History of Victoria Climbie Inquiry - Child Abuse Problems

Victoria Climbie Story

3 Victoria's story

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3.1

This section looks in detail at the interaction between Victoria, Kouao and Manning, and the various professionals they came into contact with during the course of Victoria's life in this country. It gives a brief account of the evidence received by the Inquiry about Victoria's background. It also looks at the way she was treated by people who were supposed to have assumed responsibility for her welfare while she was in this country.

Victoria meets Kouao

3.2

Victoria Adjo Climbié was born near Abidjan in the Ivory Coast on 2 November 1991. She was the fifth of seven children and, according to her parents, she had a healthy and happy early childhood. She started school at the age of six and showed herself to be intelligent and articulate. She seems to have been a child who stood out.

3.3

Perhaps this was why Victoria came to the attention of her father's aunt, Marie- Therese Kouao, when she turned up at the Climbié house in October 1998. Kouao had lived in France for some years but was visiting the Ivory Coast to attend the funeral of her brother. She told Mr and Mrs Climbié that she wished to take a child back to France with her and arrange for his or her education. Apparently, Victoria was happy to be chosen.

3.4

In fact, Victoria was a late substitute for another young girl called Anna whom Kouao had originally intended to take. However, Anna's parents appear to have had second thoughts. This would explain why the 'daughter' named on the French passport used by Kouao and Victoria to gain entry into the UK was called 'Anna'. This was also the name by which Victoria was known throughout her life in this country.

3.5

Victoria's parents' reasons for allowing her to travel to Europe with Kouao fall outside the Terms of Reference of this Inquiry. It is not a matter I will be dealing with, except to observe that I have seen evidence which shows that entrusting children to relatives living in Europe who can offer financial and educational opportunities unavailable in the Ivory Coast is not uncommon in Victoria's parents' society.

3.6

After leaving her parents' house, Victoria travelled first to another part of the Ivory Coast, where she stayed with Kouao's brother. Shortly afterwards, probably some time in November 1998, she and Kouao flew to Paris.

Victoria in France

3.7

Victoria spent approximately five months in France. It is possible that she lived in Rue George Meliés, Villepinte, which was the address given by Kouao to Ealing Social Services shortly after they arrived in the UK. However, on other occasions she gave a different address, in Tremblay-en-France. There is little credible evidence available concerning Kouao's background, but it appears from documents the Inquiry has seen that her husband, whom she divorced, died in 1995. Before Victoria arrived, according to French social services, Kouao lived with her three sons, claiming welfare benefits.

3.8

In the beginning, Kouao seemed prepared to honour her promise to make sure Victoria received a proper education. Shortly after her arrival in France, Victoria was enrolled at the Jean Moulin primary school in Villepinte. However, by December 1998, Kouao began to receive formal warnings from the school about Victoria's absenteeism. The situation became serious enough by February 1999 for the school to issue a Child at Risk Emergency Notification. A social worker became involved and she reported a difficult 'mother and child relationship' between Victoria and Kouao.

3.9

Some of Victoria's absences from school were justified by medical certificates, all of which said she needed to rest. When she was at school, staff worried about Victoria's tendency to fall asleep in class. As a result, the school formed the view that Victoria was clinically unwell and being monitored and treated by doctors. The head teacher, Monsieur Donnet, also recalled Kouao mentioning that Victoria was suffering from some form of dermatological condition.

3.10

Some time in the spring of 1999, Kouao gave the school notice that she was removing Victoria so she could receive "treatment" in London. The home address of Esther Ackah was given as a forwarding address. Ms Ackah was a distant relative of Kouao's and the two had been in intermittent contact for the previous two years. When Victoria went to say goodbye to her classmates on 25 March 1999, Monsieur Donnet noticed that Victoria had a shaven head and was wearing a wig.

3.11

Why Kouao decided to leave France for the UK is unclear. For a long while before leaving, she had been claiming benefits that she was not entitled to. The French benefits agency was trying to recover money for these benefits, and this could have influenced her decision.

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Victoria arrives in the UK

3.12

Kouao and Victoria boarded a flight from Paris to London on 24 April 1999. They travelled on Kouao's French passport, in which Victoria was described as her daughter. The picture in the passport was not of Victoria but 'Anna', the child she had replaced. The two children did not look particularly similar so it is likely that Victoria was made to wear a wig so she looked more like the child in the photograph.

3.13

Kouao and Victoria travelled as EU citizens, so no immigration record of their arrival exists. However, the date they travelled can be established by the airline ticket that was later shown to Ealing Social Services by Kouao as proof of her identity. Kouao also presented documentation from the French travel company that arranged the trip.

