News analysis of the Climbie inquiry and fears over the funding of free nursing care

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Climbie inquiry told of gaps in the child
protection safety net

hearing into the death of Victoria Climbie began last week. Lauren Revans
reports on the opening statements of an inquiry set to consider evidence from
232 witnesses

the 10 months Victoria Climbie spent in England, she was known to 70 health,
social, and child care professionals. Yet somehow she suffered alone.

when she arrived at St Mary’s Hospital in Paddington, west London, at 3.10am on
25 February 2000 did the gravity of her situation finally hit home.

was pronounced dead at 3.30am that same morning, having suffered repeated
episodes of respiratory and cardiac arrest. A post- mortem carried out the
following day confirmed that the eight-year-old, brought from her home in the
Ivory Coast, west Africa, by her great-aunt Marie-Therese Kouao, had died of
hypothermia as a result of neglect and ill-treatment.

week marked the start of the hearings of the independent public inquiry set up
to establish the circumstances leading to and surrounding Climbie’s death, to
consider the services sought or provided for her and her "carers",
and to make recommendations to the health and home secretaries as to how such
an event may be avoided in the future.

first phase of the inquiry is expected to last until late December, with 144
witnesses due to take the stand. In all, 232 witnesses have been required to
give evidence.

opening statement by counsel to the inquiry, Neil Garnham QC, serves as a
reminder that, far from being an "isolated act of madness" or being
"hidden away, out of sight of the authorities", Climbie’s suffering
was both prolonged and detectable. "The signs were there," he pointed
out. "But they went unheeded."

insisted there were "at least 12 chances" when timely and appropriate
action on the part of the agencies charged with duties of child protection
might have saved Climbie.

acknowledging that agencies have to work within their resource limitations,
Garnham concluded: "When information about a child comes to the attention
of such an agency, it is vital that it is used effectively to safeguard that
child’s welfare. The missed opportunities to do so in Victoria’s case are
central to an understanding of the way in which she was failed by the services
whose function it was to protect her."

particular, Garnham described the nature and scale of the opportunity to
protect Climbie afforded by her admission in late July 1999 to North Middlesex
Hospital as "unique in the history of the case".

was admitted to the north London hospital with scalds to her head and face and
remained an in-patient there for two weeks, during which time numerous
professionals commented on the scars and marks to her body, the strange
relationship between her and the woman purporting to be her mother, and the
feasibility of Kouao’s story that Climbie had scalded herself.

said this opportunity to protect Climbie was "entirely squandered".
He drew attention to the failure of hospital social worker Karen Johns to
examine the girl before referring the case to Haringey social services
department; the failure of Haringey social worker Lisa Arthurworrey and child
protection officer PC Karen Jones to assess Climbie’s needs or carry out a
visit to her home prior to her discharge; and the failure of nursing and
medical staff to arrange follow-up care or to challenge Kouao.

the agencies that came into contact with Climbie, Kouao, and Kouao’s boyfriend,
Carl Manning, are not prepared to take all of Garnham’s criticisms lying down.

Council denied inappropriate action on the part of its employee, Johns.
Enfield’s lawyer, Mr Verdan, told the inquiry that Johns had acted in line with
Enfield child protection guidelines where child abuse is suspected in a
non-Enfield case, and had referred the matter to Haringey social services
within 26 hours of Climbie being brought to her attention.

said she had passed on the information about the girl, including concerns about
marks and the strange "mother-daughter" relationship, "clearly
and unambiguously".

Arthurworrey’s defence, Jane Hoyal argued that the relatively young and
inexperienced social worker "relied upon the advice she was given by her
team manager, and acted at all times in accordance with that advice".
Hoyal told the inquiry that Arthurworrey’s then team manager, Carole Baptiste,
was later replaced having been found "professionally unfit for her

claimed Arthurworrey was sent no discharge summary or comprehensive report by
North Middlesex Hospital, and that information faxed to her by a nurse and a
telephone conversation with consultant paediatrician Dr Mary Rossiter prior to
Climbie’s discharge "indicated a lack of serious concern in relation to
any likelihood or risk of physical abuse faced by Victoria".

added:"Neither Lisa nor any other social worker in her position could be
expected to have knowledge of medicine which could in any way enable them to
not accept entirely the medical opinions that they were provided with."

from Arthurworrey and Jones indicated that they decided not to visit Manning’s
home to assess Climbie’s living conditions after Jones was advised by a nurse
in the hospital’s accident and emergency department that scabies – the skin
disease diagnosed in Climbie by Central Middlesex Hospital three weeks earlier
– was highly infectious. Instead, Kouao was invited to a meeting, after which
Arthurworrey and Jones agreed there were no grounds for seeking an emergency
protection order.

lawyer, Elizabeth Lawson QC, said Haringey was satisfied that the concerns of
emotional abuse and neglect raised by nursing and medical staff were jointly
investigated by Arthurworrey and Jones.

also pointed out that social workers’ hands were tied by the legal framework
surrounding child protection proceedings, which require any allegations of
abuse to be substantiated with evidence – not suspicions – before action can be

stated: "The key question, therefore, is whether at any stage Haringey had
sufficient evidence, not merely to justify bringing emergency or care
proceedings, but to satisfy a court that this child should be removed from her
home. Haringey believes it did not."

the stage is set for months of inter-professional wrangling over the
circumstances that allowed an eight-year-old girl to die at the hands of her

has denied that its staff were given clear evidence by other agencies of
non-accidental injuries, and has accused Garnham of applying "different
weights and measures" to the doctors and nurses from those being applied
to social workers.

the council is also keen to ensure that the inquiry and the public do not lose
sight of the real villains in this tragic story. "Social workers did not
kill this little girl, nor did the system," Lawson says. "She was
brutalised and murdered by those who should have cared for her. It is [Kouao
and Manning] who caused her death, not the doctors, not the police, not the
social workers."

a week when Association of Directors of Social Services president Moira Gibb is
warning of the danger of more children falling through the child protection
safety net, it seems appropriate that Hoyal should end her opening defence with
a plea for the inquiry to appreciate "the juggling of human resources by
busy public servants, which results in overworked individuals embarking on
careers with high expectations, which are replaced with excessive workloads,
which they have to do because there is no one else to do it".

added: "We hear this week that there are thousands of vacancies for social
workers. Perhaps one of the reasons is the way society treats social workers,
particularly junior social workers, in the expectations that are put upon them
and the inadequate resources that they are given."

