|
|
|
Paragraphs: 2.1 - 2.10 | 2.11
- 2.19 | 2.20 - 2.33 | 2.34
- 2.53 | 2.54 - 2.61
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|
|
|
2.1
|
On 25 February 2000, Victoria Adjo Climbié died in the Intensive
Care Unit at St Mary's Hospital Paddington. She died as a result
of months of appalling ill-treatment at the hands of two individuals
who were supposed to be caring for her.
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|
2.2
|
On 12 January 2001 at the Central Criminal Court, Marie-Therese
Kouao and Carl John Manning were convicted of her murder. Both were
sentenced to life imprisonment. Victoria had been called 'Anna'
by Kouao while she was in this country. I decided early on that
this Inquiry would call her by her proper name.
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|
2.3
|
On 20 April 2001, I was appointed by the Secretary of State for
Health and the Secretary of State for the Home Department to conduct
three statutory Inquiries. Together they would be known as The Victoria
Climbié Inquiry.
|
|
2.4
|
The first Inquiry was established under section 81 of the Children
Act 1989. It was concerned with the functions of local authority
social services committees and the way they relate to children.
The second Inquiry was established under section 84 of the National
Health Service Act 1977 and was concerned with matters arising under
that Act. The third Inquiry was established under section 49 of
the Police Act 1996 and was concerned with policing.
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|
2.5
|
The Inquiry's Terms of Reference were as follows:
|
|
1.
|
To establish the circumstances leading to and surrounding the death
of Victoria Climbié.
|
|
2.
|
To identify the services sought or required by, or in respect of
Victoria Climbié, Marie-Therese Kouao and Carl Manning from
local authorities in respect of their social services functions,
the Health bodies and the Police between the arrival of Victoria
Climbié and Marie-Therese Kouao in England in March 1999
and Victoria Climbié's death in February 2000.
|
|
3.
|
To examine the way in which local authorities in respect of their
social services functions, the health bodies and the police:
|
|
(i)
|
responded to those requests, or need for services
|
|
(ii)
|
discharged their functions
|
|
(iii)
|
co-operated with each other
|
|
(iv)
|
co-operated with other services including the local education authorities
and the local housing authorities;
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|
|
in respect of the three persons named above during the period referred
to above and thereafter.
|
|
4.
|
To reach conclusions as to the circumstances leading to Victoria
Climbié's death and to make recommendations to the Secretary
of State for Health and to the Secretary of State for the Home Department
as to how such an event may, as far as possible, be avoided in the
future.
|
|
5.
|
To deliver a report of the Inquiry to the Secretary of State for
Health and to the Secretary of State for the Home Department, who
will then arrange for its publication.
|
|
|
|
2.6
|
I appointed four assessors to help me to consider and analyse the
evidence:
|
|
•
|
Dr Nellie Adjaye, a Fellow of the Royal College of Paediatrics
and Child Health and a consultant paediatrician with the Maidstone
and Tunbridge Wells NHS Trust;
|
|
•
|
John Fox, a detective superintendent and the head of the Specialist
Investigations Department in the Hampshire Constabulary;
|
|
•
|
Donna Kinnair, a nurse and health visitor and formerly the strategic
commissioner for children's services for the Lambeth, Southwark
and Lewisham Health Authority;
|
|
•
|
Nigel Richardson, the assistant director of Children and Families
for North Lincolnshire Council.
|
|
2.7
|
The assessors gave advice on matters within their areas of expertise
throughout the Inquiry. Their knowledge and support were of enormous
value and I am very grateful to them, and to their employers for
releasing them so that they could take part in this important work.
|
|
2.8
|
We also had very beneficial advice and assistance on housing issues
from Mike Smith, head of Community Housing Services, Greenwich Council.
|
|
2.9
|
I appointed Mandy Jacklin as Secretary to the Inquiry. She was
responsible for the management of the overall work of the Inquiry.
With the consent of the Attorney General, I appointed Neil Garnham
QC to be Counsel to the Inquiry, and Caroline Gibson and Neil Sheldon
to be junior Counsel to the Inquiry. Their role was to help me in
the investigation, advise me on matters of law and evidence, and
present the evidence to the Inquiry at its hearings. Michael Fitzgerald
acted as Solicitor to the Inquiry. A full list of those who worked
on the Inquiry is in Annex 3.
