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Overview of contents
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Title pages

Part one Background
1 Introduction
2 The Inquiry
3 Victoria's story

Part two Social Services
4 Ealing Social Services
5 Brent Social Services
6 Haringey Social Services
7 Tottenham Child and Family Centre
8 Enfield Social Services

Part three Health
9 Central Middlesex Hospital
10 North Middlesex Hospital
11 Health analysis
12 general Practice and liaison health visiting

Part four The police
13 Brent Child Protection Team
14 Haringey Child Protection Team
15 Child protection policing in north west London
Training
Staff Levels
Equipment
Accommodation
Accountability

Part five Working with diversity
16 Working with diversity

Part five Learning from experience
17 The seminars

Part six Recommendations
recommendations
Annexes
Annexex Crown Copyright

15 Child protection policing in north west London

Paragraphs: 15.47 - 15.58 | 15.59 - 15.63 | 15.64 - 15.75

Accountability

15.47

One of the principal problems I met in seeking to determine who was ultimately accountable for the state of the CPTs in north west London in 1999, was the conflicting evidence of senior officers as to whose job it was to ensure that the teams were adequately staffed and equipped. There would seem to be two potential candidates: the commander of the crime Operational Command Unit (OCU) in whose area the CPT was located, and the 'strategic portfolio holder' with responsibility for maintaining an overview of CPTs across London.

Commander Kendrick

15.48

The portfolio holder up to February 1999 was Commander Kendrick. His evidence did little to convince me that he had much direct knowledge or understanding of the manner in which CPTs were operating during the period he was in post. In 1998, some three years after he assumed responsibility for the CPT, he commissioned an inspection of CPTs across London as a whole. The results echoed many of the findings that I have recorded above: teams were understaffed with poorly trained officers and lacked basic equipment. Prior to this inspection, however, Commander Kendrick told me that he thought that the MPS was providing the CPTs with adequate resources and appropriately trained and qualified staff.

15.49

In my view, Commander Kendrick could not have held this view throughout the three years or so prior to the inspection unless he was anything other than seriously out of touch with the condition of CPTs on the ground. The situation in which they found themselves at the time Victoria's case came to be dealt with was not one which, in my view, could have arisen overnight, and I suspect that the conclusion of DCS Kelleher in his September 2000 report that the CPTs had suffered "ten years of neglect" is sound.

15.50

On the assumption that the deficiencies revealed by his 1998 inspection had been present for some time, Commander Kendrick was asked why there had been no mechanisms in place to bring them to his attention. He replied that mechanisms should have existed within the relevant crime OCUs for identifying and addressing such matters. He told me that he was not seeking to "pass the blame" for the neglect of CPTs to area commanders, but did invite me to conclude that such commanders should be seen as having a degree of "operational responsibility" for the state of the CPTs in their OCU.

Commander Campbell

15.51

For five years leading up to March 1999, the commander (crime) for the OCU which included both Brent and Haringey CPTs was Malcolm Campbell. It was plain from his evidence that he regarded the adequate resourcing and training of CPT officers as the responsibility of Commander Kendrick as the portfolio holder. He told me, "David Kendrick already had meetings, I am not sure of the frequency of these, with the DIs from child protection teams. He was their champion, as it were, to improve their lot, to gain them better resources." When asked if he accepted that he had failed to take sufficient steps to address issues of training and resourcing within the CPTs, he replied, "No, I brought them to the notice of Commander David Kendrick."

15.52

The problem is clear. The two officers who ought to be taking responsibility for ensuring that the CPTs were properly staffed and equipped had inconsistent views as to their respective responsibilities in this regard. Put simply, each thought that the other was doing more than was in fact the case. The inevitable consequence was that not enough was done by either.

15.53

My view is that Commander Campbell, as the commander (crime) for the OCU in which Brent and Haringey CPTs were situated, was responsible for the performance of those teams. As such he should have made sure that he was properly informed about the condition of the teams and the quality of their work. I find that he did not do this, and that he demonstrated precious little understanding of the state of the CPTs in his area or the problems that they faced. This, in my view, amounts to a fundamental gap in the knowledge and awareness of a senior officer in Commander Campbell's position. The work of CPTs is of central importance to all police forces. It is vital that senior officers have an understanding of that work and an appreciation of the challenges faced by the teams. In order to increase that understanding, I make the following recommendation:

Recommendation

The Home Office, through Centrex, must add specific training relating to child protection policing to the syllabus for the strategic command course. This will ensure that all future chief officers in the police service have adequate knowledge and understanding of the role of child protection teams.

Commander Craik

15.54

Commander Campbell was succeeded in April 1999 by Commander Michael Craik, who held the post of commander (crime) throughout the period that Victoria was alive in Brent and Haringey. The timing of his appointment was such that, even if he had wished to make radical changes to the CPTs, he could have achieved little in time to help Victoria. However, it is fair to say that, whatever the explanation, Commander Craik's level of awareness about the state of the CPTs under his operational command at the time Victoria's case was being dealt with, was little different to that of his predecessor.

