|
|
|
|
|
Paragraphs: 1.1 - 1.13 | 1.14
- 1.26 | 1.27 - 1.33 | 1.34
- 1.46 | 1.47 - 1.54 |
1.55 - 1.63 | 1.64 - 1.68
|
|
|
|
|
"Victoria had the most beautiful smile that lit up the room."
Patrick Cameron
|
|
1.1
|
This Report begins and ends with Victoria Climbié. It is
right that it should do so. The purpose of this Inquiry has been
to find out why this once happy, smiling, enthusiastic little girl
- brought to this country by a relative for 'a better life' - ended
her days the victim of almost unimaginable cruelty. The horror of
what happened to her during her last months was captured by Counsel
to the Inquiry, Neil Garnham QC, who told the Inquiry:
|
|
|
"The food would be cold and would be given to her on a piece
of plastic while she was tied up in the bath. She would eat it like
a dog, pushing her face to the plate. Except, of course that a dog
is not usually tied up in a plastic bag full of its excrement. To
say that Kouao and Manning treated Victoria like a dog would be
wholly unfair; she was treated worse than a dog."
|
|
1.2
|
On 12 January 2001, Victoria's great-aunt, Marie-Therese Kouao,
and Carl John Manning were convicted of her murder.
|
|
|
|
1.3
|
At his trial, Manning said that Kouao would strike Victoria on
a daily basis with a shoe, a coat hanger and a wooden cooking spoon
and would strike her on her toes with a hammer. Victoria's blood
was found on Manning's football boots. Manning admitted that at
times he would hit Victoria with a bicycle chain. Chillingly, he
said, "You could beat her and she wouldn't cry ... she could take
the beatings and the pain like anything.
|
|
1.4
|
Victoria spent much of her last days, in the winter of 1999-2000,
living and sleeping in a bath in an unheated bathroom, bound hand
and foot inside a bin bag, lying in her own urine and faeces. It
is not surprising then that towards the end of her short life, Victoria
was stooped like an old lady and could walk only with great difficulty.
|
|
1.5
|
When Victoria was admitted to the North Middlesex Hospital on the
evening of 24 February 2000, she was desperately ill. She was bruised,
deformed and malnourished. Her temperature was so low it could not
be recorded on the hospital's standard thermometer. Dr Lesley Alsford,
the consultant responsible for Victoria's care on that occasion,
said, "I had never seen a case like it before. It is the worst case
of child abuse and neglect that I have ever seen.
|
|
1.6
|
Despite the valiant efforts of Dr Alsford and her team, Victoria's
condition continued to deteriorate. In a desperate attempt to save
her life, Victoria was transferred to the paediatric intensive care
unit at St Mary's Hospital Paddington. It was there that, tragically,
she died a few hours later, on the afternoon of 25 February 2000.
|
|
1.7
|
Seven months earlier, Victoria had been a patient in the North
Middlesex Hospital. Nurse Sue Jennings recalled:
|
|
|
"Victoria did not have any possessions - she only had the clothes
that she arrived in. Some of the staff had brought in dresses and
presents for Victoria. One of the nurses had given her a white dress
and Victoria found some pink wellingtons which she used to wear
with it. I remember Victoria dressed like this, twirling up and
down the ward. She was a very friendly and happy child."
|
|
|
|
1.8
|
At the end, Victoria's lungs, heart and kidneys all failed. Dr
Nathaniel Carey, a Home Office pathologist with many years' experience,
carried out the post- mortem examination. What stood out from Dr
Carey's evidence was the extent of Victoria's injuries and the deliberate
way they were inflicted on her. He said:
|
|
|
"All non-accidental injuries to children are awful and difficult
for everybody to deal with, but in terms of the nature and extent
of the injury, and the almost systematic nature of the inflicted
injury, I certainly regard this as the worst I have ever dealt with,
and it is just about the worst I have ever heard of."
|
|
1.9
|
At the post-mortem examination, Dr Carey recorded evidence of no
fewer than 128 separate injuries to Victoria's body, saying, "There
really is not anywhere that is spared - there is scarring all over
the body."
|
|
1.10
|
Therefore, in the space of just a few months, Victoria had been
transformed from a healthy, lively, and happy little girl, into
a wretched and broken wreck of a human being.
|
|
|
|
1.11
|
Perhaps the most painful of all the distressing events of Victoria's
short life in this country is that even towards the end, she might
have been saved. In the last few weeks before she died, a social
worker called at her home several times. She got no reply when she
knocked at the door and assumed that Victoria and Kouao had moved
away. It is possible that at the time, Victoria was in fact lying
just a few yards away, in the prison of the bath, desperately hoping
someone might find her and come to her rescue before her life ebbed
away.