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|
|
|
2.10
|
The Inquiry was accommodated at Hannibal House, a government building
at Elephant and Castle, London. The floors used for Inquiry purposes
were substantially refurbished to provide secure accommodation for
the Inquiry's offices and a well-equipped Inquiry room for the hearings.
These floors were kept entirely separate from the other occupiers
of the building.
|
|
Paragraphs: 2.1 - 2.10
| 2.11 - 2.19 | 2.20 - 2.33
| 2.34 - 2.53 | 2.54 - 2.61
|
|
|
|
|
|
2.11
|
The two secretaries of state allowed me to decide whether the Inquiry
should be conducted in public or in private. After careful consideration,
I decided it would be a public inquiry. However, I reserved the
right to hear evidence in private in exceptional circumstances.
I exercised that power on just one occasion, when it was necessary
for the Inquiry to hear evidence that involved the child of one
witness. I took the view that in order to protect the interests
of the child, their evidence should be heard in private.
|
|
|
|
2.12
|
I decided that the Inquiry would be divided into two phases. Phase
One (Parts one to four of this Report) would be mostly backward-looking.
It would try to discover what happened to Victoria while she was
in this country and why it happened. Phase One would address paragraphs
1 to 3 of the Terms of Reference (see paragraph 2.5), and look at
the conclusions that could properly be drawn from the evidence on
those topics.
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|
2.13
|
Phase Two (see Part five of this Report) would be forward-looking
and examine what recommendations might be made to avoid, as far
as possible, a tragedy like this happening again.
|
|
|
|
2.14
|
There is no statutory entitlement for any person to call witnesses,
cross-examine or make submissions in an Inquiry of this sort. However,
it was for me to decide what form the Inquiry should take, and I
decided the Inquiry would be inquisitorial not adversarial in nature.
In Phase One, Counsel to the Inquiry would decide which witnesses
it was necessary to call to give evidence, and they would examine
them.
|
|
|
|
2.15
|
A number of bodies and individuals expressed an interest in the
work of the Inquiry. Therefore, it was decided to recognise people
who had a legitimate interest in the work of the Inquiry as 'Interested
Parties'. Also, a number of witnesses not represented as an Interested
Party asked to be represented by lawyers at the Phase One hearings.
In every case, permission was granted and these witnesses were known
as 'Represented Witnesses'. A list of Interested Parties and their
representatives and Represented Witnesses and their representatives
can be found in Annex 4.
|
|
2.16
|
Most Interested Parties were public bodies or individuals involved
with Victoria's case in this country who wished to be involved in
Phase One, and who I thought could help the Inquiry with its work.
At an early stage, we received an application for Victoria's parents,
Francis and Berthe Climbié, to also be granted that status.
I decided that it would be right to grant that application, given
the obvious human interest any parent would have in an investigation
into their child's death. Mr and Mrs Climbié also asked me
to recommend to the Government that the cost of their travelling
to the UK and their accommodation here throughout Phase One be met
from the public purse. After careful reflection, I decided to make
those recommendations, and the Government accepted them.
|
|
2.17
|
I decided that, as a general rule, Interested Parties and those
acting for Represented Witnesses would not be allowed to call or
cross-examine witnesses. I had indicated at the preliminary meeting
(described in more detail in paragraph 2.20) that there might be
exceptions to this general rule. However, I was only asked to make
such an exception once, and I granted the request. Counsel to the
Inquiry agreed to consider any requests for them to call additional
witnesses and any requests for particular lines of questioning to
be put to witnesses. I indicated during the preliminary meeting
that if Counsel did not call such witnesses or ask such questions,
I would adjudicate on the need to do so. In fact, this was not necessary
and I am grateful to Counsel to the Inquiry and all the representatives
for their sensible co-operation in this regard.
|
|
2.18
|
Those representing Interested Parties and Represented Witnesses
were allowed to re-examine witnesses whom they represented. That
re-examination was time limited.
