analysis of how professions failed to communicate in Victoria Climbie case

As phase one of the Victoria Climbie Inquiry ended this
week, a picture was emerging of professions that simply do not
understand each other. Lauren Revans reports.

By the time the doors of the Victoria Climbie‚ Inquiry
opened in September 2001, the public’s finger was already pointing
at individuals on the front line who had been charged with
Victoria’s care. Newspapers were full of reports of the “failure”
and “incompetence” of social worker Lisa Arthurworrey and child
protection officer PC Karen Jones, as alleged by prosecutor Linda
Stern during the murder trial of Marie-Therese Kouao and Carl
Manning in January 2001.

But as phase one of the inquiry drew to a close this week, a
different and far more complex picture began to emerge. There is no
question that these, and other, individuals made some mistakes. But
environmental pressures, organisational structures, political
influences, managerial responsibilities and inter-agency
communication systems are all in the dock, as inquiry chairperson
Lord Laming continues his search for the truth about how Victoria
came to fall through the child protection net.

When health minister John Hutton announced the inquiry – the
first ever to have a statutory base simultaneously encompassing the
Children Act 1989, the NHS Act 1977 and the Police Act 1996 – he
identified its objectives as establishing the circumstances
surrounding Victoria’s death; considering the services sought for
her and her “carers”; and making recommendations as to “how, as far
as is possible, such events can be avoided in the future”.

In May, Laming told Community Care that he would rule out
nothing when considering how to improve the current child
protection system.

The list of seminar topics for phase two of the inquiry is
testament to this. It highlights as areas for consideration the
expansion of joint working and training, the future roles of area
child protection committees and part 8 reviews, and the concept of
a lead child protection agency – possibly multi-disciplinary and
possibly “virtual”.

Phase two topics were decided on the basis of the 55 days of
evidence of phase one. According to this evidence, one of the main
factors to influence the handling of Victoria’s case would appear
to have been an almost total breakdown of inter- and intra-agency

Many witnesses have displayed a complete lack of understanding
of the roles and working cultures of other agencies, as well as
some confusion about the responsibilities of other individuals
within their own agencies. This inevitably led to gaps in
Victoria’s care as misguided assumptions were made about the tasks
others would take on and as information gleaned by one agency was
not passed to another.

Another influential factor would appear to be the failure of
agencies to follow procedures. A system that is flawless on paper
is worthless unless it is put into practice. Yet numerous witnesses
explained how various policies were routinely ignored, usually due
to time or staff shortages. Other policies were simply out of date
or unfamiliar to the staff expected to implement them.

The pressures on front-line staff – including high vacancy
rates, insufficient resources, heavy workloads, inadequate
training, internal politics, incompatible computer systems,
ineffective administrative systems, and the negative image of child
protection work in general – were another recurring theme. No
matter how much time Laming and his team spend dreaming up an
improved child protection system, if the jobs remain undesirable to
those with the qualifications to carry them out, then the vicious
circle of environmental pressures will not be broken and nothing
will change.

Phase one has considered the events leading up to and
surrounding Victoria’s death. A catalogue of errors far greater
than anyone first imagined has been revealed, both at an individual
and organisational level. Phase two must now consider what can be
done about it.

Perhaps a multi-disciplinary lead agency is the way forward.
Counsel to the inquiry Neil Garnham suggested last month the
possibility of a “supra-ACPC” body in London in place of the
existing 31 area child protection committees. That is one of
several options Laming and his team will need to consider after the
seminars have finished in April.

If one thing is certain, it is that something must change.
Either a new system is needed or more effective implementation of
the existing system must somehow be enforced. But, whatever the
outcome, what does seem likely is that Laming will place
considerable emphasis on the merits of closer joint working.

From Abidjan to North Tottenham

Adjo Victoria Climbie‚ – known to her family as Victoria –
was born near Abidjan in the Ivory Coast on 2 November 1991. She
was one of seven siblings and had a large extended family. Her
great-aunt Marie-Therese Kouao visited from Paris in October 1998,
explaining that plans to take a mutual young relative, Anna Kouao,
back to France had fallen through. Kouao had intended to arrange
Anna’s education in France, and offered to take Victoria instead.
At that time, Victoria was one of a class of 73, and it was not
unusual in the Ivory Coast for children to live with other
relatives in order to improve their education. Victoria and Kouao
left the Ivory Coast soon after and remained in France until April
1999, when they moved to London. The two lived first in Brent, then
in July 1999 moved to north Tottenham to live with Kouao’s new
boyfriend Carl Manning. Victoria died on 25 February 2000 from
neglect and hypothermia. Kouao and Manning were sentenced to life
for her murder in January 2001.

Testing times at the inquiry

Not since the Stephen Lawrence Inquiry has Hannibal House in
south London’s Elephant and Castle complex seen such media

The sixth-floor office space, converted during summer 2001 to a
public inquiry room, has been home to the Victoria Climbie‚
Inquiry for five months. The ramp into the shopping centre, made
famous by protesting Nation of Islam members in 1998, has been
featured on news bulletins around the country once more as
Victoria’s parents, her murderer Marie-Therese Kouao and various
other key witnesses have come and gone from the inquiry.

While some witnesses have shed light on events surrounding
Victoria’s death – and indeed often made shocking revelations about
practice at the time – others have been noticeably less
co-operative. The decision to bring Kouao from her prison cell to
the inquiry for a day last month, for example, largely back-fired
when she refused to answer questions, and used the opportunity to
vociferously protest her innocence. Even the skilful counsel to the
inquiry, Neil Garnham, seemed wrong-footed by her uncontrolled
outbursts as she repeatedly attempted to shift the blame for
Victoria’s death onto doctors.

Just as Garnham’s impatience has grown with every witness memory
failure and every miraculous reappearance of “lost” documents, the
trademark politeness and quiet nature of inquiry chairperson Lord
Laming has slowly begun to give way to outbursts of rising

In December, when Haringey acting team manager Carole Baptiste
failed to attend the inquiry, Laming even took the unprecedented
step of instructing his legal team to take criminal action against
her, declaring that she had “exhausted” his patience. During the
course of phase one, he has also been forced to issue a summons to
Haringey social services director Anne Bristow to produce missing
evidence, to request a written explanation from the NSPCC about its
missing paperwork, and to suspend proceedings altogether last month
after more late Haringey documents were uncovered – this time in a
manager’s loft.

At times, members of the public watching the inquiry have also
tested Laming’s patience. In January, proceedings had to be
adjourned when a woman ran from the public gallery to the witness
stand and threw black ink in the face of a police officer giving

More than 150 witnesses have now appeared in person before
Laming and his silent team of experts. All have been grilled; most
have been treated courteously at least to begin with, and none have
been left in any doubt as to what Garnham and his team believe they
should have done differently. The public and the press, meanwhile,
have been left with an uncomfortable feeling in their stomachs
about the state of child protection practice in this country and
the fear that the next child death could be just around the



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