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Victoria Climbie's case could and should have started and finished in Ealing, says Lord Laming in his report into her murder by her great-aunt Marie-Th'rŠse Kouao and boyfriend Carl Manning: "The only reason Kouao was referred to Ealing social services was because of Victoria's needs - but these were ignored and the focus was on Kouao."

The reason for this was that Ealing's front-door services (Laming's shorthand for a family's first point of contact with social services) were poorly organised - a pattern that was repeated with all the agencies with which Victoria came into contact. So it is far from surprising that Laming wants all local authorities to prepare a statement on the true picture of the strengths and weaknesses of their front-door duty systems for children and families.


Laming wants children who are the subject of allegations of deliberate harm seen and spoken to within 24 hours of the allegation being reported to social services. But many believe this should already be happening as standard good practice.

Ben Jones (not his real name), a team manager of a children and families team, agrees, but adds that there has to be an element of discretion for the system to work. "Any trawl of child protection referrals will show that there's ambiguity or conflicting information about the extent of harm or risk of harm. The main issue is for social workers and managers to have the right post-qualifying training, resources and management systems within which to practice, and to be given the autonomy and respect to decide whether that child needs to be seen that day, a week later, or whether a conversation with the teacher or health visitor over the phone is sufficient for that day."

And, rightly or wrongly, staff resources help to create the threshold, says Jones. "If a teacher rings in to say a six-year-old boy has said his mother often hits him but there's no sign of injury, and a referral comes in about a six-month-old baby with a suspicious fracture and another where a mother has left her two young children on their own for seven hours, and you only have two social workers available, the boy at school doesn't come anywhere near top of the priority list."

Such timescales are a minimum standard, says Steve Love, assistant director and head of children and family services at Hampshire social services department. And, although they need to be in place, he is cautious about a minimum standard being set and then everyone thinking everything is going to be all right. "You could have one case where waiting one hour is too late, while for another situation, spending a week assessing the case and talking to people might be better than going in with heavy-handed panic."

Laming has much to say about improving the quality and effectiveness of front-line social work. A key measure in keeping children safe is an accurate assessment during a home visit. Recommendation 34 says that social workers must not undertake home visits without being clear about the purpose of the visit, the information that needs to be gathered and the steps to be taken if no one is at home. No visits should be undertaken without the social worker checking whether other child protection agencies have any information about the child.

Lisa Arthurworrey, Victoria's allocated social worker at Haringey social services department, made two announced home visits. Although she didn't talk to Victoria during the first visit in August 1999, her impression was that she was happy. By the time of the second visit in October, Victoria was already sleeping in the bath, but Arthurworrey noticed nothing untoward. Manning later admitted that the flat had been specially cleaned for the visit.

The opportunities for being manipulated on a home visit are great, says Janet Foulds, deputy chairperson of the British Association of Social Workers and a team manager in a children's services department. Untrained, unqualified or inexperienced social workers may take things at face value. Without proper back-up from a experienced supervisor who can question the evidence, they run the risk of getting it wrong. While assessing the situation, a social worker can be victimised, bullied or manipulated by the family to see things through their eyes, which can take the emphasis away from the child.


"If you are going to be in contact with people who may be abusing their children you need to be fully trained and aware as to how you, the worker, can be drawn into these abusing dynamics," says Foulds.

A social worker needs to be a skilled communicator and know the signs and symptoms of child abuse - for example, recognising bruises from normal play and those that are non-accidental, and understanding that a child clinging to a parent does not always mean they are close.

It is asking a lot of them, says Foulds. "The quality of the assessment is as good as the person's ability to perceive."

As a front-line social worker for London's Westminster social services department, Keith Warren is well aware of the difficulties in a home visit. "It's very difficult to gauge [abuse] when the parents will not leave the room. I go there with a remit to speak to the child. You have to reach the client on their level, inform them of the power you have as the worker and the repercussions if they don't allow you access."

Good front-line services need trained social workers and competent supervisors, he says. "Social workers will make mistakes. You need a supervisor who can pick up on them and look at what is being presented."

Victoria's case had an inexperienced worker, no supervision, lack of communication and a couple determined to keep the truth from the worker, which ensured a catalogue of wrong turns, says Foulds.

The greatest irony, says Laming, is that Victoria's case was closed by Haringey on the day she died. Hence recommendation 26, which states that social services directors must ensure that no case involving a vulnerable child is closed until the child and the child's carer have been seen and spoken to and a plan for safeguarding welfare agreed. If this had been good practice Victoria's life might have been saved. In the last few weeks before Victoria died a social worker called at her home several times. When there was no reply she assumed they had moved. "It is possible that at the time Victoria was in fact lying just a few yards away in the prison of the bath, desperately hoping someone might find her," says Laming.

Part of Laming's new vision for children's services is a recommendation to replace the child protection register with a plan to safeguard and promote a child's welfare. Whether Laming wants to scrap registers altogether is unclear, but most agree with the sentiment in his proposal that removes the emphasis from registering to planning. As Love says: "Registering a child is no use at all unless you have a child protection plan."

Jones agrees: "The focus of the child protection meeting should be on what is going to be done by whom and when, and not primarily whether the child fits a particular category." He, and others, would be reluctant to see the register scrapped as it is an important indicator, not just for identifying need but also the type of abuse being perpetrated.

Will Laming's vision for front-door and front-line services work? It will, if the government puts its money where its mouth is, says Foulds. "A lot of it is about making sure that resources and training are in place to equip front-line workers. Then you can start holding people to account. If they don't come up with the goods we will struggle on until the next tragedy."