Victoria Climbié
Encyclopedia
In 2000 in London, England, an eight-year-old Ivorian
girl Victoria Adjo Climbié (2 November 1991 – 25 February 2000) was tortured and murdered by her guardians. Her death led to a public inquiry
and produced major changes in child protection
policies in England.
Born in Abobo
, Ivory Coast, Climbié left the country with her great-aunt Marie-Thérèse Kouao, a French citizen, for an education in France, where they travelled, before arriving in London in April 1999. It is not known exactly when Kouao started abusing Climbié, although it is suspected to have worsened when Kouao and Climbié met and moved in with Carl Manning, who became Kouao's boyfriend. During the abuse, Climbié was burnt with cigarettes, tied up for periods of longer than 24 hours, and hit with bike chains, hammers and wires. Up to her death, the police, the social services
department of four local authorities
, the National Health Service
, the National Society for the Prevention of Cruelty to Children (NSPCC), and local churches all had contact with her, and noted the signs of abuse. However, in what the judge in the trial following Climbié's death described as "blinding incompetence", all failed to properly investigate the case and little action was taken. Kouao and Manning were convicted of murder and sentenced to life imprisonment.
After Climbié's death, the parties involved in her case were widely criticised. A public inquiry, headed by Lord Laming
, was ordered. It discovered numerous instances where Climbié could have been saved, noted that many of the organisations involved in her care were badly run, and discussed the racial aspects surrounding the case, as many of the participants were black. The subsequent report by Laming made numerous recommendations related to child protection in England. Climbié's death was largely responsible for the formation of the Every Child Matters
initiative; the introduction of the Children Act 2004
; the creation of the ContactPoint project, a government database
designed to hold information on all children in England; and the creation of the Office of the Children's Commissioner chaired by the Children's Commissioner for England
.
near Abidjan
, Ivory Coast, the fifth of seven children. Her parents were Francis Climbié and his wife Berthe Amoissi. Marie-Thérèse Kouao, Francis' aunt, was born on 17 July 1956 in Bonoua, Ivory Coast and lived in France with her three sons, claiming welfare benefits. She divorced her ex-husband in 1978 and he died in 1995. Kouao was attending her brother's funeral in the Ivory Coast when she visited the Climbié family in October 1998. She informed them that she wanted to take a child back to France with her and arrange for their education; this sort of informal fosterage
is common in the family's society. Victoria Climbié was apparently happy to be chosen, and although her parents had only met Kouao a few times, they were satisfied with the arrangements.
From that point onwards, Kouao pretended that Climbié was her daughter. Kouao had originally planned to take another young girl called Anna Kouao, but Anna's parents changed their minds. Climbié travelled on a French passport in the name of Anna Kouao and was known as Anna throughout her life in England. It is not known exactly when Kouao started abusing Climbié. Climbié's parents received three messages about her from when she left them to her death, all saying she was in good health.
Kouao and Climbié left the Ivory Coast possibly in November 1998 and flew to Paris, France, where Climbié enrolled at school. By December 1998, however, Kouao began to receive warnings about Climbié's absenteeism
, and in February 1999, the school issued a child-at-risk notification and a social work
er became involved. The school observed how Climbié tended to fall asleep in class, and the headteacher later recalled Kouao mentioning Climbié suffering from some form of dermatological
condition and that, on her last visit to the school on 25 March 1999, Climbié had a shaven head and was wearing a wig. When they left France, Kouao owed the authorities £2,000, after being wrongly paid in child benefit
, and it is claimed that Kouao viewed Climbié as a useful tool for claiming benefits. Kouao had also been evicted from her home in France because of rent arrears.
