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According to many professionals, new technology and the beefing up of area child protection committees would help ensure that the kind of communication errors which contributed to Victoria Climbie's death do not reoccur. Mark Hunter reports.

If the various agencies involved in child protection found sharing information as easy as passing the buck then Victoria Climbie might never have died. As witness after witness at the recent inquiry gave their accounts of the disjointed sequence of interventions in Victoria's case, a sorry story emerged of individuals working on different pieces of the jigsaw with no one able to see the whole terrifying picture.

The breakdowns in communication were astonishing to outsiders. Victoria was seen by more than 70 different professionals during her 10-month stay in the UK. At least 12 different opportunities to intervene were missed. But while housing officials dealt with her housing issues and doctors treated her wounds, health visitors didn't visit, social workers remained unaware of the risk and police officers failed to investigate.

Concerns about Victoria's safety were raised at almost every juncture, but were lost in the cracks between professions or within the black hole that appears whenever someone moves between boroughs in London. Important information was left scribbled on scraps of paper, messages were not passed on, computer systems were incompatible, and searches for the records of at-risk children failed because of a simple misspelling of their name.

The situation was summed up at the inquiry when lead counsel Neil Garnham QC questioned Ealing's senior commissioning manager Judith Finlay on the mess within the council's case-tracking system. "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."

"You obviously have not experienced local authority infrastructures," was Finlay's reply.

Some of the lack of communication came about because of a disturbing ignorance among different professions over each other's roles and responsibilities. Doctors, police officers and housing officials clearly felt that child protection was the role of social services. Yet social workers would often defer to the judgement of other professions. For instance, when consultant paediatrician Ruby Schwartz diagnosed Victoria's skin condition as scabies, social services stopped investigating the case. Yet Schwartz described herself as "stunned and puzzled" when she heard that Victoria had been taken off the at-risk register.

In the series of seminars that have formed the second stage of the inquiry, a number of solutions have been suggested to ensure the breakdown in communication does not happen again. One suggestion from the inquiry chairperson Lord Laming is that "virtual teams" could be set up using computer systems to link different professionals so that each would be aware of what the other was doing.

Such a scheme has already been developed in Bradford and is due to be launched as a pilot project within the next two months.

Constructed in co-operation between Bradford Council, the Bradford area child protection committee and software company Liquidlogic, the system aims to provide an interactive link between medical staff in the local primary care groups, paediatricians at the region's two teaching hospitals, the police child protection unit and the social services child protection unit.

Rather than trying to achieve compatibility between the various agencies' disparate computer networks, the system uses software that is able to dip into the relevant databases and retrieve the necessary information. Computerised protocols aim to ensure that access is limited to authorised personnel and that only the relevant data can be retrieved. Although Richard Bates, Bradford's manager of policy performance and commissioning (children) baulks at the term "virtual agency", he claims the system will "enable professions to look at what others are doing and see what stage they are at in a particular case."

Importantly it will offer "a real-time view" of exactly what contact has taken place with whom, what information has been gathered and what actions taken by the individual parties. "It means you won't have to wait three days for a letter to arrive before you know something has happened," says Bates.

The system will also be able to bring together snippets of information that on their own do not appear significant but which viewed together may indicate that a child is at risk. "For instance, if there have been two separate queries about a particular child, the system can flag that up and alert social services so that they can have a closer look," says Bates.

Bates claims that had such a system been available to agencies involved with Victoria Climbie, an electronic multi-agency case file would have been created at her first presentation to a care provider. This would have been augmented by each subsequent contact and been available to clinicians when she presented at hospital. "Her injuries could then have been assessed in the knowledge of her referral to social services made a month earlier."

The idea of virtual child protection teams has also met with cautious approval from the Association of Directors of Social Services.

In his submission to the Victoria Climbie inquiry ADSS president Michael Leadbetter expresses interest in exploring "the model of virtual child protection teams operating to specific national standards and outcomes".

Leadbetter is quick to stress, however, that inter-agency interaction should involve more than a few clicks on a computer mouse. "The ADSS has long argued that a close working relationship between the relevant professionals is a key component in protecting children."

And in one recent and perhaps encouraging example of inter-agency co-operation, the ADSS has joined forces with a number of children's charities, the Local Government Association, the NHS Confederation, the Royal College of Paediatrics and Child Health, the Society of Education Officers and the Metropolitan Police to urge the government to strengthen the role of area child protection committees. In a joint statement they are calling for ACPCs to be placed on a statutory footing and jointly funded to oversee national policies for protecting children.

Social services director of Kensington and Chelsea, Moira Gibb believes ACPCs may also be able to help combat the loss of information between local authority boundaries and to encourage professions other than social workers to take more of an interest in child protection. In her submission to the Victoria Climbie inquiry Gibb calls for ACPCs to tackle the disincentives experienced by some professions to following up concerns about children.

"Housing departments and other agencies which deal with the public should be enabled to understand the system through some form of participation in ACPCs," she says. "For complex areas such as London where children frequently cross authority boundaries there should be a regional ACPC or strategic and problem-solving body to ensure collaboration across organisational boundaries."

Of course the moves to strengthen ACPCs may also be designed to head off calls for the creation of a separate agency whose sole role is child protection. This suggestion has been vehemently opposed by the ADSS, which believes that a separate agency would simply strengthen false perceptions that at-risk children form a discrete group.

In fact there appears to be little support within any of the professions involved in child protection for a widespread organisational change. According to John Ransford, the Local Government Association's director of education and social policy, it is not so much the system that needs to be changed as the whole concept of multi-agency working. The current rigid demarcation of roles within a team can create a reluctance to challenge across professional and agency boundaries, he says.

"The LGA would like to see the establishment of individual personal authority, enshrined in procedures as part of multi-agency team working."

Perhaps if this concept of personal authority can be combined with that of personal accountability we will be spared the experience of another inquiry in which each professional witness tries to blame the next for the lack of communications that contributed to a child's death.