|
|
2.19
|
At the end of oral hearings, representatives of Interested Parties
and Represented Witnesses who wished to do so were allowed to make
time-limited closing submissions, which could be supplemented with
written submissions.
|
|
Paragraphs: 2.1 -
2.10 | 2.11 - 2.19 |
2.20 - 2.33 | 2.34 -
2.53 | 2.54 - 2.61
|
|
|
|
2.20
|
On 30 May 2001, we held a preliminary meeting at Hannibal House
and invited everyone who had expressed an interest in the work of
the Inquiry. The meeting was open to the public. We began the meeting
by holding a minute's silence in memory of Victoria.
|
|
2.21
|
At the meeting, I set out the arrangements I proposed to make for
the running of the Inquiry, and I invited comments on those arrangements.
No one suggested then, or in the weeks that followed, that the arrangements
should be changed. Therefore, the arrangements proposed at the meeting
were put into effect.
|
|
|
|
2.22
|
In order to structure the work in Phase One, a list of issues was
produced which reflected the Terms of Reference.
|
|
2.23
|
The Solicitor to the Inquiry wrote to everyone who might be able
to give relevant evidence, asking them to produce a witness statement.
A questionnaire was included that set out matters arising from the
list of issues, which it was thought they would be able to speak
about. In most cases these requests were made through the Interested
Parties, and I am grateful for their assistance with this.
|
|
2.24
|
A bundle of witness statements was prepared by the secretariat
and copies were made available to Interested Parties. The Interested
Parties made a written statement that they understood they had to
keep that material confidential and only use it for the purposes
of this Inquiry.
|
|
|
|
2.25
|
The three statutes to which I have referred gave me power to require
the production of documents. The secretariat wrote to the relevant
public bodies asking them to produce all relevant documents. One
of the more difficult tasks that fell to the secretariat was managing
the vast amount of documentation that was produced in response.
|
|
2.26
|
This work was made particularly difficult because of the late supply
of some relevant material by some of the Interested Parties, and
by others. For example, Brent council was late providing some documents
and at times I felt material was drip-fed to us. Similarly, at one
stage I was unhappy with the NSPCC's provision of documents. Documents
which were supposedly lost were suddenly discovered, and on one
occasion it was only during witness examinations that it became
clear that documents had been given to the Inquiry in an edited
form. However, in most cases, including those of Brent and the NSPCC,
the problems were temporary and solved quickly due to the good sense
and co-operation of those concerned.
|
|
2.27
|
I regret to say this was not always the case with Haringey council.
I was so concerned about the way Haringey was responding to requests
for documents that I issued a summons, in line with my powers under
section 250 of the Local Government Act 1972. The summons was directed
to Haringey's director of social services requiring her to produce
four identified documents and any other documents relevant to the
lessons learned by Haringey as a result of Victoria's death. From
then on, there could be no confusion as to what the Inquiry required.
|
|
2.28
|
More than 650 new documents were produced in response to this summons.
Several times after this, Haringey produced even more documentation.
This was material that should have been produced, at the latest,
by the date stated in the summons. I invited Haringey's chief executive
to attend the Inquiry and explain Haringey council's conduct. He
did so, and expressed his embarrassment at what had happened.
|
|
2.29
|
More material continued to be produced. I found it particularly
disturbing that documents directly relevant to Victoria's case were
found in a filing cabinet in the office where her case had been
handled, and in a locked storage area next to that office. Haringey's
Counsel told me that her client's embarrassment about these discoveries
was "off the scale". I requested a further explanation from Haringey's
chief executive. In the course of that explanation, I was told that
to describe him as "absolutely furious" about what had happened
would be an understatement.
|
|
2.30
|
I have seriously considered whether Haringey's method of dealing
with its documentation was the result of a deliberate attempt to
frustrate the Inquiry's work, or simple incompetence. Having considered
the observations of Haringey's chief executive, I have concluded
it was incompetence.
|
|
2.31
|
The smooth functioning of Inquiries such as this will always depend
on the co-operation and assistance of the public bodies involved.