|
|
1.12
|
At no time during the weeks and months of this gruelling Inquiry
did familiarity with the suffering experienced by Victoria diminish
the anguish of hearing it, or make it easier to endure. It was clear
from the evidence heard by the Inquiry that Victoria's intelligence,
and the warmth of her engaging smile, shone through, despite the
ghastly facts of what she experienced during the 11 months she lived
in England. The more my colleagues and I heard about Victoria, the
more we came to know her as a lovable child, and our hearts went
out to her. However, neither Victoria's intelligence nor her lovable
nature could save her. In the end she died a slow, lonely death
- abandoned, unheard and unnoticed.
|
|
|
|
1.13
|
Before moving on to the introductory part of this Report, I wish
to pay a warm tribute to Victoria's parents, Francis and Berthe
Climbié. They were present for the whole of Phase One of
this Inquiry. Their love for Victoria was clear, as were their hopes
that she would receive a better education in Europe. In the face
of the most disturbing evidence about the treatment of their daughter,
they displayed both courage and dignity.
|
|
Paragraphs: 1.1 - 1.13
| 1.14 - 1.26 | 1.27 -
1.33 | 1.34 - 1.46 | 1.47
- 1.54 | 1.55 - 1.63 | 1.64
- 1.68
|
|
|
|
1.14
|
I recognise that those who take on the work of protecting children
at risk of deliberate harm face a tough and challenging task. Staff
doing this work need a combination of professional skills and personal
qualities, not least of which are persistence and courage. Adults
who deliberately exploit the vulnerability of children can behave
in devious and menacing ways. They will often go to great lengths
to hide their activities from those concerned for the well-being
of a child. Staff often have to cope with the unpredictable behaviour
of people in the parental role. A child can appear safe one minute
and be injured the next. A peaceful scene can be transformed in
seconds because of a sudden outburst of uncontrollable anger.
|
|
1.15
|
Whenever a child is deliberately injured or killed, there is inevitably
great concern in case some important tell-tale sign has been missed.
Those who sit in judgement often do so with the great benefit of
hindsight. So I readily acknowledge that staff who undertake the
work of protecting children and supporting families on behalf of
us all deserve both our understanding and our support. It is a job
which carries risks, because in every judgement they make, those
staff have to balance the rights of a parent with that of the protection
of the child.
|
|
|
|
1.16
|
But Victoria's case was altogether different. Victoria was not
hidden away. It is deeply disturbing that during the days and months
following her initial contact with Ealing Housing Department's Homeless
Persons' Unit, Victoria was known to no less than two further housing
authorities, four social services departments, two child protection
teams of the Metropolitan Police Service (MPS), a specialist centre
managed by the NSPCC, and she was admitted to two different hospitals
because of suspected deliberate harm. The dreadful reality was that
these services knew little or nothing more about Victoria at the
end of the process than they did when she was first referred to
Ealing Social Services by the Homeless Persons' Unit in April 1999.
The final irony was that Haringey Social Services formally closed
Victoria's case on the very day she died. The extent of the failure
to protect Victoria was lamentable. Tragically, it required nothing
more than basic good practice being put into operation. This never
happened.
|
|
1.17
|
In his opening statement to the Inquiry, Neil Garnham QC listed
no fewer than 12 key occasions when the relevant services had the
opportunity to successfully intervene in the life of Victoria. As
evidence to the Inquiry unfolded, several other opportunities emerged.
Not one of these required great skill or would have made heavy demands
on time to take some form of action. Sometimes it needed nothing
more than a manager doing their job by asking pertinent questions
or taking the trouble to look in a case file. There can be no excuse
for such sloppy and unprofessional performance.
|
|
|
|
1.18
|
Not one of the agencies empowered by Parliament to protect children
in positions similar to Victoria's - funded from the public purse
- emerge from this Inquiry with much credit. The suffering and death
of Victoria was a gross failure of the system and was inexcusable.
It is clear to me that the agencies with responsibility for Victoria
gave a low priority to the task of protecting children. They were
under-funded, inadequately staffed and poorly led. Even so, there
was plenty of evidence to show that scarce resources were not being
put to good use. Bad practice can be expensive. For example, had
there been a proper response to the needs of Victoria when she was
first referred to Ealing Social Services, it may well be that the
danger to her would have been recognised and action taken which
may have avoided the need for the later involvement of the other
agencies.
|
|
1.19
|
Even after listening to all the evidence, I remain amazed that
nobody in any of the key agencies had the presence of mind to follow
what are relatively straightforward procedures on how to respond
to a child about whom there is concern of deliberate harm. The most
senior police officer to give evidence from the MPS was Deputy Assistant
Commissioner William Griffiths. He said of the investigation carried
out by Haringey Child Protection Team, "In the A to Z of an investigation,
that investigation did not get to B." Therefore, I conclude that,
despite the Children Act 1989 having been in force for just under
a decade, the standard of investigation into criminal offences against
children may not be as rigorous as the investigation of similar
crimes against adults.
