1. Visits made by Kouao and Victoria to Ealing social
services during spring 1999
Social workers at Ealing dealt with the case, which was seen as a
housing and finance issue. Yet workers taking time off meant the
assessment process drifted. After two months, the case was
allocated to social worker Pamela Fortune. An assessment interview
was arranged with an interpreter but Marie Th’rŠse Kouao
attended alone and was unco-operative. Fortune found it difficult
to complete the assessment. Observations about the contrast between
Victoria’s and Kouao’s appearances and the lack of an obvious
mother and daughter relationship were not noted because they were
not deemed “important enough”.
Penny Thompson, executive director of social services at Sheffield
Council, says: “The document is clear: social services, health and
education, among others, should request and share information more
readily, and it sets out proposals for developing information
systems based on national standards. If this practice had been
followed, alarm bells would have rung that Victoria wasn’t in
school or taking up universal services that are available to every
Thompson says the first mistake was about the quality of the
assessment and priority afforded to the case. “The green paper
envisages a common assessment framework for vulnerable children
being implemented comprehensively across the country. With this,
such a contact will be the start of an assessment process, rather
than a single event.”
2. Anonymous phone call to Brent’s one-stop shop 18 June
1999 and visit to Nicoll Road 14 July 1999
Kouao’s cousin phoned Brent’s one-stop shop to report concerns,
including cuts and bruises on Victoria. But intake and duty team
manager Edward Armstrong claimed he never received a faxed referral
but only a telephone referral three days later that included
concerns only about Victoria wetting herself. The case was
consequently classified as a child in need. Armstrong said he
arranged two unannounced visits to Nicoll Road in Brent, where
Kouao and Victoria were staying in temporary accommodation. The two
social workers who made the visit found nobody home but a
connection was made later that day to a separate referral following
Victoria’s admission to Central Middlesex Hospital.
Caroline Abrahams, director of public policy at the NCH, says there
are a number of key issues the green paper raises including: how
easy it is for the public to convey child protection concerns to
the authorities, the effectiveness of administrative and recording
systems, and the capacity of agencies to share information. There
are questions about where responsibility and accountability lie and
issues to do with front-line staff and the quality of their
management and supervision.
She says:”The area we must do more than the green paper suggests is
in strengthening the links between child protection professionals
and communities and educating the public about child protection to
make it easier for concerns to be raised.
“I also hope the government will be prepared to invest the money
required over the next five to 10 years.”
3. Victoria’s admission to Central Middlesex Hospital on 14
Suspicions of non-accidental injury were overruled by consultant
paediatrician Dr Ruby Schwartz, who diagnosed scabies. Another
doctor wrote on the notes that there were “no child protection
issues”, a phrase repeated in the referral letter to social
services. Schwartz allowed Victoria to be discharged without
investigating the GP, school or childminding arrangements. She
assumed the latter two would be investigated by social services.
Andrew Dearden, chairperson of the British Medical Association’s
community care committee, says that human error and differences of
opinion among clinicians will always exist, but doctors would feel
more confident in making judgments if they had access to all the
information held by different agencies. “It can sometimes take two
days to get hold of a social worker and doctors are very busy. We
have been saying we want a single patient record for years.”
He welcomes the emphasis on information sharing and integration in
the green paper, but warns “all these problems have been identified
before. What we need now is for the government to price up the
solution in the green paper, make clear what its priorities are and
put its money where its mouth is.”
4. Victoria’s and Kouao’s visit to Ealing’s Acton area
office on 15 July 1999
When Kouao returned to Ealing social services the day after
Victoria was discharged from Central Middlesex Hospital, she was
told her case had been closed. Social worker Pamela Fortune said
she was unconcerned about Victoria’s welfare because Kouao had a
part-time job so she could provide financially. She also presented
as a loving mother. In a response to an inquiry from Brent, Fortune
sent a summary of Ealing’s involvement in Victoria’s case. Concerns
about Victoria being left alone in reception were not passed
Andrew Christie, assistant director of children’s services,
Hammersmith and Fulham Council, says the document could be a
“potentially significant” step in the right direction.
“The collective failure to protect Victoria was in part a failure
to properly apply analytic social work skills and, at this
particular ‘opportunity,’ keep in mind that children may always
require protection, even if the presenting problem is one of need.
“We should welcome the fact that the green paper has resisted the
idea of hiving off child protection to some specialist agency, as
though it is a discrete activity.”
