The Haringey social worker responsible for Victoria Climbie's case told the independent inquiry into the girl's death that she had been "out of her depth", overworked, and poorly supervised throughout her handling of the case.
During two-and-a-half days of evidence to the public inquiry, Lisa Arthurworrey accepted that she had made mistakes, but insisted that all her actions and decisions had been confirmed with her managers first.
She accused her original manager, Carole Baptiste, of being unavailable and of preferring to spend rare supervision sessions talking about God and her experiences as a black woman, rather than casework. She described Baptiste's successor, Angella Mairs, as a "bully" who did not like to be challenged.
Arthurworrey said there was no systematic evaluation of the way she handled Victoria's case, adding that her supervision sessions amounted to "me telling them what was happening in the case and then I was just handed a list of actions."
She said the total time dedicated to discussing Victoria's case by "the people who were supposed to be advising and assisting me" between August 1999 and February 2000 amounted to no more than half an hour.
She reminded the inquiry that, in August 1999 when she was allocated Victoria's case, she had had only 19 months' experience as a qualified social worker, had prepared only one case conference, had never carried out a joint section 47 investigation, and had a caseload of 19 cases, including 10 child protection cases.
Counsel to the inquiry Neil Garnham QC said Arthurworrey's evidence had highlighted 25 occasions on which she had failed to act appropriately, including her failure to reflect on and evaluate Victoria's case, her failure to report Victoria to the education authorities, her failure to speak to Victoria during a home visit, and her assumption that Victoria and her great aunt Marie-Therese Kouao had "moved on" when they failed to contact the department.
Arthurworrey said half of these occasions were at least to some degree the result of poor information or lack of managerial guidance.
However, she accepted responsibility for the other half, admitting that her most significant mistake had been her "dangerous assumption" that Kouao and Victoria had left the country when they failed to keep an appointment on 1 December 1999.
Arthurworrey told the inquiry she had also made a "big error of judgement" the day she decided the case was no longer one of child protection.
She said her whole perception had been altered by a fax from the Central Middlesex Hospital, which Baptiste believed justified the decision to return Victoria to Kouao's care. Victoria was subsequently reclassified as a family support case.
Arthurworrey admitted that an entirely different course of action would have been taken had she and Baptiste read the fax properly instead of assuming the front letter - which confirmed that marks on Victoria were due to scabies - was a fair summary.
Arthurworrey told the inquiry that, on 28 February 2000, following Victoria's death and a request from assistant director of social services Carol Wilson for a copy of the file, she saw Angella Mairs remove the final contact sheet from Victoria's file.
The sheet had Mairs' signature on it and indicated there should be "no further action".
She told the inquiry she had not known who to protest to, explaining that she had never met either the assistant director or the director, Mary Richardson, despite having been with Haringey social services department for 16 months at that stage.
She added that she had not initially reported the incident to the part 8 review panel because the panel had been "oppressive", "accusatory" and "not interested in finding the truth", and she had not felt comfortable.
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