|
|
|
|
1.20
|
It seems that the basic discipline of medical evaluation, covering
history-taking, examination, arriving at a differential diagnosis,
and monitoring the outcome, was not put into practice in Victoria's
case. I accept the evidence of Dr Peter Lachman, clinical director
for Women and Children Services Directorate of North West London
Hospitals NHS Trust, that paediatric doctors and nurses are highly
trained in helping sick children get well. However, as he said,
"child abuse is one of the most complex areas of paediatrics and
child health". That being so, I found it hard to understand why
established good medical practice, that would have undoubtedly helped
clarify the complexities in Victoria's case, was not followed on
the paediatric wards at the Central Middlesex Hospital and North
Middlesex Hospital.
|
|
1.21
|
Having considered the response to Victoria from each of the agencies,
I am forced to conclude that the principal failure to protect her
was the result of widespread organisational malaise.
|
|
1.22
|
It is, however, instructive to contrast the inadequate response
to safeguarding Victoria with the work of the health service in
attempting to save her life at the end, and the professionalism
of the police investigation after her death that led to the prosecution
of Kouao and Manning. Alas, it was then too late for Victoria.
|
|
|
|
1.23
|
It is not to the handful of hapless, if sometimes inexperienced,
front-line staff that I direct most criticism for the events leading
up to Victoria's death. While the standard of work done by those
with direct contact with her was generally of very poor quality,
the greatest failure rests with the managers and senior members
of the authorities whose task it was to ensure that services for
children, like Victoria, were properly financed, staffed, and able
to deliver good quality support to children and families. It is
significant that while a number of junior staff in Haringey Social
Services were suspended and faced disciplinary action after Victoria's
death, some of their most senior officers were being appointed to
other, presumably better paid, jobs. This is not an example of managerial
accountability that impresses me much.
|
|
1.24
|
Following Victoria's death, the response of the various agencies
involved was variable. One example of the approach taken by senior
management to the tragedy was provided by Dr John Riordan, medical
director at the Central Middlesex Hospital, who told me:
|
|
|
"If I am totally frank I was being advised by other partners
in the health economy 'get an external inquiry done because it will
protect your position' and I thought that was a good idea initially,
but I later came to the view that, given the difficulty we had in
getting it, as time had moved on it was not going to be worth pursuing."
|
|
|
Credit should be given to both UNISON and the Police Federation
for the support they gave to some front-line staff who gave evidence
to this Inquiry.
|
|
1.25
|
The front-line staff of the key public services were all employees.
They acted on behalf of the organisations which employed them. Those
in senior positions in such organisations carry, on behalf of society,
responsibility for the quality, efficiency and effectiveness of
local services. I believe that several of those in such positions
who gave evidence to this Inquiry, either did not understand this,
or did not accept it. Front-line staff may well have a different
perception of the organisation they work in from that of their senior
managers. Based on the evidence to this Inquiry, the differences
could only be described as a yawning gap. The failure to grasp this
was undoubtedly the fault of the managers because it was their job
to understand what was happening at their 'front door'.
|
|
1.26
|
Some used the defence "no one ever told me". The chief executive
of Brent council, Gareth Daniel, chose to describe his role as "strategic"
and to distance himself from the day-to-day realities. Gina Adamou,
a Haringey councillor, said, "If I ask questions she [Mary Richardson,
the director of social services] would say 'everything is okay,
do not worry, if there is a problem I will let you know'." I find
this an unacceptable state of affairs. Elected councillors and senior
officers must ensure that they are kept fully informed about the
delivery of services to the populations they serve, and they must
not accept at face value what they are told. There was also a reluctance
among senior officers to accept there was anything they could have
done for Victoria. The former chief executive of Haringey council,
Gurbux Singh, said, "There is the issue of resources ... but beyond
that I cannot honestly think of what else I could have actually
done to ensure that the tragedy which happened did not happen."
This is not a view I share.
|
|
Paragraphs: 1.1 - 1.13
| 1.14 - 1.26 | 1.27 -
1.33 | 1.34 - 1.46 | 1.47
- 1.54 | 1.55 - 1.63 | 1.64
- 1.68
|
|
|
|
1.27
|
I strongly believe that in future, those who occupy senior positions
in the public sector must be required to account for any failure
to protect vulnerable children from deliberate harm or exploitation.
