A valuable legacy

Those of us who were engaged in the inquiry into Victoria
Climbie’s death took the view early on that her suffering would
stay at the forefront of our minds throughout.

Anyone who has read Lord Laming’s report will have felt his
anger that such a thing could have happened. Anger is good. It
stops us forgetting the little girl this was all about. It stops us
getting so wrapped up in procedures, protocols and structures that
we forget what it is all for. And it makes us cautious about
accepting easy explanations.

Now the inquiry is all over, there is time to reflect on some of
Victoria’s legacies. One is the inquiry process itself and whether,
in the light of experience, we should change the way we examine
such cases.

Firstly, I have absolutely no doubt that Lord Laming was right
to reject arguments that the inquiry should be held in private. The
attentions of the press make it impossible to dodge uncomfortable
realities. The fact that every action of an inquiry is conducted in
the full glare of publicity is a great discipline to
decision-making. The option of saying “we will probably get away
with it” simply disappears.

A second issue on process was the decision to hold seminars.
These were devised to help Lord Laming make general recommendations
as opposed to specific points arising in Victoria’s case.

We were not a Royal Commission into child protection. With the
resources at our disposal and in the timescale envisaged for
producing the report, we could not possibly conduct a review of the
entire child protection system throughout the country, although
there was some ill-informed comment that that was what we were
about. But we had to ensure that we did not confine our analysis to
a single silo.

The purpose of the seminars was firstly to ensure we did not
jump to conclusions about practice around the country based on
experience of what had happened in one part of London. And secondly
the purpose was to generate ideas. In my view, they achieved both
objectives thanks entirely to the high quality of contributions
from the participants.

Another of Victoria’s legacies is, of course, Lord Laming’s
recommendations themselves. I confess that when we began the
inquiry I was sure that the “answer” lay in establishing a national
child protection agency. By the end, I was equally certain that it
was not. You surely cannot categorise children as “in need” or “in
need of protection” and decide simply on the basis of that
categorisation what services they require. The needs of children
and families are simply too complicated for that.

The obvious attractions to the sort of new structure suggested
by Lord Laming would be firstly the maintenance of the best of the
present system whereby children in need and children in need of
protection are managed together.

And, second, the replacement of unwieldy and ineffective area
child protection committees with an organisational structure
providing clear lines of responsibility from the centre of
government to the delivery of local services.

As Lord Laming put it, such an arrangement would make it
virtually impossible in the future for a senior manager or
politician to be able to say “but I did not know, nobody told
me”.

Which brings me to one of the underlying themes of his report –
the concept of individual and corporate accountability. Properly
understood this has the potential to be the most significant of the
legacies of Victoria Climbie.

It seems to me wholly unacceptable for managers to impose a
substantial workload on inexperienced staff without ensuring they
are properly trained, supervised and debriefed.

And it is the job of senior managers to ensure that the line
managers are providing that level of supervision. Otherwise it is
nonsensical to suggest that the blame can stop with junior
staff.

“Accountability” in the sense the word is used in the report is
not a legal concept. Lord Laming is, in truth, striving for the
essence of good management. To develop this I have to go “off
piste” a little so what follows comes with the health warning that
what matters is what the report says, not the refinements I
offer.

However, it seems to me that “accountability” in this context
has several strands. Firstly, it imposes an obligation to provide
an account. When things go wrong and a service fails a child,
senior managers must be obliged to provide an explanation and
accept responsibility – personal responsibility – for the failings.
It is never enough to say “my role is strategic” or “I cannot be
expected to explain why this particular event occurred; I relied on
others to manage this service”.

Second, it is a necessary precondition for providing such an
account that senior management know why something went wrong and
this requires that the reporting lines from shop floor to manager
have to be made to work.

Third, reporting lines need to operate not just after mistakes
have been made. The fact that things are going wrong must be
detected while correction is still possible and before disaster
occurs.

Lastly, the accountability is not just about systems and
procedures. It is also what Americans call “walking the talk”. How
likely is it that the sort of organisational disasters we learned
about in this inquiry would have persisted if the director of
social services had been regularly in the habit of dropping in
without warning and spending an hour going through the files of the
relevant duty teams?

I don’t mean that this should happen every now and again. What I
am suggesting (and remember it is me, not Lord Laming, talking now)
is that they should consider spending an hour of every day sitting
in someone else’s office, looking over the shoulders of the staff
they are accountable for, getting a feel as to how well they are
working.

Of course, these are busy people who sit on every committee,
sign off every report, prepare every budget. But the only reason
they do all this grand work is to ensure that the service is
delivered. And if that is not happening, frankly they might as well
not bother with the committees, the reports and the budgets.

What Victoria’s case demonstrated was that the process had
become more important than the product. Her death should be a
clarion call to every manager to get off their backside and out of
their office and into the duty teams, the ward and the police
stations to make sure that they don’t learn about the next Victoria
Climbie because the post-mortem report has just landed on their
desk.

A final point is that it was not social workers, police officers
or health professionals who killed Victoria Climbi‚. It was
two evil individuals. Child protection professionals face, on a
daily basis, the most difficult of judgements, because for every
Victoria there are hundreds of families who, with a little support,
might just make a go of it and for whom the dramatic removal of a
child would be a disaster for parent and child alike.

Every time those professionals get it right, they are
potentially preventing another child suffering as Victoria
suffered. It is impossible to stress too highly what a priceless
achievement that is – every time it happens. We as a society owe
the people willing to take on that challenge the most enormous debt
of gratitude – and so do all the children, who as a result, will
not finish up like Victoria Climbie.