3.14

When they arrived in the UK, Kouao and Victoria went to Acton and moved into a double room in a bed and breakfast in Twyford Crescent. The reservation had been made in France and lasted until 1 May 1999.

3.15

At about 4.30pm on 25 April 1999, Victoria and Kouao paid an unannounced visit to Ms Ackah. Ms Ackah had just come home from work when she heard the doorbell ring at her house in Hanwell, west London. Victoria was introduced to her as 'Anna'. Despite being somewhat taken aback by their presence, Ms Ackah invited Kouao and Victoria inside.

3.16

The first thing Ms Ackah noticed about Victoria was that she was wearing a wig. This was also remarked upon by Ms Ackah's daughter, Grace Quansah, who joined her in a visit to see Victoria and Kouao later that day. Ms Quansah removed the wig from Victoria's head to discover that she had no hair and her scalp was covered with patchy marks. She also thought Victoria looked rather small and frail, but neither she nor her mother noticed anything inappropriate or disturbing about Victoria's behaviour or her interaction with Kouao at this stage.

3.17

The following day, Kouao and Victoria visited Ealing's Homeless Persons' Unit because they needed somewhere to live when their week in Twyford Crescent ran out. The unit agreed to provide them with accommodation in a hostel situated at Nicoll Road, Harlesden, and they moved in around 1 May 1999.

The first warning signs

3.18

Over the next few weeks, Victoria and Kouao attended Ealing Social Services several times to collect subsistence payments and, on one occasion, to complain about the standard of their accommodation. During this period, concerns first started to emerge. A number of Ealing staff who saw Kouao and Victoria together during May 1999 noticed a marked difference between Kouao's appearance (she was always well dressed) and that of Victoria (who was far scruffier). Deborah Gaunt, who saw the two of them together on 24 May 1999, went as far as to say that she thought Victoria looked like an "advertisement for Action Aid".

3.19

It is unclear how Victoria passed her days during the first month she spent in the Nicoll Road hostel. No effort was made, either by Kouao or by Ealing Social Services, to enrol her in any form of educational or daycare activity, and there is no evidence to indicate she had any friends or playmates.

3.20

On 8 June 1999, Kouao took Victoria to a GP surgery on Acton Lane, Harlesden. Here she was seen by the practice nurse, Grace Moore. Nurse Moore did not carry out a physical examination of Victoria because she was reported not to have any current health problems or complaints. She felt there were "no child protection concerns that required follow up or reporting to other agencies".

3.21

Shortly afterwards, Victoria began to show what may have been early signs of deliberate physical harm. Ms Ackah, who had not seen Victoria since her visit six weeks earlier, bumped into her and Kouao on the street on or around 14 June 1999. Victoria was wearing a dress with long sleeves, leaving only her face and hands exposed. Ms Ackah noticed a fresh scar on Victoria's right cheek, which Kouao told her had been caused when Victoria fell on an escalator.

Victoria meets Manning

3.22

Later that same day, Victoria met Manning for the first time. He had been driving a bus boarded by Kouao four days before and the two had fallen into conversation. According to Manning, he gave Kouao his telephone number and she called him a few days later inviting him to visit her at Nicoll Road. This appears to have been the start of their relationship. It lasted until their arrest just over eight months later.

Anonymous telephone call

3.23

Ms Ackah was sufficiently concerned by what she had seen of Victoria in the street to visit Nicoll Road on 17 June 1999. She thought the accommodation was unsuitable for a child because it was dirty, cramped and ill-equipped. She also thought Victoria had lost weight since she had last seen her. A Ghanaian man was present and he told Ms Ackah he was concerned about the way Kouao treated Victoria. The following day, Ms Ackah made the first of her two anonymous telephone calls to Brent Social Services.

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Victoria and the childminder

3.24

By the middle of June, Victoria was spending the majority of her days being looked after by Priscilla Cameron, an experienced, but unregistered, childminder. Kouao approached Mrs Cameron when she (Kouao) got a job at the Northwick Park Hospital on 8 June 1999. Victoria's history was taken by Dr Rhys Beynon at the Central Middlesex Hospital on 14 July 1999 from Mrs Cameron's daughter, Avril. His notes record that Mrs Cameron had been caring for Victoria for the previous five weeks. Typically, Victoria would arrive around 7am and not be picked up until the evening, sometimes as late as 10pm.