The single most important change in the future must be the drawing
of a clear line of accountability, from top to bottom, without doubt
or ambiguity about who is responsible at every level for the well-
being of vulnerable children. Time and again it was dispiriting
to listen to the 'buck passing' from those who attempted to justify
their positions. For the proper safeguarding of children this must
end. If ever such a tragedy happens again, I hope those in leadership
posts will examine their responsibilities before looking more widely.
|
|
1.28
|
The most lasting tribute to the memory of Victoria would be if
her suffering and death resulted in an improvement in the quality
of the management and leadership in these key services. What is
needed are managers with a clear set of values about the role of
public services, particularly in addressing the needs of vulnerable
people, combined with the ability to 'lead from the front'. Good
administrative procedures are essential to facilitate efficient
work, but they are not sufficient on their own and cannot replace
effective management. This Inquiry saw too many examples of those
in senior positions attempting to justify their work in terms of
bureaucratic activity, rather than in outcomes for people.
|
|
|
|
1.29
|
It is important to understand what went wrong in the way individual
social workers, police officers, doctors and nurses responded to
Victoria's needs, and how deficiencies in their organisations contributed
to this. This is dealt with in detail in sections 4 to 16. However,
this Inquiry has been more than just a forensic exercise. It has
been charged with looking forward and to make recommendations for
"how such an event may, as far as possible, be avoided in the future".
|
|
1.30
|
The gross failings that I heard about during the Inquiry caused
me to consider a number of ways in which current arrangements for
the safeguarding of children might be strengthened. For example,
I have given careful thought as to whether or not this might be
achieved by the development of a National Child Protection Agency.
While at first this seemed to be a worthwhile proposition, on reflection,
I believe the following points are factors which rule against this:
|
|
•
|
It is not possible to separate the protection of children from
wider support to families. Indeed, often the best protection for
a child is achieved by the timely intervention of family support
services. The wholly unsatisfactory practice, demonstrated so often
in this Inquiry, of determining the needs of a child before an assessment
has been completed, reinforces in me the belief that 'referrals'
should not be labelled 'child protection' without good reason. The
needs of the child and his or her family are often inseparable.
|
|
•
|
I am in no doubt that effective support for children and families
cannot be achieved by a single agency acting alone. It depends on
a number of agencies working well together. It is a multi-disciplinary
task.
|
|
•
|
Evidence to this Inquiry demonstrated very clearly the dangers
to children if staff from different agencies do not fulfil their
separate and distinctive responsibilities. No set of responsibilities
is subordinate to another, and each must be carried out efficiently
and effectively. Gathering together staff in a dedicated team might
well run the risk of blurring their responsibilities.
|
|
•
|
I am not persuaded there is an untapped source of talent standing
ready to operate a national child protection service. It is likely
that staff would simply transfer from their current employment into
the new organisation.
|
|
•
|
I recognise the fact that over the years, successive governments
have refined both legislation and policy, no doubt informed in part
by earlier Inquiries of this kind, so that in general, the legislative
framework for protecting children is basically sound. I conclude
that the gap is not a matter of law but in its implementation.
|
|
•
|
I am convinced that it is not just 'structures' that are the problem,
but the skills of the staff that work in them. For example, at the
time of the joint review of Haringey, they were convinced of the
merit of integrating the management of housing and social services.
They have since separated these two departments at the very time
that Ealing was combining them into a single organisation. Therefore,
I am satisfied that organisational structure is unlikely to be an
impediment to effective working. What is critical is the effectiveness
of the management and leadership.
|
|
1.31
|
From the evidence I heard I conclude that it is neither practical
nor desirable to try to separate the support services for children
and families from that of the service designed to investigate and
protect children from deliberate harm. Therefore, an alternative
solution must be found. To address this, I set out elsewhere in
this Report a number of changes which I recommend should be introduced
to the organisation and management of services designed to protect
children and support families. These changes are intended to build
on the best in the current arrangements, and to respond to the changes
since the Children Act 1989. The recommendations that flow from
these changes are intended to secure a clear line of accountability
for the safety of children and the support of families - a factor
sadly lacking in the current arrangements.
|
|
|
|
|
|
1.32
|
Current inter-agency arrangements for protecting children depend
very heavily on the key agencies in health, the police and social
services working within closely related geographical boundaries.
This is no longer the case. Local authorities with responsibility
for social services have been reorganised so they are now smaller
and more numerous. Indeed, there are now 150 of them in England.
In contrast, health authorities are now larger and fewer, numbering
only 30. Front-line health services are provided by a growing number
of Primary Care Trusts, currently over 300, while 43 police authorities
cover England and Wales.
|
|
1.33
|
As a result, Area Child Protection Committees (ACPCs), the organisations
with responsibility for co-ordinating child protection services
at a local level, have generally become unwieldy, bureaucratic and
with limited impact on front-line services. I was told that in the
London Metropolitan Police area, there are 33 local authorities
with social services responsibilities and 27 Area Child Protection
Committees. In Liverpool, there are five ACPCs, while in Essex (with
a population of over one million) there is one. Such wide variations
in geographical areas and populations served by the ACPCs must inevitably
lead to equally wide variations in the co-ordination and quality
of services offered to vulnerable children. A new arrangement is
needed.
|
|
Paragraphs: 1.1 - 1.13
| 1.14 - 1.26 | 1.27 -
1.33 | 1.34 - 1.46 | 1.47
- 1.54 | 1.55 - 1.63 | 1.64
- 1.68
|
|
|
|
|
|
1.34
|
Therefore, I recommend a fundamental change in the way that services
to support children and families are organised and managed. With
the support of the Prime Minister, a Children and Families Board
should be established at the heart of government. The Board should
be chaired by a minister of Cabinet rank and have representatives
at ministerial level from each of the relevant government departments.