He says that the key to many of the proposals working is ensuring
there are enough properly trained social workers with good support.
“We must welcome the government’s acknowledgement of the
recruitment crisis in social work, and the recognition that it is
particularly acute in London. It remains to be seen whether this
recognition is translated into action and properly resourced.”
He is disappointed that mention was not made of the same problem in
health visiting and school nursing.
He is “encouraged” with the emphasis on proper arrangements for
information exchange, but adds that the focus also needs to be on
exchanging information between authorities as well as agencies.
“If these had been in place then perhaps Victoria might have been
better protected as she, like many other vulnerable children, moved
5. Victoria’s admission to North Middlesex Hospital on 24
Victoria was not interviewed by a social worker until two weeks
after she was admitted to hospital, despite suspicions of abuse.
Communication between social services and hospital staff was poor
and consultant paediatrician Mary Rossiter says she failed to
realise that this was clearly a case of child abuse that had not
been comprehended by social services. Haringey social worker Lisa
Arthurworrey visited Victoria once she had been discharged but
failed to pick up any signs of abuse.
Janet Foulds is chairperson of the the British Association of
Social Workers. She says: “What the green paper is trying to do is
break down the barriers between the agencies so people have a
common language about what children need and how to address needs
when they appear.”
It is not just about co-location, but “making sure people are
trained to know what they should be communicating. Shared training
between the agencies is the way to bring that about”. She adds that
the common assessment approach is key to people sharing
information. Also: “Supervision is crucial. It is essential not to
overload workers and be absolutely clear about the expectations
around the case.” Foulds says it is “crucial” to attract high
calibre people through better rewards.
6. Referral to Tottenham Child and Family Centre, 5 August
Haringey senior practitioner Barry Almeida referred Victoria to the
NSPCC-managed centre. Once the case was allocated to practice
manager Sylvia Henry more than a week later, Almeida told her the
case was now closed as the family had moved away.
Catherine Watkins, team manager in a child assessment team at West
Sussex Council, says that the delay in the allocation of the case
and its subsequent tracking after referral would not be addressed
by the green paper as it is an internal procedure that “cannot be
“There could still be a delay in allocation as this is down to
resources and priorities,” she adds.
However, the proposed common assessment tool to prevent the
duplication of assessments may have enabled this opportunity not to
have been missed. Arthurworrey’s assessment of Victoria could have
been shared with staff at the family centre, enabling concerns to
be made clearer and at an earlier stage.
Plans for clearer accountability and to introduce a lead
professional on cases known to more than one specialist agency
certainly “would have made a difference” at this time, adds
7. Health visitor referral in early August 1999
The liaison health visitor at North Middlesex Hospital told the
inquiry that she referred Victoria’s case to a community health
visitor. It never reached her, so there was no follow-up
Mark Jones, director of the Community Practitioners’ and Health
Visitors’ Association, says that the removal of barriers to
information sharing and the adoption of common systems of
assessment and referral, plus defined and enhanced chains of
accountability are key.
“The referral system considered by Lord Laming was ad hoc whereas
we now have proposals leading toward common data standards on the
recording and transfer of information.
“The ability to identify a child passing through various agencies
and undergoing assessment in different health facilities – such as
the GP practice and accident and emergency – will go a long way to
ensuring everyone who is involved and the family has the most
contemporaneous information to hand.”
Clearer and in some cases entirely new lines of accountability will
also help, says Jones.
“From the requirement for an intra-agency lead professional,
through to the identification of a de facto lead for children at
local and national level, we will once and for all know who is
responsible for ensuring the child protection system is working
8. Visit to Manning’s flat in Somerset Gardens by Lisa
Arthurworrey on 16 August 1999
Lisa Arthurworrey visited Victoria and Kouao when they were living
with Kouao’s boyfriend Carl Manning. Arthurworrey believed the
master and servant relationship she saw between Victoria and Kouao
was typical of many African families. She insisted she came to this
conclusion only after noting that there were no concerns about the
relationship between the pair but admitted it should have been
discussed in supervision.
Mike Leadbetter is head of the Practice Learning Taskforce and
former president of the Association of Directors of Social
Services. He says that co-location, shared record keeping and
“flagging”, should make it less easy to overlook information.
However, he says that the issue of cultural assumptions is nothing
to do with the green paper.
“A master and servant relationship is not a healthy relationship
for a child no matter what the culture. There needs to be a debate
about cultural misperceptions and their influence on practice,” he
Leadbetter sees a key recommendation as being the suggestion of a
move to clinical social workers. “I would like to see a career
progression for social workers on the basis of the medical model.