3.25

There is nothing to indicate that Victoria was treated with anything other than kindness and generosity by Mrs Cameron during the days she spent at her house. She would watch television, draw, play and often took a nap after lunch. Her English improved and she appears to have struck up a good relationship with Mrs Cameron's adult son, Patrick, whom she showed how to dance. Mrs Cameron provided all her meals on the days Victoria came to stay.

3.26

Mrs Cameron was not greatly impressed by the way Victoria was treated by Kouao. She noticed that Kouao would often speak very harshly to Victoria. On one occasion, when Mrs Cameron mentioned to Kouao that Victoria would sometimes move household objects around when she should not, she was shocked to hear Kouao shout at Victoria that she was a "wicked girl", something she repeated on numerous occasions. Her unease was increased by a conversation she had with a woman she referred to as "Nigerian Mary", who asked Mrs Cameron what it was she said to Kouao that made her beat Victoria every night. Both Mrs Cameron and her son, Mr Cameron, recalled that Victoria would become very quiet and reserved when Kouao arrived at the house to take her home. Victoria tended to look down at the floor, rubbing her hands together, whenever Kouao was present.

3.27

On several occasions, Victoria turned up at Mrs Cameron's house with a number of small cuts to her fingers. When questioned about them, Kouao said they had been caused by Victoria playing with razor blades. Mr Cameron also noticed marks to Victoria's face, although these were not serious and he thought they could have been caused by ordinary childish rough and tumble.

Kouao and Victoria move in with Manning

3.28

Kouao's relationship with Manning developed quickly. On 6 July 1999, Victoria and Kouao moved into his flat at 267 Somerset Gardens. The flat was really no more than a small bedsit. There was a separate bathroom and kitchen area, but only one room for all three people to sleep in. The bedsit contained two sofa beds. Manning said Victoria slept on one of them, and he and Kouao slept on the other. This arrangement continued until October, when Victoria's sofa bed was thrown out and she began to spend her nights in the bathroom.

3.29

There is some evidence to suggest that Victoria's physical abuse increased considerably soon after she moved into Manning's flat. Both Ms Ackah and Mrs Cameron had seen marks on Victoria's face and fingers before July, but the injuries she was suffering from when she turned up at Mrs Cameron's house on the evening of 13 July 1999 seem to have been of a different order.

3.30

According to Mrs Cameron, Kouao was in an agitated state when she turned up on her doorstep that evening. She asked Mrs Cameron to take Victoria "for good" because apparently Manning was not prepared to tolerate Victoria living with him. Mrs Cameron refused but agreed to take Victoria in for one night because "the poor child was looking so ill". Kouao then presented Mrs Cameron with two large bags full of Victoria's clothes.

3.31

When she arrived, Victoria was wearing a baseball cap pulled down over her brow. When Mrs Cameron removed it, she saw what she took to be a burn the size of a 50 pence piece on Victoria's face. Mr Cameron also noticed three circular marks on Victoria's lower right jaw which looked to him "like injuries that had been healing for a little while". Both he and Mrs Cameron noticed Victoria's eyes were bloodshot, and Mrs Cameron also observed a loose piece of skin hanging from her right eyelid. Mrs Cameron's opinion as to the likely cause of these injuries is shown by the fact she asked Kouao who had burned and beaten Victoria. Kouao replied that all the injuries were self-inflicted.

3.32

Manning's account offers a different explanation. He said Victoria began to suffer from urinary incontinence very soon after she came to live in his flat. He told the police that this prompted him to hit Victoria. He recalled that he began by slapping her, but by the end of July he had started using his fist. It is highly likely that at least some of the injuries observed by the Camerons on the night of 13 July 1999 were the result of deliberate physical harm.

3.33

Mrs Cameron gave Victoria a clean pair of pyjamas and put her to bed. Later that evening, she heard groaning coming from the room and went in to see what was the matter. Victoria was asleep but Mrs Cameron saw that her face was swollen and her fingers were oozing pus. Mrs Cameron called her daughter Avril to come and look. They agreed that Victoria had to be taken to hospital.

3.34

The next morning, Avril Cameron took Victoria to see Marie Cader, a French teacher at her sons' school. She wanted to discover the cause of the injuries as well as get them treated. Ms Cader noticed injuries to Victoria's face and fingers, but Victoria was reluctant to talk about how she got them. She advised Ms Cameron to take Victoria to hospital.

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Victoria's first visit to hospital

3.35

Ms Cameron took Victoria to the accident and emergency department of the Central Middlesex Hospital around 11am on 14 July. Victoria was seen by Dr Beynon within an hour of her arrival. Dr Beynon took a history from Ms Cameron which, together with the results of a basic examination of Victoria, concerned him enough to refer the matter to a paediatric registrar. In his view there was a "strong possibility" that this was a case of non-accidental injury.