This Inquiry was told that well-intentioned ministerial initiatives
are introduced piecemeal, and either do not fulfil their potential
or divert staff from other essential front-line work. This Board
should be charged with ensuring that the impact of all such initiatives
that have a bearing on the well-being of children and families is
considered within this forum.
|
|
|
|
1.35
|
In addition, a National Agency for Children and Families should
be created. The chief executive of this agency - who may have the
functions of a Children's Commissioner for England - would be responsible
for servicing the Government's Children and Families Board. The
National Agency for Children and Families should:
|
|
•
|
assess, and advise the Children and Families Board about, the impact
on children and families of proposed changes in policy;
|
|
•
|
scrutinise new legislation and guidance issued for this purpose;
|
|
•
|
advise on the implementation of the UN Convention on the Rights
of the Child;
|
|
•
|
advise on setting nationally agreed outcomes for children and how
they might best be achieved and monitored;
|
|
•
|
ensure that policy and legislation are implemented at a local level
and are monitored through its regional office network;
|
|
•
|
report annually to Parliament on the quality and effectiveness
of services to children and families, in particular on the safety
of children;
|
|
•
|
at its discretion, conduct serious case reviews or oversee the
process if this task is carried out by other agencies.
|
|
|
|
1.36
|
Clearly, it is for central government to make key decisions on
overall policy, legislation and the funding of services. However,
it is unrealistic for service delivery to be managed centrally.
The managers of local services must be given the responsibility
to assess local need and to respond accordingly. However, where
the care and protection of children and the support of children
and families is concerned, this independence must not be pursued
to the detriment of effective joint working. I recognise that committee
structures and job descriptions vary between local authorities.
|
|
1.37
|
The future lies with those managers who can demonstrate the capacity
to work effectively across organisational boundaries. Such boundaries
will always exist. Those able to operate flexibly need encouragement,
in contrast to those who persist in working in isolation and making
decisions alone. Such people must either change or be replaced.
The safeguarding of children must not be placed in jeopardy by individual
preference. The joint training of staff and the sharing of budgets
are likely to ensure an equality of desire and effort to make them
work effectively.
|
|
|
|
1.38
|
In order to secure strong local working relationships so that collaboration
on the scale of that which I envisage takes place, I propose that
each local authority with social services responsibilities should
establish a Committee for Children and Families, with members drawn
from the relevant committees of the local authority, the police
authority and relevant boards and trusts of health services. This
committee will oversee the work of a Management Board for Services
to Children and Families.
|
|
|
|
1.39
|
In each local authority, the chief executive should chair a Management
Board for Services to Children and Families, made up of chief officers
(or very senior officers) from the police, social services, relevant
health services, education, housing and the probation service. The
Management Board for Services to Children and Families will be required
to appoint a director of children and family services at local level.
This person will be responsible for ensuring service delivery, including
the effectiveness of local inter-agency working, which must also
include working with voluntary and private agencies. Each board
must also establish a local forum to secure the involvement of voluntary
and private agencies, service users, including children, and other
contributors as appropriate. Special arrangements will have to be
made in London, to take account of the fact there are 33 London
authorities.
|
|
|
|
1.40
|
The relevant government inspectorates should be jointly required
to inspect the effectiveness of these arrangements.
|
|
1.41
|
In order to ensure coherence within this proposed structure, it
should be a requirement that each Management Board for Services
to Children and Families reports to its parent Committee for Children
and Families. In turn, the Committee for Children and Families will
report through the regional structure to the National Agency for
Children and Families. The Children and Families Board should report
annually to Parliament on the state of services to children and
families.
|
|
1.42
|
The purpose of these proposals is to secure a clear line of accountability
for the protection of children and for the well-being of families.
Never again should people in senior positions be free to claim -
as they did in this Inquiry - ignorance of what was happening to
children. These proposals are designed to ensure that those who
manage services for children and families are held personally accountable
for the effectiveness of these services, and for the arrangements
their organisations put in place to ensure that all children are
offered the best protection possible.
|
|
|
|
1.43
|
Improvements to the way information is exchanged within and between
agencies are imperative if children are to be adequately safeguarded.
