47
- 13.61 | 13.62 - 13.71
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13.62
|
In trying to find an explanation for the lack of useful action
by Brent CPT, I was helped by another exchange between PC Dewar
and her Counsel. He asked her, "In a multi-agency investigation
such as this, who did you understand the lead agency to be?" PC
Dewar replied that she understood it to be social services.
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13.63
|
This was a view she held in common with several other police officers
who gave evidence to the Inquiry. If the impression given by their
evidence is representative, it would appear that child protection
officers, for some considerable time, have been unsure about exactly
where they fit within the Working Together system and what
their precise responsibilities are in the investigation of the possible
deliberate harm of a child.
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13.64
|
The principal function of the police is the prevention and detection
of crime. I entirely reject the notion that the police should seek
to avoid their responsibility to conduct a swift and thorough criminal
investigation by hiding behind the excuse of others being the 'lead
agency'. The police are the 'lead agency' in a criminal investigation,
and I am concerned that the good intentions of multi- agency decision-making,
information sharing and joint working may have now led to a blurring
of roles, uncertainty about who should take what action, and a convenient
excuse for poor investigation. PC Dewar's view that social services
were the lead agency in the investigation of Victoria's case would
appear to be reflective of a common view held by child protection
officers in the MPS.
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13.65
|
When Victoria came to notice in Brent, social services had an important
role to play and should undoubtedly have taken a lead in co-ordinating
the various strands of information which were becoming available.
However, there should have been a parallel police investigation
into the serious crime reported against Victoria, and the evidence
gathering exercise for that should have been led, and in large measure
conducted, by the police.
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13.66
|
The MPS, and the police service generally, needs seriously to examine
its role in child protection investigations. As with other types
of crime, it must take responsibility for gathering the necessary
evidence. In order to advance this objective, I make the following
recommendation:
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Recommendation
|
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The Association of Chief Police Officers must produce and implement
the standards-based service, as recommended by Her Majesty's Inspectorate
of Constabulary in the 1999 thematic inspection report, Child
Protection.
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13.67
|
Finally, I turn to the issue of police protection. Section 46 of
the Children Act 1989 provides a power for a police officer to remove
a child into police protection, or cause the child to remain in
a safe place such as a hospital, if there is evidence that the child
is at risk of significant harm. A crucial safeguard for the child
and the family is that an independent supervisory officer, known
for these purposes as the 'designated officer', assesses the action
taken and ensures that there is a need to remove the child from
the control of the carers, and to inform the relative parties why
the steps were taken. The Home Office issued guidance to the police
service in the form of circular 54/91, which suggested that the
designated officer role was most appropriately carried out by an
inspector.
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13.68
|
In Victoria's case, PC Dewar acted as the actioning officer as
well as the designated officer for the purposes of police protection.
It was clear from her evidence to this Inquiry that, when dealing
with Victoria's case, she was unaware that the Home Office circular
required these roles to be separate and filled by different officers.
I heard evidence from senior officers in the MPS to the effect that
they had acknowledged their failure to comply with government guidance
on this issue and that this had now been corrected. I will therefore
restrict myself to urging all police forces to ensure that they
operate within Home Office guidelines relating to police protection,
that a clear understanding of the designated officer's role is established,
and that they comply with the following recommendation:
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Recommendation
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Police forces must review their systems for taking children into
police protection and ensure they comply with the Children Act 1989
and Home Office guidelines. In particular, they must ensure that
an independent officer of at least inspector rank acts as the designated
officer in all cases.
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13.69
|
It is doubtful whether there was a need to take Victoria into police
protection at all. This is due to the fact that there was no known
threat from Kouao that she would seek to remove Victoria from hospital.
However, having taken this action, if an independent inspector had
been overseeing the case, as laid down in the Children Act 1989
and the Home Office circular, there is a chance that he or she would
have spotted the deficiencies in the way the case was being handled,
and prevented the police protection from being lifted until a proper
investigation had taken place.
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13.70
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I am also concerned about the fact that Victoria was taken into
police protection over the telephone, and with no police officer
having been to see her. Examination of the Children Act 1989 and
Home Office guidance does not reveal any specific instruction that
the child must be seen before taken into police protection. However,
I believe it is poor practice for this not to happen. For the police
to deny a parent access to their child is a serious step and requires
the most searching examination of the need to take such action.
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13.71
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Whether or not the child needs to be seen, the legislation and
guidance is clear that both the child and his or her carer must
be told why police protection has been implemented. No attempt was
made by any of the officers concerned with this case to explain
either to Victoria or to Kouao why this step had been considered
necessary.
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