3.36

The paediatric registrar who saw her next was Dr Ekundayo Ajayi-Obe. She performed a more extensive physical examination than Dr Beynon and discovered a large number of injuries to Victoria's body, which she recorded on a set of body maps. She formed the view that at least some of Victoria's injuries might be non-accidental. Dr Ajayi-Obe arranged for Victoria to be admitted overnight and called Brent Social Services to inform them. The police were told and Victoria was placed under police protection at 5.20pm. The medical notes record the instruction that there were to be no unsupervised visits by Victoria's mother.

3.37

That evening, a very agitated and displeased Kouao discovered from the Camerons that Victoria had been admitted to the Central Middlesex Hospital. She went to the hospital and was there when Dr Ruby Schwartz saw Victoria as part of her evening ward round. As a result of her examination that evening, Dr Schwartz concluded Victoria was suffering from scabies.

3.38

Due to the infectious nature of scabies, Victoria was nursed in isolation for the rest of her stay on the ward. Victoria was extremely distressed to see Ms Cameron leave earlier that evening, but then seemed to settle down and, apart from wetting the bed, she passed a fairly uneventful night. The next morning, after the police had withdrawn their protection, Kouao returned to the hospital and left with Victoria.

3.39

The first agency they visited on leaving hospital was Ealing Social Services' Acton Area Office. Kouao left Victoria in the waiting room on her own for over an hour, much to the annoyance of a social worker named Pamela Fortune. They spent that night in a hotel in Wembley before returning to Somerset Gardens the next day.

3.40

On the way, they stopped off at the Camerons' house to collect Victoria's clothes. Mrs Cameron tried to speak to Victoria but she would not answer her. Mr Cameron was also there and recalled that Victoria seemed "totally different" from other times he had seen her. She would not smile at him and she did not respond when he said hello to her in French. The clothes were retrieved and Kouao and Victoria left. Apart from one occasion when Mrs Cameron saw Kouao and Victoria walking together down the street, the Camerons never saw either of them again.

Victoria's second visit to hospital

3.41

Just over a week later on 24 July 1999, Victoria was back in hospital. This time it was the North Middlesex Hospital and Kouao who brought her in. Her most urgent injury was a serious scald to the face, which Kouao said was caused by Victoria placing her head under the hot tap in the bathroom to try and relieve the itching caused by scabies. According to one of the versions of events put forward by Kouao, she had been asleep in bed at around midday when a scream from the bathroom woke her up. Victoria's burns were so serious she was admitted to the paediatric ward - known as Rainbow ward - where she stayed for the next 13 nights.

3.42

At about 11pm on 24 July 1999, Dr Simone Forlee, the senior house officer who first examined her, explained the position to Haringey Social Services. A more detailed referral was made three days later by Karen Johns, an Enfield social worker based at the hospital. As a result, a strategy meeting was held at Haringey's offices on 28 July 1999 and Victoria's case was allocated to a social worker - Lisa Arthurworrey.

3.43

A number of medical staff who cared for Victoria during her stay on Rainbow ward noticed marks on her body which they considered were signs of serious deliberate physical harm. Nurse Beatrice Norman saw what she thought was a belt buckle mark on Victoria's shoulder, and Nurse Millicent Graham noticed a mark which made her suspect Victoria had been deliberately burned. Nurse Grace Pereira, who bathed Victoria the following day, saw marks which led her to believe Victoria had been hit with a belt and bitten.

3.44

It seems Victoria had started to suffer serious deliberate harm by late July 1999. This is also indicated by her behaviour when Kouao and Manning came to visit her on the ward. She gave the impression of being frightened of them. When Kouao came onto the ward, Victoria changed from being lively and vivacious to withdrawn and timid, and the relationship between her and Kouao was recorded in the ward's critical incident log as being like that of "master and servant". On one occasion she was seen to wet herself while standing to attention in front of a seated Kouao, who was apparently telling her off.

3.45

Her reaction to Manning when he came to visit seems to have been similar. He said Victoria seemed "wary of his presence" and was anxious to keep her distance from him. Neither he nor Kouao ever brought Victoria anything in the way of clothes, food, toys or treats throughout the fortnight she spent in hospital.