Clinical practitioners would be at the top, paid much more than
they [social workers] are now. There could be consultants in child
protection and if there is a cultural misunderstanding then you
could go to them.”
9. Mary Rossiter’s letter received by Petra Kitchman, child
protection adviser, Haringey on 20 August 1999
The letter took a week to arrive at Haringey from North Middlesex
Hospital, which according to Kitchman was “not unusual”. Although
Rossiter suggested a referral to a child psychiatrist, social work
assessment and an urgent planning meeting, Kitchman thought a
section 47 investigation was under way and would include these
processes. However, a proper section 47 investigation had not been
Barnardo’s director of operations Chris Hanvey believes that the
common core assessment with a common language and approach “should
assist joint working”. The development of electronic social care
and health records and the proposed integrated case records
service, should also ensure “important communications shouldn’t
take a week to arrive”.
Greater accountability and joint working at a local level “should
speed up the referral to other professionals, such as child
psychiatrists”, he adds, but warns “it remains to be seen how far
children’s trusts will assist towards this”.
Local safeguarding children’s boards will have the power to hold
serious case reviews when things go wrong and the creation of the
new children’s services directors responsible for ending
silo-working should mean that “buck stopping will replace buck
10. Second letter from Rossiter to Kitchman dated 2
Rossiter’s second letter to Kitchman arrived on 9 September when
Kitchman was on leave, so it remained unopened until she returned
two weeks later. She assumed her manager would check her post.
She did not speak to Arthurworrey about it until 1 October 1999 and
admitted that she failed to provide her with any proper advice in
relation to Victoria’s case. In her reply to Rossiter, Kitchman
gave the impression that everything was in order but told the
inquiry that she was not “fully sure” because of Rossiter’s and
Schwartz’s conflicting views.
Alison King is chairperson of the Local Government Association
social affairs and health executive. She says: “Not opening a
letter is a management issue. It would have been normal for someone
else to open the mail.”
She sees the aim of the proposals as providing far greater
integration of work between professionals.
“There is always a chance that a child will be abused but the green
paper will minimise the possibility of abuse, filling in the gaps
to enable children to be better protected.”
She welcomes plans for identification, referral and tracking
numbers. “Children move around the country and there are often
delays with the paperwork catching up and they disappear from the
She hopes the emphasis on multi-agency working, creating a team
environment will give social workers more confidence by improving
11. Sexual abuse allegation on 1 November 1999
PC Karen Jones did not act on the allegation that Manning sexually
abused Victoria until after a strategy meeting because she agreed
with social services that it was false and a bid to obtain housing.
She was on leave for three weeks and failed to let her manager know
the case needed to be followed up urgently. Arthurworrey arranged
for Victoria and Kouao to stay with friends following allegations
that Manning sexually abused Victoria, although she failed to check
the adequacy of the accommodation as a refuge.
Ron Aitken is social services spokesperson for Haringey Liberal
Democrats. He says that the police’s limited child protection role
within the green paper proposals makes it unlikely this problem
would be addressed.
Police will be represented on the local safeguarding children
boards but Aitken fears “there will still be barriers working at
“Issues such as visiting a place where a child is staying and
reading a case file are very basic things and the legislation will
not make a difference here.”
But he believes that professionals working on the same site could
have helped to address some of the issues raised in these
circumstances, although he insists they still could have
communicated via telephone.
12. Three visits by Arthurworrey to Manning’s flat in
December 1999 and January 2000
Arthurworrey made the “dangerous assumption” that Kouao and
Victoria may have returned to France after they failed to turn up
at the social services department.
Ian Johnston, director of the British Association of Social
Workers, says that this assumption would have been less likely if
professionals weren’t so “fragmented”.
The proposals for health, social services, education and Connexions
professionals to work together in children’s trusts alongside plans
for multi-disciplinary teams working together in schools and
children’s centres means the numerous professionals who came into
contact with Victoria would have been working alongside one
With these in place professionals may not have made assumptions
about her whereabouts, according to Johnston.
There were supervisors in position to help Arthurworrey, and he
believes the greater accountability plans would have made a real
difference, with a clearer structure of accountability ensuring
case records were checked more frequently.
However, Johnston would like to have seen the introduction of a
probationary period for new social workers to have restricted case
loads for a year while they put their training into practice.