The enormous inconvenience that can be caused by the late submission
of relevant material was graphically illustrated by a document provided
by the Social Services Inspectorate (SSI) after the Phase One hearings
had been completed.
|
|
2.32
|
I describe in paragraphs 2.37 to 2.41 the significance of the document
in question and the impact that its late submission had on the running
of this Inquiry. For present purposes, I simply wish to express
my surprise and disappointment that the work of the Inquiry was
delayed in this manner.
|
|
2.33
|
The documents were read and assessed by the Inquiry team and bundles
of relevant material were produced. Copies of the bundles were made
available to Interested Parties in the same way referred to in paragraph
2.24. The material was made available in hard copy form and a searchable,
electronic index on disk was produced to accompany the Inquiry bundle.
|
|
Paragraphs: 2.1 - 2.10
| 2.11 - 2.19 | 2.20 - 2.33
| 2.34 - 2.53 | 2.54 - 2.61
|
|
|
|
2.34
|
The hearings began on 26 September 2001, when Counsel to the Inquiry
made his opening statement. That statement identified the matters
which the Inquiry would need to focus on over the following months.
In line with what had been said at the preliminary meeting, a television
crew was given access to the Inquiry on that day. The next day,
opening statements from the other Interested Parties were received.
|
|
2.35
|
The first witness, Francis Climbié, Victoria's father, was
called on 28 September 2001. After this, Counsel to the Inquiry
called a further 158 witnesses, all of whom gave their evidence
on oath. In the case of four witnesses who had subsequently moved
abroad, it was decided that the most convenient and economic method
of obtaining their evidence was to use a video link between studios
in their present country of residence and a Department of Health
building close to the Inquiry's premises. This evidence was recorded
and the video recordings were played in the public sessions of the
Inquiry. The arrangements worked extremely well.
|
|
2.36
|
The written statements of a further 119 witnesses were put into
evidence without the need for them to attend the Inquiry. Most of
the oral evidence was completed by 4 February 2002. A list of the
witnesses who were called to give evidence and those whose statements
were read into the evidence can be found in Annex 2. Final submissions
from the Interested Parties and Counsel to the Inquiry were heard
on 18, 19 and 27 February 2002. Proceedings on the first two of
those days were also televised.
|
|
|
|
2.37
|
I had expected the final submission on 27 February 2002 to mark
the end of the public hearings in Phase One. However, on the advice
of Counsel to the Inquiry, I chose not to close Phase One at that
point because it was possible that further matters might emerge
which would require the taking of additional evidence.
|
|
2.38
|
This advice turned out to be crucial. On 27 February 2002, the
SSI gave the Inquiry a report of the Joint Review of Haringey Social
Services. The Joint Review had been conducted by the SSI and the
Audit Commission and published in November 1999.
|
|
2.39
|
It quickly became obvious that this document was not just relevant
but potentially greatly important to Phase One of the Inquiry. It
was immediately distributed to the Interested Parties and documents
relevant to its preparation were sought from the SSI and the Audit
Commission. These documents filled a further six lever-arch files.
|
|
2.40
|
This additional material was read and analysed. Then Counsel to
the Inquiry advised that further witness statements should be obtained.
The Inquiry was given 14 such statements, which were then circulated
to the Interested Parties.
|
|
2.41
|
Having considered these additional statements, I reluctantly came
to the view that I had no option but to reconvene the Phase One
public hearings in order to take additional oral evidence. As a
result, the Inquiry sat for two days on 9 and 10 July 2002. Four
witnesses gave oral evidence subject to the same procedures used
before. Interested Parties and the SSI were given the opportunity
to make closing submissions on the new material, although not all
Interested Parties took up that opportunity.
|
|
2.42
|
The three statutes under which the Inquiry was established gave
me the power to call witnesses to attend and answer questions. It
was necessary for me to exercise that power on only three occasions.
The first was in respect of Carole Baptiste, the Haringey social
work manager, who refused to agree to attend the Inquiry voluntarily.