15.55

Commander Craik accepted from the outset of his evidence to the Inquiry, that he was responsible for the operational performance of the CPTs in the north west London area during his time in post. When asked by Counsel for the MPS to what extent he personally accepted responsibility for police failures that may have contributed to Victoria's death, Commander Craik candidly replied, "My officers let Victoria and her parents down. I was responsible for those officers. I was the commander. By anybody's definition - you can go through job descriptions as much as you like - I was the boss in the organisation. If they let the family down and Victoria down, I let them down, and I would like to apologise to them for that." This was refreshing to hear. I was impressed by Commander Craik's evidence, and the manner in which he gave it.

15.56

I will say one more thing about Commander Craik, which applies equally to DCS David Cox. Following Victoria's death, it was essential that her killers were identified and successfully prosecuted. The crime OCU managed by these two senior officers, which let Victoria down so badly when she was alive, appears to have carried out a highly professional and detailed murder investigation, which resulted in the conviction of both Kouao and Manning. It is right to give the MPS, and the North West Crime OCU, credit for that successful investigation.

15.57

I recognise the difficulty faced by senior officers in the MPS in maintaining an accurate picture of the standards of work carried out by individual police units operating across the capital. I was reminded during the course of the Inquiry that the MPS is an organisation with 40,000 employees operating from more than 100 sites. One of the principal challenges posed by the management of large organisations such as this, is to be able to retain a feel for life on the 'shop floor'. I do not underestimate the scale of that challenge.

15.58

In order to be able to meet it, it seems to me that senior officers need regular and reliable intelligence from their junior staff. In view of this, I turn now to consider the level of awareness of the condition of the CPTs demonstrated by officers further down the chain of command who gave evidence to the Inquiry.

Paragraphs: 15.47 - 15.58 | 15.59 - 15.63 | 15.64 - 15.75

DCS David Cox

15.59

I start with DCS Cox, who took considerable trouble in both his written and oral evidence to ensure that I was aware of the context in which he and his officers were working in north west London in 1999. Of particular relevance, I was told, was the unusually high murder rate. Put briefly, his area of London had the misfortune to be the scene of 92 murders during the course of that year. This, apparently, is equivalent to the total number of murders dealt with in a typical year by the whole of Greater Manchester Police plus West Midlands Police plus any other county's police force.

15.60

The fact that there were a large number of murders occurring in north west London in 1999 cannot explain or excuse the individual failings of the officers who had direct contact with Victoria's case. However, it may help in understanding why more senior officers in the OCU failed to give the CPTs the attention they deserved. Whatever the explanation, it was clear from his evidence that DCS Cox was not aware of the true state of the CPTs for which he was responsible. Much of his evidence is summarised well by the following answer: "I realised, certainly, the situation on the murder teams was out of control. I do not think I realised the situation on the CPTs was as desperate as it was. I thought they were in better shape."

15.61

Regardless of the murder rate, the CPTs were a critical part of the OCU for which DCS Cox was responsible. Therefore, it was essential that he took the necessary steps to find out whether they were operating in a satisfactory manner. It is plain to me that he either had no mechanisms in place for keeping abreast of the state of his CPTs, or that those mechanisms were inadequate. My overall impression is that DCS Cox, like many of his senior colleagues, actually paid little regard to the CPTs under his command in 1999 because he did not see them as a high priority.

D Supt Susan Akers

15.62

It is possible that DCS Cox drew some comfort from the fact that his deputy, D Supt Akers, was herself a former child protection detective inspector, and appeared to take a keen interest in that side of the work. Of the three detective superintendents working in the crime OCU, she was the one who, for most of the relevant period, had specific responsibility for managing the CPTs. DCS Cox plainly thought that D Supt Akers was keeping a close eye on the teams. He told me, "Child protection was always a topic which Sue had on her lips, so I felt that she was doing that, and she had a good grasp."

15.63

D Supt Akers's view was somewhat different. She said that although she had nominal responsibility for the CPTs, the huge bulk of her work was with the murder squads. Once again, there appears to have been some confusion between senior officers as to the extent to which their colleagues were monitoring and taking responsibility for the work and condition of the CPTs. In my view, this further supports the conclusion that CPTs in the period with which I am concerned had slipped a very long way down the MPS's agenda.

Paragraphs: 15.47 - 15.58 | 15.59 - 15.63 | 15.64 - 15.75

DCI Philip Wheeler

15.64

I deal finally with DCI Wheeler, the most senior officer in the crime OCU who was not heavily engaged in murder inquiries in 1999. As I have stated above, it is vital that senior managers in large organisations of any sort receive accurate intelligence from their subordinates as to the state of affairs on the 'shop floor'. Within the context of the CPTs, someone had to have the job of 'drilling down' into the individual teams to ensure that they were carrying out proper investigations and were adequately equipped for the task.

15.65

All the senior officers to whom this question was addressed were clear in their recollection that the person whose job it was to fulfil this function was DCI Wheeler. Unfortunately, DCI Wheeler did not agree. He told me that he was in no way responsible for the operational management of the CPTs and that his function was an administrative one only. Specifically, when asked if DCS Cox had expressly told him that this was to be the extent of his role, he replied, "He did indeed. I went and spoke to him after one of the reports and he said, 'Do your best, do the best you can' and it is simply administrative, and that is all."