3.46

When Kouao was not around, Victoria seems to have enjoyed her time on Rainbow ward. She certainly became something of a favourite of several of the nurses, including Nurse Lucienne Taub, a French speaker whom Dr Mary Rossiter, the hospital's named doctor for child protection, had asked to befriend Victoria. She liked to dress up and was given clothes to dress up in by the nursing staff. Nurse Taub would take her to see the babies in the neo-natal ward and bought her sweets and treats. According to Dr Rossiter, she was a "little ray of sunshine".

3.47

Apart from Kouao and Manning, the only other visitors Victoria received while in the North Middlesex Hospital were Ms Arthurworrey and PC Karen Jones. They visited on 6 August 1999 and, after speaking briefly to Victoria, decided it would be appropriate for her to be discharged back into Kouao's care.

3.48

The brief interlude in her life in this country during which Victoria was safe, happy and well cared for ended. She left the North Middlesex Hospital with Kouao at approximately 8pm on 6 August 1999. They went straight back to Manning's flat in Somerset Gardens where Victoria was to spend the remaining seven months of her life.

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The first social worker visit

3.49

During the course of those seven months, Victoria's contact with the outside world was limited and sporadic. Professionals saw her on only four separate occasions during this period. The first two times were home visits made by Ms Arthurworrey to Somerset Gardens. The other two occasions were at the beginning of November when Kouao took Victoria to Haringey Social Services' North Tottenham District Office. Here Kouao made, then later retracted, allegations that Victoria had been sexually harmed by Manning.

3.50

No representative from the Tottenham Child and Family Centre, to which she had been referred by Haringey Social Services on 5 August 1999, ever visited Victoria at Manning's flat. She was registered in November at the health centre that stands approximately 100 yards from Manning's flat, but she never attended it and none of the medical staff who worked there ever saw her.

3.51

The first of Ms Arthurworrey's two visits to Somerset Gardens took place on 16 August 1999, shortly after Victoria was discharged from the North Middlesex Hospital. She found her to be smartly dressed and well cared for. Victoria spent most of the visit playing with a doll - one of a number of toys seen by Ms Arthurworrey. Although Ms Arthurworrey did not talk to Victoria during the course of this visit, she formed the impression that Victoria was happy and seemed like the "little ray of sunshine" described by the nurses. As far as Ms Arthurworrey was concerned, the priority was to move Kouao and Victoria to alternative accommodation, because she did not think their current living arrangements were satisfactory.

3.52

Ms Arthurworrey did not ask Kouao how Victoria was spending her days at this stage. She was not enrolled in a school and there is no indication she participated in any form of daycare activity. Kouao no longer worked at the Northwick Park Hospital (her employment had been terminated due to prolonged absences) and so Manning's assumption that Kouao and Victoria spent most of their time in his bedsit seems correct.

Mr and Mrs Kimbidima

3.53

Some time in July, probably just before Victoria was admitted to the Central Middlesex Hospital, Kouao approached a man on the street and engaged him in conversation. They discovered that they both spoke French and the man, Julien Kimbidima, invited Kouao back to his house so that she could meet his wife, Chantal. Kouao visited the Kimbidimas again on 2 August 1999 (to celebrate their daughter's birthday) and appears to have struck up a friendship with Mr Kimbidima in particular.

3.54

Shortly after Victoria's discharge from the North Middlesex Hospital, Kouao took her to meet Mr and Mrs Kimbidima for the first time. Victoria appeared quiet and withdrawn, although she started to cry when Kouao told Mrs Kimbidima that Victoria was not her real daughter. Judging by the strength with which Kouao complained to the Kimbidimas, Victoria's incontinence had become serious by this stage.

3.55

The Kimbidimas saw Victoria several times over the following months, and Mrs Kimbidima sometimes looked after Victoria when Kouao was otherwise engaged. When at the Kimbidimas' house, Victoria would, on Kouao's instruction, sit quietly in the corner unless instructed to do otherwise. Once or twice she wet herself while at their house but she was never incontinent of faeces. According to Mrs Kimbidima, Kouao would shout at Victoria all the time and never showed her much affection. At one stage, Kouao told her that Victoria was possessed by an evil spirit.

Victoria and the church

3.56

Kouao visited church towards the end of August and this helps explain why she began to believe Victoria was possessed. Since her arrival in the UK, Kouao had shown an interest in attending church. According to Pat Mensah, a Baptist pastor based at a church in north west London, Kouao started visiting her church on a fairly regular basis from the middle of May 1999. The move to Manning's flat in early July may have prompted her to look elsewhere. On 29 August 1999, Kouao and Victoria attended the Mission Ensemble pour Christ, a church which meets in a hall close to Borough High Street.