She also disobeyed the summons I issued and, as a result, criminal
proceedings were begun against her. After this, she did attend and
answered questions put to her. However, I decided that the criminal
proceedings should go ahead.
|
|
2.43
|
I also issued summonses against Kouao and Manning. Kouao, who had
refused to co-operate with the Inquiry in any way, was brought from
prison to the Inquiry to give evidence in person. At first she refused
to answer Counsel's questions. Eventually she was persuaded by him
to give answers to some of the matters he raised with her. Manning,
by contrast, had co-operated throughout and had given the Inquiry
a witness statement when requested. It was arranged that he would
give his evidence by video link from the Combined Court Centre in
Leeds. That evidence was recorded and then played at the public
hearings.
|
|
|
|
2.44
|
A number of broadcasting organisations applied for access to the
video evidence of Manning. At the time of the recording of his evidence,
I sought Manning's views on whether I should allow his evidence
to be broadcast. He opposed it. Having considered his views and
the detailed oral and written submissions from Counsel acting on
the broadcasters' behalf and from others, I decided to refuse the
application.
|
|
|
|
2.45
|
All oral evidence was simultaneously transcripted using a system
called Livenote. The system proved very useful.
|
|
2.46
|
I believed it was important that the Inquiry should conduct its
work as openly and transparently as possible. I wanted to give those
with an interest in the evidence as much access to it as possible,
at the same time ensuring the fair conduct of the proceedings. In
particular, I wanted those who might be able to contribute to Phase
Two to have a convenient way of learning about the issues being
raised in Phase One.
|
|
2.47
|
As a result, an Inquiry website was established (www.victoria-climbie-inquiry.org.uk).
All statements provided to the Inquiry and transcripts of each day's
evidence were placed on this website. The website received around
three million hits in the period 30 September 2001 to 30 September
2002. The average length of the website's 'visitor sessions' was
20 minutes (compared with an internet average of three minutes).
This suggests that members of the public were using the site for
detailed reading, rather than out of a passing interest.
|
|
2.48
|
Before statements and transcripts were published in this manner,
the Inquiry contacted the assistant data protection commissioner.
It was agreed with him that the Inquiry constituted legal proceedings
for the purposes of section 35 of the Data Protection Act 1998,
and that the Inquiry might lawfully process non-sensitive personal
data without the consent of the data subject. It was made clear
that telephone numbers, addresses and names of family members would
be removed from witness statements before they were placed on the
website, and that the security of such information would be strictly
maintained by the Inquiry team. It was confirmed that the Inquiry
could also lawfully process sensitive personal data without the
explicit consent of the person concerned.
|
|
2.49
|
The assistant data protection commissioner agreed that statements
and transcripts of the public hearings would be placed on the website
but would not contravene the Eighth Data Protection Principle. The
Principle restricts the communication of personal information to
countries which have adequate protection for personal information
in place. It was in the public interest to make this information
available, especially to those who would be able to make a contribution
to Phase Two of the Inquiry.
|
|
|
|
2.50
|
The Inquiry does not have any power to order payment of legal costs
from public funds or by any other party. However, the Government
indicated to me that if I made a recommendation that the costs of
an Interested Party or Represented Witness should be met out of
public funds, then it would be sympathetically considered. I made
such a recommendation for one Interested Party and two Represented
Witnesses and on each occasion the Government accepted my recommendation.
|
|
|
|
2.51
|
I made clear at the preliminary meeting that some individuals or
organisations could be criticised in this Report, and that out of
fairness I would adopt a procedure that allowed those concerned
to address any criticism. The procedures for the representation
of Interested Parties and Represented Witnesses and the preparation
of their statements seemed to me to already meet those requirements.
However, I proposed taking an extra step to ensure proceedings were
conducted fairly.
|
|
2.52
|
I made it clear that I would make no findings significantly adverse
to an individual or organisation without ensuring that they first
had a proper opportunity to answer the criticism. Wherever it was
possible to do so, the witness would be informed by the Inquiry
team of the nature of the potential criticism before they were called
to give evidence. Where that was not possible, either because of
the time at which grounds for the potential criticism emerged or
otherwise, arrangements would be made either for the witness to
respond in writing, or for the witness to be recalled so that they
could answer the criticism. At the preliminary meeting, I made it
clear that I would particularly welcome representations on those
procedures. I received no suggestions indicating a need to amend
the proposed arrangements and so they were put into practice during
the course of the Inquiry.
|
|
2.53
|
Notices of potential criticism were sent to individuals or public
bodies where it appeared they may be criticised for their conduct
in relation to matters covered by the Inquiry's Terms of Reference.
