The Victoria Climbié inquiry revealed a high level of
decision-making based on mistaken assumptions. How does the green
paper on children ‘Every Child Matters’ approach such flawed
asks Amy Weir.
The green paper ‘Every Child Matters’ makes a series of
ground-breaking recommendations, some of which have flowed directly
from issues raised by the Victoria Climbié report, and
particularly from the 12 missed opportunities where intervention
could have saved Victoria’s life.
But while these missed opportunities are primarily actions and
events which did not take place, there was also a pattern of
thoughts and assumptions which affected the behaviour of those
involved. These fateful threads of assumptions, and how they
develop and are maintained, will also need to be addressed if any
of the green paper’s new systems or structures for
children’s services are to succeed.
Fixed assumptions, prejudices and mindsets can be powerful
influences on behaviour and decision-making, and their influence on
staff responsible for protecting children cannot be
under-estimated. Child death inquiries are full of examples of
information being misinterpreted or disregarded. Professionals did
or did not do things because they thought someone else was acting,
because they did not think it was important, because they thought
the family had moved and so on.
Three fateful assumptions
In Victoria’s case, there were three particularly fateful
threads of assumptions which clouded the thinking and behaviour of
many of those involved. The power of these mindsets grew in
significance over time and continued cumulatively to colour the
judgement of professionals.
1. Victoria’s worth as a person and as a
child with rights was not truly valued. The lack of clarity in
national policy about the position of economic migrant families
contributed to this; the family was seen as being in housing need
only. Victoria was not seen as the primary client and was invisible
in a family seen as transitory economic migrants within the rising
numbers of such families in London about whom policy was
In subsequent contacts with various agencies, she continued to
be seen in this light and this mindset about her
“worth” stuck. She was rarely spoken to, and the fact
that French was her first language was scarcely considered. In
addition, although we have a universal education service and
parents are legally required to send children to school, no-one
ensured that she was in school.
2. Early statements that Victoria had
definitely not been abused resulted in others who later came into
contact with her either denying or explaining away what they saw.
Even when there was clear physical evidence of abuse, the early
comments about Victoria having not been abused, but rather as
suffering from an infectious skin condition (scabies), were
recalled by practitioners as a reason for not visiting or checking
out her circumstances. She had been described as a child in need,
but not as in need of protection and this view took hold. The rule
of optimism dominated and, even when there was direct evidence of
physical abuse, some professionals failed to behave as though this
was the case or even to make sure that they saw her.
3. Professionals consistently assumed that
someone else had responsibility and did not exercise their own full
duty of care; on many occasions, professionals and agencies who
came into contact with Victoria failed to make sure not only that
they fulfilled their own role but also that others had taken up
their full responsibilities. As a result, her needs were neglected.
Even when serious concerns were identified that she had been
physically abused, it was assumed something was happening. It was
as though she ceased to matter and became someone else’s
responsibility – living in another area or the responsibility
of another agency to follow up.
These assumptions had a cumulative affect. They were used to
explain why things were not done and enabled professionals to lower
their guard, and to reduce the proper level of professional
scrutiny, which they should have exercised.
All professionals accountable
Does the green paper deal with mindsets and the danger they can
present? In fairness, it does not set out to examine the issues to
that level of detail. But, it is not clear that the structural
changes proposed would deal with these particular mindset issues,
which played a large part in how Victoria’s circumstances
were managed. All of those involved were accountable – maybe
not to one director of children’s services, but, even if they
had been, would things have been different? It is ironic that, in
the end, it was an asylum-seeking minicab driver who took control
and ensured she received medical treatment, albeit too late.
As far as Victoria’s worth as a black child is concerned,
there is comparatively little reference in the green paper to the
diverse child population in England, or to the need to ensure that
we provide services that serve all ethnic minority children well.
We know it is important to have good representation of ethnic
minority staff in services if we are going to ensure all children
receive the services they need. However, the workforce part of the
green paper does not address the under-representation of ethnic
minorities in the most senior managerial posts within
The green paper stresses the importance of good quality
supervision and support for staff. It does not spell out why this
is so important in this complex work, when there may be conflicting
evidence about the circumstances of a child. Although the green
paper describes what the structure – through schools and
children’s centres – will be for safeguarding children,
it does not spell out how exactly multi-disciplinary teams will
operate to ensure safe practice.
The green paper quite rightly stresses the need for clear
accountability. The evidence from Victoria’s case is that it
is accountability and the duty of care at all levels which must be
appropriately exercised. However, it is hard to see how the green
paper’s emphasis on a top-down model of managerial
accountability within a very large infrastructure will necessarily
ensure that there is appropriate individual and professional
Simply introducing a director’s post will not deliver true
root and branch accountability at all levels and particularly at
the frontline. A director of children’s services, as
proposed, will have very wide-reaching responsibilities both in
scale and also in terms of professional remit. Many commentators
have criticised the green paper for advocating structural change as
the solution in a one-size-fits-all model. It is far more important
to empower and support frontline staff to take ownership of their
own practice and development by all the very sensible means in the
paper about raising status and improving conditions.
The approach of the green paper could well deliver a safer and
more effective delivery of children’s services. The starting
point needs to be at the frontline. In my view, its reforms need to
be developed from the bottom-up, building on existing alliances and
networks and making sure practice is challenging, confident and
thorough. Rushing into new structures will potentially be divisive,
and will mean that children are not necessarily being put first and
placed at the heart of everything we do.
Instability in services
The green paper seems to suggest a two-stage structural change
to directors and then to trusts by 2006; this will be challenging
for organisations and staff alike, and may well lead to uncertainty
and instability in services. A one-step introduction of trusts with
health as well as education and social services starting together
would be much less disruptive and is likely to deliver results more
Lord Laming suggested in the Victoria Climbié report that
it is the day-to-day interactions which make all the difference. It
is the qualities and effective practice of staff at the frontline
(singly and together) – teachers, doctors, social workers,
nurses and others – that will ensure children’s safety
and help them achieve the twin aims of the paper.
Growing better services by supporting best practice on the
frontline will take time, but it will be worth the investment.
Above all, we need to make sure that we focus on results –
the best possible outcomes for children and what enables these to
Amy Weir is deputy director, children and families
department, Somerset Council. As lead inspector of
children’s services performance at the Department of Health,
she was one of the first professionals to review Victoria
Climbié’s case. She wrote a briefing for ministers on
the case in December 2000.