3.57

The pastor here was Pascal Orome. He had a detailed recollection of Victoria's appearance at this stage. Despite the season, Victoria was dressed in heavy clothing that covered all of her body apart from her head and hands. He noticed wounds on both and advised Kouao to cut Victoria's hair shorter so that the injuries to her scalp could "breathe". Kouao told him about Victoria's incontinence and he formed the view that she was possessed by an evil spirit. He advised that the problem could be solved by prayer.

3.58

Two weeks after her first visit to his church, Kouao phoned Pastor Orome and told him that, following a brief improvement, Victoria's incontinence had returned. He claims he reproached her for being insufficiently vigilant and allowing the evil spirit to return. Whatever its cause, the incontinence appears to have continued throughout the rest of September because it was in October, according to Manning, that the sofa bed Victoria had been sleeping on was thrown out and she began to spend her nights in the bathroom.

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The second social worker visit

3.59

The bathroom in Manning's flat was small and the door opened out onto the living room. There was no window and, although there was a heater, it was either broken or unused. When Victoria was inside, the door was kept closed and the light was switched off. She began to spend her nights alone, cold and in pitch darkness.

3.60

However, Ms Arthurworrey noticed nothing untoward when she made the second of her two pre-announced home visits to Somerset Gardens on 28 October 1999. The purpose of her visit was to explain to Kouao that the housing application, made after the previous visit in August, had been turned down and to discuss the remaining options. Victoria seems to have been all but ignored during this visit as she sat on the floor playing with a doll. The fact that she was still not attending school was raised during the conversation, but no questions seem to have been asked about how Victoria was spending her days.

3.61

At his trial, Manning described this second visit of Ms Arthurworrey's as "a put up job". It seems that the flat had been made especially clean and tidy in preparation for the visit. This seems to be consistent with Ms Arthurworrey's evidence: she said she neither saw nor smelt any evidence of Victoria's incontinence. According to Manning, Victoria was told how to behave in front of Ms Arthurworrey. Victoria was said to be sleeping on the remaining sofa bed, with Manning and Kouao sharing a newly-purchased bed on the other side of the room. At the end of the visit, Victoria suddenly jumped up and shouted at Ms Arthurworrey. She said words to the effect that she did not respect her or her mother, and that they should be given a house. This behaviour surprised Ms Arthurworrey at the time.

3.62

During the course of their conversation, Ms Arthurworrey told Kouao that the council only accommodated children who were "at risk of serious harm" and that, in the council's view, Victoria was not at such risk. It may be no coincidence that within three days of this conversation, Kouao contacted Ms Arthurworrey to make allegations which, if true, would have placed Victoria squarely within that category.

3.63

On 1 November 1999, Kouao telephoned Ms Arthurworrey and told her that Manning had been sexually harming Victoria. Ms Arthurworrey told Kouao to come to her office. Kouao arrived with Victoria and Manning later that morning. Understandably, Ms Arthurworrey thought it would be better if Manning left. Kouao then cited three separate instances of sexual abuse. Victoria was then spoken to alone and repeated what Kouao had said, almost word for word. She appeared very anxious to be believed and both Ms Arthurworrey and the other social worker present, Valerie Robertson, thought she had been coached. However, in Ms Arthurworrey's view, Victoria did not seem to be "a particularly nervous, frightened or fearful child" on this occasion.

3.64

The short-term solution devised by Ms Arthurworrey to deal with the sexual harm allegations was to arrange for somewhere else for Victoria to stay while the allegations were investigated. A call was made to Mrs Kimbidima whom Kouao had identified as a friend who might be willing to help. It is unclear what precisely was agreed to by the Kimbidimas as a result of this telephone call. Mrs Kimbidima, whose English is far from perfect, may have initially agreed but later changed her mind having spoken about the matter to her husband. In any event, the result was that Victoria and Kouao left the office in a taxi bound for the Kimbidimas' house, but by the end of the day they were both back at Somerset Gardens.

3.65

The next day, Victoria and Kouao returned to north Tottenham to withdraw the allegations of sexual harm. They spoke to Rosemarie Kozinos who told Kouao that, despite the retraction, she and Victoria would have to live elsewhere while the matter was investigated. Kouao told Ms Kozinos that she and Victoria could continue to stay with the Kimbidimas. In fact, they simply returned to Somerset Gardens.

3.66

This was the last time any of the professionals involved in Victoria's case saw her before her admission to hospital on the night before her death. This fact, together with the incoherence of much of Kouao's evidence - both at her trial and before the Inquiry - means that any account of the last four months of Victoria's life must partly be guesswork.