Each witness was given the chance to address these points during
the course of their evidence. The Solicitor to the Inquiry wrote
to the relevant party afterwards to make sure they felt they had
been given a fair chance to respond. No one said that they had not.
|
|
Paragraphs: 2.1 - 2.10
| 2.11 - 2.19 | 2.20 - 2.33
| 2.34 - 2.53 | 2.54 - 2.61
|
|
|
|
|
|
2.54
|
The fourth paragraph of our Terms of Reference requires us to make
recommendations as to how a tragedy like this could be avoided in
the future.
|
|
2.55
|
It was apparent early on that, in responding to this, we were likely
to have to consider making two different types of recommendations.
The first type would be addressed to the particular circumstances
of Victoria's case and to the events that occurred in Ealing, Brent
and Haringey while Victoria lived there. The second type would be
recommendations with wider potential impact and that might affect
relevant agencies across the country.
|
|
2.56
|
In the course of Phase One, we were likely to become familiar with
practice and procedure in certain parts of London, but it would
be an obvious mistake to assume that these same practices and procedures
were necessarily followed elsewhere. We are not charged with conducting
a review of the whole child protection system in this country. However,
we had to devise a way for a wider audience to test the ideas prompted
by Victoria's case so that they could be used elsewhere.
|
|
|
|
2.57
|
Phase Two was designed to be a way for such wider consideration
to happen. In order to give some shape to our thinking on these
subjects, the Inquiry produced a provisional framework document
for Phase Two in late October 2001. That framework was based on
our reading of the documents and witness statements gathered for
Phase One. It identified broad issues, aspects of which we believed
might be worthy of consideration in Phase Two. We asked for comments
on the structure and contents of that framework and suggestions
for topics that should be considered. We received a large number
of responses to that framework document and, in the light of those
responses, we drew up a discussion paper, which we published on
the website and circulated widely.
|
|
2.58
|
The issues were addressed in two ways. First, we invited written
submissions from the public at large. We anticipated that not all
of the submissions we received were likely to help us, so we made
it clear in the beginning that only those that were relevant and
valuable would be treated as evidence to the Inquiry. In fact, out
of over 200 submissions we received, we accepted 77 as evidence
and published them on the website. I am very grateful to all those
who took the trouble to send in written submissions.
|
|
2.59
|
Second, the Inquiry organised a series of five seminars, which
were held in March and April 2002. They were conducted in public
at the Inquiry's premises at Hannibal House. The seminars covered
the following aspects of working with children:
|
|
•
|
Ensuring that children and their families receive the full range
of services they are entitled to;
|
|
•
|
Making sure that children and families in need of extra care and
support are identified at an early stage;
|
|
•
|
Carrying out a proper assessment of the needs of children and families
and developing plans to achieve the best outcomes for them;
|
|
•
|
Making sure that key agencies are able to deliver an effective
service;
|
|
•
|
Monitoring the performance of the key agencies.
|
|
2.60
|
A wide range of people with an interest in our work were invited
to the seminars. These included practitioners and managers from
social services, the police, health services, academics, lawyers
and commentators. They were chosen from those who had responded
to our framework document and discussion paper, and from those not
previously involved in the Inquiry. A full list of those who took
part in the seminars can be found in Annex 5. The seminars were
chaired by Neil Garnham QC and attended by the assessors and myself.
They were a most valuable source of ideas, and are discussed further
in section 17 of this Report. I am most grateful to all those who
took part.
|
|
Paragraphs: 2.1 - 2.10
| 2.11 - 2.19 | 2.20 - 2.33
| 2.34 - 2.53 | 2.54 - 2.61
|
|
|
|
2.61
|
On 31 July 2002, I formally closed the evidence-gathering process
of the Inquiry. No material received by the Inquiry after this date
has been considered for the purposes of preparing this Report.
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