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Climbie inquiry told of gaps in the child protection safety net

The hearing into the death of Victoria Climbie began last week. Lauren Revans reports on the opening statements of an inquiry set to consider evidence from 232 witnesses

During the 10 months Victoria Climbie spent in England, she was known to 70 health, social, and child care professionals. Yet somehow she suffered alone.

Only when she arrived at St Mary's Hospital in Paddington, west London, at 3.10am on 25 February 2000 did the gravity of her situation finally hit home.

Climbie was pronounced dead at 3.30am that same morning, having suffered repeated episodes of respiratory and cardiac arrest. A post- mortem carried out the following day confirmed that the eight-year-old, brought from her home in the Ivory Coast, west Africa, by her great-aunt Marie-Therese Kouao, had died of hypothermia as a result of neglect and ill-treatment.

Last week marked the start of the hearings of the independent public inquiry set up to establish the circumstances leading to and surrounding Climbie's death, to consider the services sought or provided for her and her "carers", and to make recommendations to the health and home secretaries as to how such an event may be avoided in the future.

The first phase of the inquiry is expected to last until late December, with 144 witnesses due to take the stand. In all, 232 witnesses have been required to give evidence.

The opening statement by counsel to the inquiry, Neil Garnham QC, serves as a reminder that, far from being an "isolated act of madness" or being "hidden away, out of sight of the authorities", Climbie's suffering was both prolonged and detectable. "The signs were there," he pointed out. "But they went unheeded."

Garnham insisted there were "at least 12 chances" when timely and appropriate action on the part of the agencies charged with duties of child protection might have saved Climbie.

While acknowledging that agencies have to work within their resource limitations, Garnham concluded: "When information about a child comes to the attention of such an agency, it is vital that it is used effectively to safeguard that child's welfare. The missed opportunities to do so in Victoria's case are central to an understanding of the way in which she was failed by the services whose function it was to protect her."

In particular, Garnham described the nature and scale of the opportunity to protect Climbie afforded by her admission in late July 1999 to North Middlesex Hospital as "unique in the history of the case".

Climbie was admitted to the north London hospital with scalds to her head and face and remained an in-patient there for two weeks, during which time numerous professionals commented on the scars and marks to her body, the strange relationship between her and the woman purporting to be her mother, and the feasibility of Kouao's story that Climbie had scalded herself.

Garnham said this opportunity to protect Climbie was "entirely squandered". He drew attention to the failure of hospital social worker Karen Johns to examine the girl before referring the case to Haringey social services department; the failure of Haringey social worker Lisa Arthurworrey and child protection officer PC Karen Jones to assess Climbie's needs or carry out a visit to her home prior to her discharge; and the failure of nursing and medical staff to arrange follow-up care or to challenge Kouao.

However, the agencies that came into contact with Climbie, Kouao, and Kouao's boyfriend, Carl Manning, are not prepared to take all of Garnham's criticisms lying down.

Enfield Council denied inappropriate action on the part of its employee, Johns. Enfield's lawyer, Mr Verdan, told the inquiry that Johns had acted in line with Enfield child protection guidelines where child abuse is suspected in a non-Enfield case, and had referred the matter to Haringey social services within 26 hours of Climbie being brought to her attention.

He said she had passed on the information about the girl, including concerns about marks and the strange "mother-daughter" relationship, "clearly and unambiguously".

Outlining Arthurworrey's defence, Jane Hoyal argued that the relatively young and inexperienced social worker "relied upon the advice she was given by her team manager, and acted at all times in accordance with that advice". Hoyal told the inquiry that Arthurworrey's then team manager, Carole Baptiste, was later replaced having been found "professionally unfit for her job".

Hoyal claimed Arthurworrey was sent no discharge summary or comprehensive report by North Middlesex Hospital, and that information faxed to her by a nurse and a telephone conversation with consultant paediatrician Dr Mary Rossiter prior to Climbie's discharge "indicated a lack of serious concern in relation to any likelihood or risk of physical abuse faced by Victoria".

Hoyal added:"Neither Lisa nor any other social worker in her position could be expected to have knowledge of medicine which could in any way enable them to not accept entirely the medical opinions that they were provided with."

Evidence from Arthurworrey and Jones indicated that they decided not to visit Manning's home to assess Climbie's living conditions after Jones was advised by a nurse in the hospital's accident and emergency department that scabies - the skin disease diagnosed in Climbie by Central Middlesex Hospital three weeks earlier - was highly infectious. Instead, Kouao was invited to a meeting, after which Arthurworrey and Jones agreed there were no grounds for seeking an emergency protection order.

Haringey's lawyer, Elizabeth Lawson QC, said Haringey was satisfied that the concerns of emotional abuse and neglect raised by nursing and medical staff were jointly investigated by Arthurworrey and Jones.

She also pointed out that social workers' hands were tied by the legal framework surrounding child protection proceedings, which require any allegations of abuse to be substantiated with evidence - not suspicions - before action can be taken.

Lawson stated: "The key question, therefore, is whether at any stage Haringey had sufficient evidence, not merely to justify bringing emergency or care proceedings, but to satisfy a court that this child should be removed from her home. Haringey believes it did not."

So the stage is set for months of inter-professional wrangling over the circumstances that allowed an eight-year-old girl to die at the hands of her "carers".

Haringey has denied that its staff were given clear evidence by other agencies of non-accidental injuries, and has accused Garnham of applying "different weights and measures" to the doctors and nurses from those being applied to social workers.