Staff must be held accountable for the quality of the information
they provide. Information systems that depend on the random passing
of slips of paper have no place in modern services. Each agency
must accept responsibility for making sure that information passed
to another agency is clear, and the recipients should query any
points of uncertainty. In the words of the two hospital consultants
who had care of Victoria:
|
|
|
"I cannot account for the way other people interpreted what
I said. It was not the way I would have liked it to have been interpreted."
(Dr Ruby Schwartz)"
|
|
|
"I do not think it was until I have read and re-read this letter
that I appreciated quite the depth of misunderstanding." (Dr Mary
Rossiter)"
|
|
|
The fact that an elementary point like this has to be made reflects
the dreadful state of communications which exposed Victoria to danger.
|
|
1.44
|
There can be no justification for hospitals in close proximity
to each other failing to access information about earlier patient
contact. In this day and age, it must be reasonable to expect the
free exchange of information within the National Health Service.
The need for this is all the more critical because experience shows
that 'shopping around' the health service is one of the favourite
ploys of carers wishing to evade suspicion about their treatment
of their children.
|
|
1.45
|
Effective action designed to safeguard the well-being of children
and families depends upon sharing relevant information on an inter-agency
basis. The following contribution to one of the Phase Two seminars
was compelling in this respect:
|
|
|
"Whenever we do a Part 8 case review ... we have this huge
chronology of information made available to the Panel and it is
very frustrating to read that ... a long way before that happened,
a pattern of things emerging, but knowing that at the time ... separate
agencies held those bits of information. So GPs will be seeing things,
accident and emergency will be seeing things, the police may be
dealing with other aspects of what is going on in that child's life,
and nobody is bringing it together."
|
|
1.46
|
However, I was told that the free exchange of information about
children and families about whom there are concerns is inhibited
by the legislation on data protection and human rights. It appears
that, unless a child is deemed to be in need of protection, information
cannot be shared between agencies without staff running the risk
of contravening this legislation. This has two consequences: either
it deters information sharing, or it artificially increases concerns
in order that they can be expressed as the need for protection.
This is a matter that the Government must address. It is not a matter
that can be tackled satisfactorily at local level.
|
|
Paragraphs: 1.1 - 1.13
| 1.14 - 1.26 | 1.27 -
1.33 | 1.34 - 1.46 | 1.47
- 1.54 | 1.55 - 1.63 | 1.64
- 1.68
|
|
|
|
1.47
|
Those who deliberately harm children have a tendency to cover their
tracks. Poor record-keeping, doubts about the exchange of information
between services, and inadequate client information systems make
that easy. We live in a highly mobile society. Ninety million people
pass through our ports of entry each year. Many children experience
several moves. I have considered the benefits of establishing a
national database on children. In the circumstances set out above,
there is much to be said in favour of a database covering all children.
I was told that such a database is technically feasible and that
there are many much larger systems. The benefit of such a database
would be that every new contact with a child by a member of staff
from any of the key services would initiate an entry that would
build up a picture of the child's health, developmental and educational
needs. I have recommended that the Government commission work to
look into the feasibility of such a national database, and this
may result in pilot studies being carried out.
|
|
|
|
1.48
|
While the introduction of the proposals set out above will require
changing the law, the vast majority of recommendations in this Report
can be implemented immediately. Some 82 of the 108 recommendations
should be implemented within six months. The Inquiry website received
around three million hits in the period 30 September 2001 to 30
September 2002, and already a number of the key agencies have reviewed
their practices. In this respect, the Inquiry has already had a
considerable impact on service delivery. This momentum must be maintained
and, where necessary, speeded up, if the unacceptable practice I
heard about is to be eliminated. This Report is intended to have
an impact on practice now - not just some time in the future. Its
recommendations cannot be deferred to some bright tomorrow. Robust
leadership must replace bureaucratic administration. The adherence
to inward-looking processes must give way to more flexible deployment
of staff and resources in the search for better results for children
and families.
|
|
|
|
1.49
|
Some elected councillors from Haringey and Brent insisted that
the amount of money allocated by central government to their authorities
for children's services under the Standard Spending Assessment (SSA)
was a result of the distribution formula and did not reflect the
needs of the local area. They claimed that because 80 per cent of
the funding comes from central government, and because they were
being pressed to address central government priorities, they had
little scope to influence spending at a local level.
|
|
1.50
|
In this respect, local authorities portrayed themselves as being
little more than the agents of central government, rather than being
independently elected corporate bodies. If this is correct, it has
potentially serious implications for the future of local government
in this country. Significantly, at the time that Ealing, Brent and
Haringey were spending well below their SSA on services for children,
the national picture was quite different, with most local authorities
overspending the SSA on services for children and families.
|
|
1.51
|
Nobody from these authorities could give a convincing explanation
as to why services for children and families were so significantly
underfunded. For example, in 1998/1999 the Brent SSA for children
and families was £28 million, whereas the amount spent was just
£14.5 million. Since the death of Victoria, Ealing, Brent and Haringey
have increased their budgetary provision for children and families.
