So why did so many agencies let Victoria down?

Herbert Laming is heading up the inquiry into the death of
Victoria Climbie. In an interview with Community Care, he tells
Lauren Revans how the inquiry will make a difference to children’s

As Lord Laming takes on his awesome task of heading the
statutory inquiry into the death of eight-year-old Victoria Climbie
(also known as Anna), he does so armed with no more than a
provisional list of issues and an open mind.

In terms of what the inquiry will consider, he is prepared to
rule anything in, provided it is backed up with hard evidence. He
insists that assumptions, preconceptions and ideals will have no

“It doesn’t matter what our previous experience, background,
skills or knowledge are,” says Lord Laming, former chief inspector
of social services, about himself and his soon-to-be-announced team
of experts. “This inquiry makes no assumptions. It is not committed
to anything other than to learn the truth and to evaluate evidence,
then to make recommendations.”

Victoria died from abuse and neglect in February 2000 at the
hands of her great-aunt Marie-Therese Kouao and Kouao’s boyfriend
Carl Manning.

Following the couple’s imprisonment for life in January 2001
health secretary Alan Milburn took the rare step of announcing a
statutory inquiry to examine the events surrounding Victoria’s
death and the actions of the agencies with which she had come into

In the 11 months between Victoria’s arrival in England in March
1999 and her death, the London councils of Ealing, Brent, Haringey
and Enfield all had some involvement in her case. Brent and Harrow
Health Authority, Enfield and Haringey Health Authority, the North
West London Hospitals NHS Trust, the North Middlesex Hospital NHS
Trust and the Metropolitan Police Force were also involved.

According to Lord Laming, it was for this reason that the
decision was taken to set up the complex tripartite inquiry to
supplement the internal inquiries already being carried out by
individual agencies. This will have a statutory base encompassing
the Children Act 1989, the NHS Act 1977 and the Police Act

Lord Laming judges that the driving force behind the inquiry was
that the case covered such a wide range of agencies, yet no one was
able to prevent the tragedy.

He also says it was the number of agencies involved, and
therefore the number of witnesses to be heard, that was partially
to blame for the extension of the inquiry’s deadline to Spring

Additional time is also required to allow as yet unknown
witnesses to come forward. Advertisements inviting anyone with
helpful information to offer to the inquiry are due to appear in
the local press and in trade publications.

“There may be people out there who had real concerns about
Victoria and tried to do something about it and their concerns were
ignored. I don’t know whether that’s true, but we’ve got to create
some space so that people can come forward. We want to do this job

This, according to Lord Laming, is all part of the openness that
will be central to the inquiry. He urges organisations and
individuals to recognise the opportunity provided by the inquiry to
shape the future of child protection and to come forward to submit

“I want the inquiry to be characterised by its independence, its
openness, its rigour, and its fairness,” he says. “I will be
informed by the evidence I get. If people believe the current
system provides all the safeguards that are necessary for children
and if the issue is not about changing the current system but
making sure that it is implemented and works then that is
potentially a persuasive point. But I don’t rule anything in or
rule anything out. This is an opportunity.”

At the end of April, terms of reference for the inquiry were
published and immediately met with claims that the team’s remit was
too narrow.

The terms of reference focus on the circumstances leading to and
surrounding Victoria’s death, the services sought or required in
respect of Victoria, Kouao, or Manning, and the way in which the
different agencies involved responded to those needs, discharged
their functions, and worked together and with others.

The inquiry team must then reach conclusions as to the
circumstances leading to Victoria’s death, and make recommendations
to Milburn and home secretary Jack Straw “as to how such an event
may, as far as possible, be avoided in the future”.

Lord Laming believes that rather than limiting the scope of the
inquiry, the terms of reference will allow the team to do “exactly
the job of work” he had anticipated and help the discussion of
wider issues.

The inquiry will be conducted in two parts. The first aims to
understand exactly what happened to Victoria and why the events
took place. The second will consider the ways in which safeguards
to protect children can be improved.

In between the two will be a “period of reflection” to identify
issues of wider significance from witness statements and other
evidence, which will then go on to inform the second part of the

“I have tried to refer to wider issues,” he says. “But I am not
anticipating what those wider issues are. I am trying to emphasise
that I start with an open mind. It is for other people to produce
what evidence they wish to the inquiry.”

Lord Laming’s provisional list of issues for part one of the
inquiry already introduces the subjects of immigration, social
security benefits, child minders, and the church in relation to
Victoria’s personal circumstances.

In relation to social services, the list considers race and
cultural issues; case management and monitoring arrangements; the
training, experience and caseloads of staff involved; the
supervision and management of staff; and the extent to which local
policies and procedures reflect statutory requirements and national

Other sections examine the issues of agency co-operation, and
the lessons learned by the various agencies involved.

“It’s called provisional because we are making absolutely no
assumptions about what is going to emerge in the course of our
work,” he said. “I don’t want people to think that this issues list
is the final thing because it isn’t the final thing. It’s where we
are now.”

Lord Laming refuses to be drawn on suggestions for reform put
forward by the children’s charity the NSPCC in their recent report
Out of Sight.1 The report argues for the
establishment of child death review teams, the appointment of a
children’s commissioner in each country, and increased powers for
area child protection committees.

Neither does he rule out “root and branch reform” or the
transfer of child protection services to the police. But he does
acknowledge that the child protection system in the UK is, at least
in theory, “an incredible system that would stand comparison with
any country in the world”.

“We have this tremendous guidance from the Department of Health
on working together,” he says. “The fact is that, on paper, it
ought to be impossible for something like this to happen. But it
has happened. So that’s why there’s going to be an inquiry.”

Lord Laming denied suggestions that an inquiry held in public
would encourage a blame culture or result in the vilification of
individuals involved in the case, and said he believed instead that
it would help restore public confidence.

“Although we need to look at what happened to Victoria, the
public concern out there is much more general about why it happened
and how it happened and how that could be prevented in the future,”
he says.

He also distanced his inquiry from the matters of discipline and
the internal investigations being carried out by individual
agencies. Five social workers and eight child protection police
officers are currently facing disciplinary action.

“My view is that all of these staff are employees of an
organisation,” Lord Laming says. “And it is the organisation that
is accountable in delivering effective services.

“We will be looking at a wide range of issues and not solely at
the performance of individuals. And we will handle individuals with
care and sensitivity.”

Cost was often identified as a flaw of public inquiries during
the 1980s. “We will try to be efficient and we will certainly use
money in a responsible and careful way,” he says, denying there
were any blank cheques. “But it’s in everybody’s interest that we
do a thorough job.”

So, as Lord Laming and his team begin their task, it is evident
that they are not the only ones with their work cut out.

It is now the responsibility of all organisations and
individuals who have been waiting for an opportunity to comment on
the child protection system to seize it and provide Lord Laming
with the evidence he so desires.

“The inquiry has the power to make recommendations to avoid an
occurrence of this again – and that is why I’m very keen that
people realise this is serious business,” Lord Laming says. “If
people want me to consider [ideas], they’ve got to produce
evidence. This is not idiosyncratic, this is not an individual
approach. This is about really rigorous sifting of evidence, really
rigorous testing of any ideas that come along.”

1 NSPCC, Out of Sight – An NSPCC Report
on Child Deaths from Abuse 1973-2000
, NSPCC, 2001. Available
from 020 7825 2775.

A full record of proceedings will be posted at



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