One thing the Laming report could not do was say "never again". Sadly, since Victoria Climbi''s murder, there have already been other no less terrible child care tragedies and scandals, such as the killing of toddler Ainlee Labont'. But what Laming can still signify is a break with the past. This must not be a responsibility that is laid solely at the door of the inquiry team. What really matters is what is done now that the report has been published.

The enormous expectations attached to the inquiry are a measure of the awfulness of what happened to Victoria and how she was failed. Her death has become one of those major modern occasions where there seems to have been a collective sense of empathy for a stranger's fate. She has become an embodiment of the betrayal, vulnerability and public abandonment of children. The inquiry must mark the end of child protection policy built on a hopeless process of child care tragedy, scandal, inquiry, findings, brief media interest and ad hoc political response. There is now a rare chance to take stock and rebuild.

I recently asked some of our social work students in their last year of qualifying training - an experienced and diverse group - what they saw as the positives and negatives facing them as prospective professional practitioners. The negatives included lack of support from managers and agencies, lack of resources and the media scapegoating of social work. The positives included having the support of team members and being able to make a difference. What most struck me, was their commitment to service users and their determination to keep at it. The odds are still stacked against this kind of commitment. This is no recipe for a safe and consistent service. Social work and social care must not trade on the dedication of workers like these. It must provide the conditions for their positive practice.

What Victoria's tragedy highlighted was systemic failure: failure across and between organisations and services; failure of commitment, support, resourcing, management and culture. Truly, it also represented a failure of humanity. We saw failure among social workers, but this can only be understood as part of a much bigger problem in approaches to and valuing of public services - particularly public services for powerless and devalued people. We need to review service cultures, organisations, working relationships and management systems to challenge this.

The trawl for solutions now needs to go beyond the traditional calls for restructuring, more training and new organisations. These haven't worked before. There is no reason to imagine they will work in the future. A national child protection agency sounds a good idea. But how will it actually make a difference?

What I found most difficult about Victoria's tragic end was how the service system seemed to dissociate workers from their ordinary human understanding. Not to speak to the child? From outside, it seems so difficult to understand.

Communication with the child, involving children, must be the starting point for real change. There is now a large and growing body of experience in a range of fields about how to involve children, including very young children, in effective and imaginative ways. We know how to gain their views of health care, their environment, of loss. We know how to do this in safe, sensitive and respectful ways, individually and collectively. The government has signalled its commitment to user involvement for children as well as adults. The Department of Health now has a senior officer with specific responsibility for advancing the involvement of children and young people. We must also learn and profit from the massive body of knowledge of service user organisations and movements accumulated over decades. This is an urgent priority for future child protection practice and policy.

The real lesson to learn from the tragic death of Victoria Climbi' must be why no one spoke to her - why no one listened to her. How could this happen? How can we make sure that it can never happen again? Sadly we know that children will always be at risk of violence and abuse. But this must not be made a mantra for political or professional complacency.

One real achievable target for the future is that there are no more child killings or suffering because agencies did not make every effort to speak and listen to the child.


Peter Beresford is professor of social policy, Brunel University, and is involved in the psychiatric system survivor movement