It is my opinion that elected councillors and senior managers in
these authorities allowed the services for children and families
to become seriously under-funded, and they did not properly consider
the impact this would have upon their front-line services.
|
|
|
|
1.52
|
The management of the social care of children and families represents
one of the most difficult challenges for local government. The variety
and range of referrals, together with the degree of risk and urgency,
needs strong leadership, effective decision-making, reliable record-keeping,
and a regular review of performance. Sadly, many of those from social
services who gave evidence seemed to spend a lot of time and energy
devising ways of limiting access to services, and adopting mechanisms
designed to reduce service demand.
|
|
1.53
|
The use of eligibility criteria to restrict access to services
is not found either in legislation or in guidance, and its ill-founded
application is not something I support. Only after a child and his
or her home circumstances have been assessed can such criteria be
justified in determining the suitability of a referral, the degree
of risk, and the urgency of the response.
|
|
1.54
|
Local government in this country should be at the forefront of
organisations serving the public. Sadly, little I heard persuades
me that this is so. Many of the procedures that I heard about seemed
to me to be self-serving - supporting the needs of the organisation,
rather than the public they are set up to serve. Local authorities
should take the lead in promoting social regeneration and combating
social exclusion. In this regard, I have recommended that local
authorities become more closely engaged with their local communities
in defining local needs and the ways to meet them. Little I heard
in this Inquiry convinced me that local authorities accept that
in public service, the needs of the public must come first. This
must change.
|
|
Paragraphs: 1.1 - 1.13
| 1.14 - 1.26 | 1.27 -
1.33 | 1.34 - 1.46 | 1.47
- 1.54 | 1.55 - 1.63 | 1.64
- 1.68
|
|
|
|
1.55
|
The availability of services provided by social services departments
emerged as a very important matter. The 'out-of-office-hours' teams
in Ealing, Brent and Haringey were involved with Victoria to varying
degrees. Office hours cover, at best, 40 hours of the working week.
During the remaining 128 hours, a single member of staff, possibly
with little or no experience of services for children, is frequently
expected to cover all social care needs within an authority. Inevitably,
the intervention can only be limited until the full service is again
available. As families often experience problems during the times
when they are most likely to be together - during the evening and
at weekends - it is clearly unsatisfactory to provide services in
this restricted way. In future, local authorities should be funded
to provide specialist services for children and families on a 24-hour
basis, as do the other 'emergency' services, such as the police
and the health service.
|
|
|
|
1.56
|
The practice of using a front-line 'duty team' with agency staff
is totally unacceptable. This was particularly apparent in the way
Brent Social Services managed its duty commitments. Furthermore,
even the most able members of staff working on duty should at all
times have access to someone dedicated to the task of managing the
duty arrangements and supervising the work of the staff.
|
|
1.57
|
I was also concerned to learn that a locum junior hospital doctor,
with little knowledge of local child protection procedures, was
left unsupported at the Central Middlesex Hospital and allowed to
handle alone Victoria's discharge from hospital. This is also totally
unacceptable. No member of staff, from any of the agencies, should
be put in a position that places both them and their client, or
patient, in such a vulnerable position.
|
|
|
|
1.58
|
In addition to promoting better practice immediately, I hope that
this Report will be used for the training of future generations
of social workers, police officers and doctors and nurses. There
is a huge task to be undertaken to ensure that in each of the services,
staff are trained adequately to carry out their duties in the care
and protection of children and support to families. A balance between
theoretical teaching and practical training should be guaranteed
on all training courses. All staff appointed to any of the services
where they will be working with children and families must have
adequate training for the positions they will fill. However, along
with this general requirement of competence to do the job, it is
vital that all staff have the benefit of a period of induction that
covers, specifically, their roles in protecting children and supporting
families.
|
|
1.59
|
Supervision is the cornerstone of good social work practice and
should be seen to operate effectively at all levels of the organisation.
In Haringey, the provision of supervision may have looked good on
paper, but in practice it was woefully inadequate for many of the
front-line staff. This must change. The same is true for the police
and the health services.
|
|
|
|
1.60
|
I also heard much about front-line staff working with numerous
volumes of guidance, some of which was seriously out of date. In
Ealing, the field work manual was so out of date it did not include
reference to the Children Act 1989. In Haringey, there were no fewer
than 13 documents containing policies, procedures and guidance to
staff in relation to children's services. It was the belief of two
senior staff managers from Haringey that some staff had difficulty
in reading practice guidance because of problems with literacy.
|
|
1.61
|
Judging by the material put before the Inquiry, the problem is
less about the ability of staff to read and understand guidelines,
and more about the huge and dense nature of the material provided
for them. Therefore, the challenge is to provide busy staff in each
of the agencies with something of real practical help and of manageable
length. The test is simply one of ensuring the material actually
helps staff do their job.
|
|
|
|
1.62
|
Understandably, the agencies with whom Victoria came into contact
have asked the question: "If Victoria had been a white child, would
she have been treated any differently?" Having listened to the evidence
before me, it is, even at this stage, impossible to answer this
question with any confidence. Much has been made outside this Inquiry
of the fact that two black people murdered Victoria, and a high
proportion of the staff who had contact with her were also black.