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Victoria's last four months alive

3.67

It is likely that Victoria spent most of this four-month period in the Somerset Gardens flat. However, there is some evidence to suggest she made two trips to France towards the end of 1999. Manning recalled that he, Kouao and Victoria all went to Paris on or about 11 November. They stayed for a long weekend at Kouao's son's house where Victoria was allowed to sleep in a bed. Manning recalled no particular problems concerning Victoria's incontinence during the visit.

3.68

A second visit to France seems to have been made at the end of November. Following her arrest, a Eurostar ticket in Kouao's name was found at Manning's flat showing that she had travelled to Paris on 29 November 1999 and returned on 12 December 1999. No ticket was found for Victoria, but Manning was clear that she had accompanied Kouao on the trip. As he understood it, they had again stayed with Kouao's son.

3.69

Whatever the nature or purpose of these two visits to France, they appear to have made little difference to the pattern of Victoria's life when she returned to Somerset Gardens. She continued to be forced to sleep in the bath and, from November onwards, she was tied up inside a black plastic sack in an effort to stop her from soiling the bath. We know that these were her circumstances on New Year's Eve due to the disturbing entry in Manning's diary. In it he describes an argument with Kouao which ended by her returning to his flat in order to "release satan from her bag".

3.70

This refinement of the torture meant that Victoria spent extended periods lying in her own urine and faeces. The obviously corrosive effect this was having on her skin may have prompted Kouao and Manning to abandon this policy in January 2000. In his interview with the police, Manning suggested he and Kouao became worried that the condition of Victoria's skin might cause social workers to ask "undue questions". However, in his evidence to the Inquiry he was unable to remember the thinking behind the change.

3.71

Despite no longer being kept in a bag, Victoria began to spend more and more of her time in the bathroom in January 2000. Not only did she continue to sleep in the bath, but she also began to spend some of her days in it as well. This could explain why she was not with Kouao and Manning when they met Mr Kimbidima at a tube station around 16 January 2000. They told him they had left Victoria at home because her incontinence made it difficult to get things done.

3.72

At the start of the new year, Kouao and Manning began to serve Victoria her meals in the bath. This was done by placing the food on a piece of plastic, or a plastic bag, and placing it in the bath next to Victoria. She would generally be given whatever Manning and Kouao had cooked for themselves, but by the time it reached her it was usually cold. Given that her hands were kept bound with masking tape, she was forced to eat by pushing her face towards the food, like a dog.

3.73

As well as being forced to spend much of her time in inhuman conditions, Victoria was also beaten on a regular basis by both Kouao and Manning. According to Manning, Kouao used to strike Victoria on a daily basis, sometimes using a variety of weapons. These included a shoe, a hammer, a coat hanger and a wooden cooking spoon. The forensic examination of the flat after Manning's arrest revealed traces of Victoria's blood on the walls, on his football boots and on the undersole of one of his trainers. He also admitted to sometimes using a bicycle chain.

3.74

It is unclear what Kouao's intentions were at this stage. During the course of Ms Arthurworrey's home visit on 28 October 1999, they discussed the option of returning to France. However, despite the two visits to Paris, Kouao seems to have had little inclination to return permanently. Manning was under the impression that Kouao's intention was to send Victoria back to her parents in the Ivory Coast, but despite his obvious distaste for Victoria, he said he did not push the issue.

3.75

If this was Kouao's plan, she did little to advance it and Victoria's parents were not approached to see if they would be willing to have their daughter back. Instead, Kouao kept them in complete ignorance of Victoria's condition. In early 2000, they received a Christmas card from Kouao containing several photographs of a smiling Victoria. On the back of one photograph was written in French, "She's growing up well and she finds herself … well".

3.76

Given the very limited contact Victoria had with the outside world in the weeks leading up to her death, it is difficult to identify with any accuracy the speed with which her condition deteriorated to the state she was in when admitted to the North Middlesex Hospital on 24 February 2000. The pastor from north west London, Pat Mensah, recalled that Victoria seemed "a bit poorly" when she visited Somerset Gardens on 12 February. Although she neglected to mention it in her statement, during the course of her oral evidence Ms Mensah indicated that she was sufficiently concerned about Victoria's health at this point to advise Kouao to take her to a hospital. She also advised her to take her to a church.

Victoria returns to church

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There is evidence to suggest that by 19 February 2000, Victoria was very ill. On this day, which was a Saturday, Kouao took her to the Universal Church of the Kingdom of God housed in the old Rainbow Theatre on Seven Sisters Road. This was the church recommended to her by Ms Mensah during the course of her visit earlier that month. Audrey Hartley-Martin, who was assisting Pastor Alvaro Lima in the administration of the 3pm service, noticed the two of them coming up the stairs. They were shouting at each other and Victoria seemed to be having difficulty walking.