But the council is also keen to ensure that the inquiry and the public do not lose sight of the real villains in this tragic story. "Social workers did not kill this little girl, nor did the system," Lawson says. "She was brutalised and murdered by those who should have cared for her. It is [Kouao and Manning] who caused her death, not the doctors, not the police, not the social workers."

In a week when Association of Directors of Social Services president Moira Gibb is warning of the danger of more children falling through the child protection safety net, it seems appropriate that Hoyal should end her opening defence with a plea for the inquiry to appreciate "the juggling of human resources by busy public servants, which results in overworked individuals embarking on careers with high expectations, which are replaced with excessive workloads, which they have to do because there is no one else to do it".

Hoyal added: "We hear this week that there are thousands of vacancies for social workers. Perhaps one of the reasons is the way society treats social workers, particularly junior social workers, in the expectations that are put upon them and the inadequate resources that they are given."

Twelve "missed opportunities" to save Victoria

- Visits made by Kouao and Climbie to Ealing social services during the spring of 1999.
- An anonymous phone-call made to Brent Council's one-stop shop on 18 June and the consequent visit to Kouao's bed-and-breakfast accommodation on 14 July.
- Climbie's admission to Central Middlesex Hospital with suspected non-accidental injuries on 14 July.
- The visit by Kouao and Climbie to Ealing Council's Acton area office on 15 July.
- Climbie's admission to North Middlesex Hospital on 24 July with scalds to the head and face.
- Climbie's referral by Haringey social services department to the Tottenham Child and Family Centre on 5 August.
- The liaison health visitor referral in early August.
- The visit to Manning's house by Haringey social worker Lisa Arthurworrey on 16 August.
- A letter from consultant paediatrician Dr Mary Rossiter to Haringey social services department on 20 August.
- A further letter from Dr Rossiter dated 2 September.
- Allegations by Kouao that Manning had sexually abused Climbie on 1 November.
- Three visits by Arthurworrey to Manning's home in December 1999 and January 2000.

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Free nursing care: do the sums add up?

The arrival of free nursing care in England has brought with it fears that the funding pot will need a fair amount of topping up. Jonathan Pearce checks the figures

The introduction of free nursing care in England this week should be a cause for celebration. Instead, the government faces accusations of broken promises, unfairness, and an unworkable system for assessing and delivering that care.

From 1 October, people living in nursing homes who pay for their own care will have their nursing care costs paid by the NHS. Nursing care covers care provided by a registered nurse, including the planning, supervision or delegation of care.

But splitting nursing from personal care discriminates against those people with long-term illnesses such as Alzheimer's and arthritis, claim organisations campaigning on behalf of older people.

"The government's artificial boundary to define nursing care will result in many thousands of older people still having to pay for the bulk of their care, ie personal care," says Age Concern England director general Gordon Lishman.

"Personal care is about sustaining life," adds Help the Aged head of policy Tessa Harding. "Drawing a line between nursing and personal care is a false distinction."

Nursing care will be assessed using the registered nursing care contribution RNCC tool that allocates residents into one of three bands: low, medium and high need, at £35, £70 and £110 per week respectively.

The RNCC tool is meant to dovetail with the single assessment process (SAP) to be introduced next April. In the future, agencies will use a "person-centred" and "standardised" system based on four broad types of assessment: contact, overview, in-depth and comprehensive old age assessment. A detailed care plan will follow the SAP.

If the patient or user is set to enter a nursing home, the RNCC tool draws on the SAP and the care plan in working out the appropriate level of registered nursing input.

A "holistic approach" should be taken which also addresses the "key dimensions of instability, predictability, intensity, risk and complexity of needs", according to Department of Health guidance.

Age Concern England, along with others, claims the system will place an extra burden on nurses and nursing managers, whose first priority should be caring for older people.

Another issue is the funding itself. When the DoH first consulted, it planned to give health authorities £80m for an estimated 35,000 self-funding nursing home residents for the six months between October 2001 and April 2002, including £2.6m for administration and care management costs.

With the final guidance published a matter of days before free nursing care begins, a DoH survey of England's 97 health authorities shows about 42,700 self-funders. The estimate has been adjusted to 42,000 self-funders and the overall budget has risen to £100m, but this now includes £6m for continence supplies and an unspecified amount for administration and management.

This all adds up to a tightening of the budgetary framework. The DoH estimates 10 per cent of people will fall into the low need band, while the rest will be split equally between the other two bands. Do the maths (see box) and it adds up to £92.3m.

Assuming the previous administration costs of £2.6m (which, with over 7,000 more people, may be higher) and taking out the "continence supplies" money, the DoH has allocated only £91.4m for nursing care - a shortfall of nearly £1m.

This may be an acceptable margin of error - about 1 per cent - and fewer people may fall into the higher bands, but it does little to forward the claims of a needs-led service.

And, of course, these arrangements only cover England. Last week the Scottish executive announced it was pressing ahead with its plan to implement free personal and nursing care from April next year. It will pay £90 per week for personal care, and an additional £65 per week for those needing nursing care. In Wales, the story too is different: a flat payment of £90 a week for nursing care.

Did someone say "postcode lottery"?

Funding for nursing care

Total funding for free nursing care between 1 October 2001 and 31 March 2002: £100m (including £6m for continence supplies and an unspecified amount for administration and management costs)

- Total available for free nursing care: £91.4m (assuming £2.6m administration costs)costs)
- Number of self-funders in nursing homes: 42,000

Nursing care band      % of self-funders       Total free nursing care

Low - £35 pw              10 per cent                   £3.8m
Medium - £70 pw        45 per cent                   £34.4m
High - £110 pw            45 per cent                   £54.1m           
Total                                                               £92.3m