But to dismiss the possibility of racism on the basis of this superficial
analysis of the circumstances is to misunderstand the destructive
effect that racism has on our society and its institutions.
|
|
1.63
|
As Neil Garnham QC put it so perceptively in his opening statement:
|
|
|
"Assumption based on race can be just as corrosive in its effect
as blatant racism ... racism can affect the way people conduct themselves
in other ways. Fear of being accused of racism can stop people acting
when otherwise they would. Assumptions that people of the same colour,
but from different backgrounds, behave in similar ways can distort
judgments."
|
|
|
He urged the Inquiry to "keep its antennae finely tuned" to the
possible effects of racial assumptions. This I have sought to do,
and return to the subject in section 16.
|
|
Paragraphs: 1.1 - 1.13
| 1.14 - 1.26 | 1.27 -
1.33 | 1.34 - 1.46 | 1.47
- 1.54 | 1.55 - 1.63 | 1.64
- 1.68
|
|
|
|
1.64
|
Throughout this Inquiry, it has been my firm intention to produce
a report that is unambiguous, and has a set of recommendations that
will strengthen the safeguards for children. It is my hope that
this Report will be read in its entirety. It is only by doing this
that readers will understand the full impact of the events surrounding
Victoria's life and death, the inter-relationships between them,
and the similarities of the issues emerging from the analysis of
practice and organisational factors in the three agencies charged
with Victoria's care.
|
|
1.65
|
Sadly, the Report is a vivid demonstration of poor practice within
and between social services, the police and the health agencies.
It is also a stark reminder of the consequences of ineffective and
inept management. Too often it seemed that too much time was spent
deferring to the needs of Kouao and Manning, and not enough time
was spent on protecting a vulnerable and defenceless child. This
must change. However, this Report is no more than a summary of what
was heard and can neither rehearse nor condense the vast amount
of the evidence that was put before me. That material will remain
available on the Inquiry's website for at least a year. (www.victoria-climbie-inquiry.org.uk)
|
|
1.66
|
It has felt as if Victoria has attended every step of this Inquiry,
and it has been my good fortune to have had the assistance of colleagues
whose abilities have been matched by their commitment to the task
of doing justice to Victoria's memory and her enduring spirit, and
to creating something positive from her suffering and ultimate death.
These colleagues have shared with me a determination that the Inquiry
should be open, fair and rigorous. Throughout, we have all kept
a clear focus on the facts and on finding out what happened to Victoria,
why things happened the way they did, and how such terrible events
may be prevented in the future. I am convinced that the answer lies
in doing relatively straightforward things well. Adhering to this
principle will have a significant impact on the lives of vulnerable
children. It is the duty of those in authority to see that this
happens. Unfortunately, none of us can bring Victoria back, but
we can all try to ensure that some lasting benefit comes from her
death, and that other children do not suffer a similar fate.
|
|
1.67
|
This Inquiry was established under three Acts of Parliament. In
this respect it is probably unique. I am solely responsible for
the content of this Report and any weaknesses it may have. However,
I am delighted that the four expert assessors, Dr Nellie Adjaye,
Donna Kinnair, John Fox and Nigel Richardson, endorse this Report.
The names of the whole Inquiry team are recorded in Annex 3. Each
has played their part to the full, and richly deserves the warm
tribute which I gladly pay them. They have been unfailing in the
help and support which they have given me. I am indebted to them.
It is invidious to make mention of individuals, because this has
been a real team effort. But some of my colleagues have carried
an exceptionally heavy workload and done so cheerfully. They are
Mandy Jacklin, Secretary to the Inquiry; Neil Garnham QC, Counsel
to the Inquiry; and Michael Fitzgerald, Solicitor to the Inquiry.
I am grateful to Neil Sheldon, Barrister, for assisting me in marshalling
evidential material, to Dr Valerie Brasse and Dr Susan Shepherd
for their assistance in drafting this Report, and to Paul Rees,
the Director of Communications.
|
|
1.68
|
It is the hope of the full Inquiry team that the horror of what
happened to Victoria will endure as a reproach to bad practice and
be a beacon pointing the way to securing the safety and well-being
of all children in our society.
|
|
|
Back to Top
|