3.78

Kouao and Victoria were disturbing the service, so Ms Hartley-Martin took Victoria downstairs to the crèche. She noticed Victoria was shivering and she asked her if she was cold. Victoria replied that she was not cold but she was hungry. Ms Hartley-Martin obtained some biscuits for her and Victoria hid them in her pocket when Kouao came down to collect her. Ms Hartley-Martin said in evidence that she did not seek to ensure Victoria received any medical attention because she "was not aware that the child was ill".

3.79

At the end of the service, Pastor Lima spoke to Kouao about the difficulties she said she was having with Victoria, particularly her incontinence. He expressed the view that Victoria's problems were due to her possession by an evil spirit and said he would spend the week fasting on Victoria's behalf. He believes he made it clear that Victoria was not expected to fast herself. Kouao was advised to bring Victoria back to church on the following Friday morning. According to Pastor Lima, Friday was the day on which prayers are said for deliverance from "witchcraft, bad luck and everything bad or evil".

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The events of the next week unfolded as follows. On the Sunday, Kouao and Victoria returned to the church where they were seen by Pastor Celso Junior. Apparently, Victoria was quiet and well-behaved during the visit. On Wednesday, Kouao phoned Pastor Lima in the evening and told him Victoria's behaviour had improved in that she had ceased to cover the flat in excrement. On Thursday, Kouao phoned Ms Hartley-Martin and told her that Victoria had been asleep for two days and had not eaten or drunk anything. By the evening of the same day, Kouao was sufficiently concerned to bring Victoria to the church and ask for help. Pastor Lima advised them to go to the hospital and a mini-cab was called.

Paragraphs: 3.1 - 3.11 | 3.12 - 3.23 | 3.24 - 3.34 | 3.35 - 3.48 | 3.49 - 3.58 | 3.59 - 3.66 | 3.67 - 3.80 | 3.81 - 3.85

Victoria's final visit to hospital

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Mr Salman Pinarbasi, the mini-cab driver, was sufficiently concerned about the condition Victoria was in to take her instead to the nearby Tottenham Ambulance Station. She was then taken by ambulance to the North Middlesex Hospital and admitted to the casualty unit. On arrival, Victoria was unconscious and very cold. Her temperature was 27 degrees Celsius. Initial attempts to warm her up were unsuccessful and a paediatric consultant, Dr Lesley Alsford, was called in to take responsibility for Victoria's treatment.

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Dr Alsford arrived around midnight. Her examination of Victoria was limited because her first wish was to increase Victoria's temperature, which at this point was 28.7 degrees Celsius. In any event, she could not have recorded all the injuries she saw because they were "too numerous". She formed the view that Victoria needed the type of intensive care facilities unavailable at the North Middlesex Hospital. She tried to find space in another hospital and was eventually successful. A team from the paediatric intensive care unit at St Mary's Hospital Paddington arrived at 2.30am.

3.83

Victoria was transferred to St Mary's Hospital Paddington where she remained in a critical condition with severe hypothermia and multi-system failure. The medical staff were unable to straighten her legs. Over the hours that followed, Victoria suffered a number of episodes of respiratory and cardiac arrest. Her respiratory, cardiac and renal systems began to fail. At about 3pm, Victoria went into cardiac arrest for the last time. Cardio-pulmonary resuscitation was attempted but Victoria did not respond. She was declared dead at 3.15pm on 25 February 2000. She was eight years and three months old.

The post-mortem examination

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A post-mortem examination was carried out the following day by Dr Nathaniel Carey, a Home Office-accredited pathologist. He found the cause of death to be hypothermia, which had arisen in the context of malnourishment, a damp environment and restricted movement. He also found 128 separate injuries on Victoria's body, showing she had been beaten with a range of sharp and blunt instruments. No part of her body had been spared. Marks on her wrists and ankles indicated that her arms and legs had been tied together. It was the worst case of deliberate harm to a child he had ever seen.

The arrest

3.85

Kouao was arrested on suspicion of neglect at the hospital around 11.35pm on 25 February 2000. She told the police, "It is terrible, I have just lost my child." Manning was arrested the following afternoon as he returned to his flat. Both were subsequently charged with Victoria's murder and were convicted at the Central Criminal Court on 12 January 2001. Kouao and Manning are currently serving sentences of life imprisonment.

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