analysis of how chaos in local authority offices contributed to mishandling of Victoria Climbie`s case

The inquiry has revealed chaotic, busy and unsettling
offices in Haringey, Ealing and Brent. But how much did this affect
the handling of Victoria’s case,
asks Jonathan

There is a scene in Francis Ford Coppola’s Vietnam film epic
Apocalypse Now in which the protagonist Captain Willard arrives at
a bridge deep in the jungle held by American forces. It is a
situation reminiscent of hell, with the frightened soldiers
fighting an enemy they cannot see, and seemingly without any sense
of command or control.

Willard finds a GI who seems to know what he is doing and asks
who is the commanding officer. The soldier simply stares at him,
fires a mortar into the jungle and replies: “What CO?”

The comparison may seem extreme, but in the film’s depiction of
a military outpost too far, Haringey’s front-line workers in the
North Tottenham district office’s duty investigation and assessment
team at the time of Victoria Climbie‚’s case might recognise
some of the pressures of isolation, lack of support and chaos
endured by the soldiers.

The inquiry evidence has revealed chaotic and over-pressurised
offices in Haringey, Ealing and Brent; poorly funded and badly
managed environments in which it seems surprising that more did not
go wrong.

“Basically there was just too much work for the social workers
to manage,” says Victoria’s social worker Lisa Arthurworrey in her

Shanti Jacobs, a team manager in the Hornsey district office,
describes the “bombardment factor” in the Tottenham office.
Everybody, she says, was placed under intense and unceasing demands
by the sheer volume and persistence of work that needed to be

The council was also undergoing fundamental restructuring during
1999, which created “a sense of uncertainty”, as well as low
morale. In March, the number of team managers was cut from 12 to
six – managers had to apply for their own jobs.

By the end of 1999, staff resignations had become a
“haemorrhage”, according to a council report.

Social worker and Unison convener Pauline Bradley says the
restructuring had a “devastating effect”, adding: “I think it was
maybe the major factor in Victoria’s death.”

The restructuring came out of a funding shortage. But Haringey
may have exacerbated the problem by spending at least £10m
less on children’s services than it should have done during

The budgetary evidence is still to be resolved, but what is
certain is that front-line workers were under-resourced, a factor
that might explain the staff vacancy rates of around 30 or 40 per
cent – and sometimes above. Caseloads were always higher than
recommended limits. At Haringey, staff were expected to carry no
more than 12 cases at any one time – a maximum of nine child
protection cases and three family support cases. In August 1999,
Arthurworrey had 19 cases – nine child protection, eight family
support and one looked-after child.

Commissioning manager David Duncan says it is hard to imagine
how a social worker could work on more than 12 cases at a time and
that the practical maximum would be 14 to 16.

And the line management that might have alleviated that pressure
was not there. During Victoria’s seven months with Haringey,
Arthurworrey had three managers, with little constructive

Carole Baptiste was Arthurworrey’s line manager from August to
November 1999. Despite being employed full-time, Baptiste was
rarely there, Arthurworrey and others claim. They say that, during
rare supervisions, she would spend two-thirds of her time
“discussing her experiences as a black woman and her relationship
with God”. Case files were not read, and there was little or no
cross-examination of the social worker’s actions or opinions.

Although with her two subsequent managers – Rose Kozinos and
Angella Mairs – there was no talk of personal religion, race or
gender, Arthurworrey describes a similar pattern where little was

In short, Arthurworrey felt alone, isolated and overworked. The
office was under-resourced, badly run and demotivated. Furthermore,
personality clashes and enmity were splashed all over the

She describes the office in terms of a school, with Mairs and
Kozinos as the headmistress and head girl, and the social workers
as children.

Ealing and Brent Councils had similar problems. During 1999,
Ealing, which dealt with Victoria and Kouao’s case between April
and July, was on special measures following a highly critical
inspection by the Social Services Inspectorate in 1997.

The following year saw new senior management, before
restructuring began. But on the front-line, the workers were
“swamped”. In Ealing’s homeless persons unit – where Marie-Therese
Kouao first presented – each officer would deal with between three
and five new cases on a “duty day”, but would also carry between 35
and 50 open cases.

In the social services department, social worker Pamela Fortune
says the office would deal with about 50 or 60 new enquiries each
day, most of them asking for financial assistance and

Senior practitioner Sharmain Lawrence describes practice at the
time as “very, very baseline”. She had no induction training when
she joined, there was a backlog of cases, the newly created
referral and assessment team could not deal with the workload,
case-tracking systems were antiquated, and office systems generally
were in disarray.

At Brent, which had the least involvement with Victoria, senior
management plead lack of resources for the pressure that their
services and workers were under. But, as with Haringey, evidence
suggests the council was spending far less – £26m over two
years – on children’s services than they were meant to be. The
staff vacancy rate was also high during 1999, with a consequent
reliance on agency workers to meet demand. Workload, too, was
described as “heavy”, while lack of training and inexperienced
staff were also issues.

Meanwhile, at the Metropolitan Police’s child protection teams –
variously known as the “Cinderella department”, “the baby sitters”
or “the cardigan squad” – things were not much better. Child
protection work lacked the high status of other specialised police
work – a situation exposed by the Climbie‚ case that has
forced the Met to completely overhaul its child protection

At the time, however, its teams were understaffed, overworked
and lacking in any resources or management. The work itself had
been downgraded so that police officers were assigned to teams
without any training or qualifications in detective work –
essential for investigating physical or sexual abuse of

PC Karen Jones – based at Haringey Child Protection Team during
1999 and the officer who dealt with Victoria’s case – details the
drop in staff levels, which meant the workload was “more
pressurised because of the volume of work”. Such teams also lost
out on resources. Equipment, premises and transport were either
non-existent or inadequate.

The story is repeated in all the agencies involved in Victoria’s
death. Those giving evidence have often said that the front-line
pressures were not directly responsible for Victoria’s death. Maybe
that is true, but the feeling still remains that collectively they
must have had a bearing.

Soundbite quotes

– “The Duty Investigation and Assessment Team reminded me of a
school. Angella Mairs was the headmistress, Rose Kozinos was the
head girl and the social workers were the children.” Haringey
social worker Lisa Arthurworrey

– “Nobody appears in Haringey social services to take the
responsibility for what went wrong. Everybody is pointing the blame
to somebody else.” Counsel to the inquiry Neil Garnham

– “New desks and new chairs are not very useful if you have no
one to put behind them.” Haringey senior practitioner Rose

– “Most people thought I was stark raving bonkers.” Haringey
director of social services Mary Richardson, on her move to

– “Haringey is not a quiet place. That is one of the joys of
working there.”

Mary Richardson

– “I’m dangerous when I’m silent.” A furious Lord Laming,
inquiry chairperson, reacting to news that Haringey was submitting
yet more late documents

– “Was it not the obvious way to deal with this problem, as the
number of cases grew, not to depend on scribbling notes on sheets
of paper, but to computerise it? This is not 1970, this is 1998-9.”
Neil Garnham quizzing Ealing senior commissioning manager Judith
Finlay on the council’s case-tracking system

– “You obviously have not experienced local authority
infrastructures.” Judith Finlay’s reply

– “It is an imperfect science, social work.” Judith Finlay

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