15.66

This seems to me to be a critical matter. Either there was a senior officer responsible for determining whether the CPTs with which I am concerned were doing a good job or there was not. If there was, then he or she will inevitably bear some responsibility for the shortcomings evident in Victoria's case. If not, then one is left facing the remarkable conclusion that nobody in the MPS was charged with the operational management of the north west London area CPTs.

15.67

Furthermore, the practical result of this confusion would seem to be that nobody properly managed the CPTs of Haringey or Brent from within the crime OCU. DCI Wheeler said that he never visited those CPT offices during the relevant period because he did not see it as his role, and the respective detective inspectors confirmed that they hardly ever saw him. This is, frankly, disastrous management on the part of the MPS. For example, had a senior officer taken the trouble to visit Haringey CPT in the months leading up to Victoria's death, there is every chance that he or she would have discovered the same deficiencies in practice highlighted in the two reviews of the team conducted after Victoria's death. Had they done so, then steps could have been taken to remedy the situation in time to have helped Victoria. In view of the seriousness of these matters, I deal with this conflict of evidence in some detail.

15.68

Commander Craik was asked what his understanding of DCI Wheeler's role was in terms of the operational supervision of the CPTs. He replied, "I would expect him to have the capacity to get down and dip sample at that level, as well as checking what the inspector said and checking that the inspector was doing exactly the same thing, looking into the work and quality checking. I would expect him [the inspector] to be able to do some of that himself and verify it. But I would say Mr Wheeler would be the last point in that chain. Mr Wheeler could certainly do it for the number of officers under his command.

15.69

D Supt Akers was equally clear when she was asked if DCI Wheeler had responsibility for operational matters or whether his post was purely concerned with administrative matters. She answered, "both". When informed that DCI Wheeler's evidence was that DCS Cox had assured him that his (DCI Wheeler's) role with regard to the CPTs was purely administrative, D Supt Akers replied, "I find it incredible to believe that Mr Cox would have said that because his view, like my own, was that CPTs needed more than administrative support." When it was put to her that the differences between her and DCI Wheeler on this issue were irreconcilable, and that if her evidence is correct it must mean that DCI Wheeler is lying about what he was told by DCS Cox, D Supt Akers replied, "Yes, I am afraid it does."

15.70

For completeness, I should record that DCS Cox was adamant in his oral evidence that he never told DCI Wheeler that his (DCI Wheeler's) role was restricted to the administrative management of the CPTs and that he fully expected him to take operational responsibility as well.

15.71

I have to make a judgement about whether DCI Wheeler knew he was the operational line manager of the CPTs, or whether, as he put it, he was simply asked to look after their administration. I am satisfied not only that he was the operational line manager for the CPT detective inspectors, but also that he knew his role was to oversee the work of their teams and ensure they were operating to a high standard. He chose not to discharge that function, with the result that the CPTs with which I am concerned operated throughout 1999 without the benefit of any adequate operational supervision.

15.72

In reaching this conclusion, I have been influenced to some degree by the fact that I find it inconceivable that DCS Cox would have said to DCI Wheeler that he was just to act as an administrator. Even if that had happened, I would have expected DCI Wheeler immediately to point out that the result of such an arrangement would be the CPT detective inspectors operating unsupervised - a plainly unsatisfactory state of affairs. When this was put to him, DCI Wheeler replied that he did not do so because he did not see it as part of his function to bring such matters to the attention of his superiors. I reject his evidence in this regard. As a senior officer within the crime OCU it would plainly have been his responsibility to bring any inherent defects in the management structure to DCS Cox's attention. I find it inconceivable that he would have chosen to keep such matters to himself, had he indeed been given the wholly inappropriate role he claims.

15.73

The resolution of this issue has been far from easy but I was assisted to some extent by the insight into DCI Wheeler's working practices provided by D Supt Copson, who took over as his line manager in late 1999. He said of DCI Wheeler, "I think he was hard-working within his own definition and hard-working according to his own priorities, but his priorities were not my priorities, and they are not the priorities he should have had. Phil Wheeler was probably the most difficult supervision case I have had in 23 years' service and I tried hard for a long time to find a way of reaching him and persuading him that he ought to do things differently, and the conclusion I was forced to, was that he did not want to be managed.

15.74

The lack of supervision by DCI Wheeler was, in my view, a crucial factor in Haringey and Brent CPTs being allowed to deteriorate to the state they were in by the time they came to deal with Victoria's case. In the absence of any indication from him to the contrary, it was possible for more senior officers, when they thought about the CPTs at all, to think that all was well. The evidence that I have heard, together with the findings of the reviews of Haringey CPT carried out after Victoria's death, demonstrates precisely the opposite.

15.75

In my view, DCI Wheeler, given his operational responsibility for the CPTs involved, should have been aware that they were struggling to provide an adequate service. He should then have brought this information to the attention of more senior officers so that the deficiencies in the composition, resourcing and practices of the teams could have been addressed. His failure to do so means, in my view, that he must assume a great deal of responsibility for the flawed investigations that were carried out by those under his command.

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