"missed opportunities" to save Victoria

Visits made by Kouao and Climbie to Ealing social services during the spring of
– An anonymous phone-call made to Brent Council’s one-stop shop on 18 June and
the consequent visit to Kouao’s bed-and-breakfast accommodation on 14 July.
– Climbie’s admission to Central Middlesex Hospital with suspected
non-accidental injuries on 14 July.
– The visit by Kouao and Climbie to Ealing Council’s Acton area office on 15
– Climbie’s admission to North Middlesex Hospital on 24 July with scalds to the
head and face.
– Climbie’s referral by Haringey social services department to the Tottenham
Child and Family Centre on 5 August.
– The liaison health visitor referral in early August.
– The visit to Manning’s house by Haringey social worker Lisa Arthurworrey on
16 August.
– A letter from consultant paediatrician Dr Mary Rossiter to Haringey social
services department on 20 August.
– A further letter from Dr Rossiter dated 2 September.
– Allegations by Kouao that Manning had sexually abused Climbie on 1 November.
– Three visits by Arthurworrey to Manning’s home in December 1999 and January


Free nursing care: do the sums add up?

arrival of free nursing care in England has brought with it fears that the
funding pot will need a fair amount of topping up. Jonathan Pearce checks the

introduction of free nursing care in England this week should be a cause for
celebration. Instead, the government faces accusations of broken promises,
unfairness, and an unworkable system for assessing and delivering that care.

1 October, people living in nursing homes who pay for their own care will have
their nursing care costs paid by the NHS. Nursing care covers care provided by
a registered nurse, including the planning, supervision or delegation of care.

splitting nursing from personal care discriminates against those people with
long-term illnesses such as Alzheimer’s and arthritis, claim organisations
campaigning on behalf of older people.

government’s artificial boundary to define nursing care will result in many
thousands of older people still having to pay for the bulk of their care, ie
personal care," says Age Concern England director general Gordon Lishman.

care is about sustaining life," adds Help the Aged head of policy Tessa
Harding. "Drawing a line between nursing and personal care is a false

care will be assessed using the registered nursing care contribution RNCC tool
that allocates residents into one of three bands: low, medium and high need, at
£35, £70 and £110 per week respectively.

RNCC tool is meant to dovetail with the single assessment process (SAP) to be
introduced next April. In the future, agencies will use a
"person-centred" and "standardised" system based on four
broad types of assessment: contact, overview, in-depth and comprehensive old
age assessment. A detailed care plan will follow the SAP.

the patient or user is set to enter a nursing home, the RNCC tool draws on the
SAP and the care plan in working out the appropriate level of registered
nursing input.

"holistic approach" should be taken which also addresses the
"key dimensions of instability, predictability, intensity, risk and
complexity of needs", according to Department of Health guidance.

Concern England, along with others, claims the system will place an extra
burden on nurses and nursing managers, whose first priority should be caring
for older people.

issue is the funding itself. When the DoH first consulted, it planned to give
health authorities £80m for an estimated 35,000 self-funding nursing home
residents for the six months between October 2001 and April 2002, including
£2.6m for administration and care management costs.

the final guidance published a matter of days before free nursing care begins,
a DoH survey of England’s 97 health authorities shows about 42,700
self-funders. The estimate has been adjusted to 42,000 self-funders and the
overall budget has risen to £100m, but this now includes £6m for continence
supplies and an unspecified amount for administration and management.

all adds up to a tightening of the budgetary framework. The DoH estimates 10
per cent of people will fall into the low need band, while the rest will be
split equally between the other two bands. Do the maths (see box) and it adds
up to £92.3m.

the previous administration costs of £2.6m (which, with over 7,000 more people,
may be higher) and taking out the "continence supplies" money, the
DoH has allocated only £91.4m for nursing care – a shortfall of nearly £1m.

may be an acceptable margin of error – about 1 per cent – and fewer people may
fall into the higher bands, but it does little to forward the claims of a
needs-led service.

of course, these arrangements only cover England. Last week the Scottish
executive announced it was pressing ahead with its plan to implement free
personal and nursing care from April next year. It will pay £90 per week for
personal care, and an additional £65 per week for those needing nursing care.
In Wales, the story too is different: a flat payment of £90 a week for nursing

someone say "postcode lottery"?

for nursing care

funding for free nursing care between 1 October 2001 and 31 March 2002: £100m
(including £6m for continence supplies and an unspecified amount for
administration and management costs)

Total available for free nursing care: £91.4m (assuming £2.6m administration
– Number of self-funders in nursing homes: 42,000

care band      % of self-funders       Total free nursing care

– £35 pw              10 per cent                   £3.8m
Medium – £70 pw        45 per cent                   £34.4m
High – £110 pw            45 per cent                   £54.1m           
Total                                                               £92.3m

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