, England, to the London Borough of Ealing
. They had a reservation in a bed and breakfast at Twyford Crescent, Acton where they lived until 1 May 1999, when they moved to Nicoll Road, Harlesden
, in the London Borough of Brent
. On 25 April 1999, Kouao and Climbié visited Esther Ackah, a distant relative of Kouao by marriage, and a midwife, counsellor and preacher. Ackah and her daughter noted that Climbié was wearing a wig and looked small and frail. On 26 April 1999, Kouao and Climbié visited the Homeless Persons' Unit of Ealing Council, where they were seen by Julie Winter, a homeless persons' officer. Together, Kouao and Winter completed a housing application form. Kouao explained that Climbié was wearing a wig because she had short hair, an explanation accepted by Winter. Although Winter was shown Climbié's passport (with a photograph of Anna), she paid no attention to them, believing that Kouao's application was ineligible on the grounds of habitual residence
. Winter confirmed her decision with her duty senior and told Kouao that she was not eligible for housing. She telephoned the referral across to Pamela Fortune, a social worker in Ealing's Acton referral and assessment team. She did not produce a written or electronic documentation of the referral, however, something which would have helped in double-checking the accounts that Kouao gave.
Between 26 April and early July 1999, Kouao visited Ealing social services 18 times for housing and financial purposes. Climbié was with her on at least ten occasions. The staff there noted Climbié's unkempt appearance, with one staff member, Deborah Gaunt, thinking that she looked like a child from an ActionAid
advertisement. However, they did not take any action and may have assumed that Climbié's appearance was a purposeful attempt to "persuade the authorities to hand out money". On 8 June 1999, Kouao got a job at Northwick Park Hospital
. During her first month, no effort was made by Kouao or Ealing social services to enroll Climbié in educational or daycare activities.
On 8 June 1999, Kouao took Climbié to a GP
surgery. The practice nurse there did not carry out a physical examination as she was not reported to have any current health problems. By the middle of June 1999, Climbié was spending the majority of her days at the Brent home of Priscilla Cameron, an unregistered childminder, who Kouao met at her job at the hospital. There is no evidence that Climbié was treated badly during her time with Cameron, and she had a good relationship with Cameron's adult son, Patrick. On several occasions, Cameron observed small cuts to Climbié's fingers. When questioned by Cameron, Kouao said that they were caused by razor blades that Climbié played with. Kouao and Climbié met Ackah on the street on or around 14 June 1999. In what may have been early signs of deliberate physical harm, Ackah noted a scar on Climbié's cheek, which Kouao said was caused by a fall on an escalator. On 17 June 1999, in response to what she had seen three days earlier, Ackah visited Kouao and Climbié's home, and thought that the accommodation was unsuitable.
On 18 June 1999, Ackah anonymously telephoned Brent social services, expressing concern over Climbié's situation. Samantha Hunt, the customer-service officer who received the call at the One Stop Shop at Brent House, faxed the referral to the children's social work department on that same day. Nobody picked up the referral on that Friday afternoon, and what happened to it was—according to Lord Laming
, who headed the subsequent inquiry—the subject of "some of the most bizarre and contradictory evidence" the inquiry heard. A few days later, possibly on 21 June 1999, Ackah phoned Brent social services again to make sure her concerns were being addressed. Ackah said that she was told by the person on the other end of the telephone that "probably they [social services] had done something about it". This call, however, did not trigger a new, separate referral. The first referral was not seen until three weeks later on 6 July 1999, when Robert Smith, the group administrative officer, logged the details of the referral onto the computer, with details of Climbié's injuries. Laming said the delay constituted "a significant missed opportunity" to protect Climbié. Edward Armstrong, the team manager of the intake duty team, said that he completed a duty manager's action sheet not for the 18 June referral, which he said never arrived in his office, but for the 21 June referral, which was a less serious case than the first; Laming called this version of events "wholly unbelievable". Laming said that Armstrong's evidence was out of line with that of the other Brent witnesses, that the quality of it "[left] much to be desired", and that Armstrong's insistence that he dealt with the 21 June referral was an attempt to cover up his team's "inept handling" of a genuine child protection case.
On 14 June 1999, Kouao and Climbié met Carl Manning (born 31 October 1972) on a bus which he was driving. This was the start of Kouao and Manning's relationship which ended at the time of their arrest eight months later. She was his first girlfriend. The relationship developed quickly and on 6 July 1999, Kouao and Climbié moved into Manning's one-bedroom flat—described as a small bedsit
—at Somerset Gardens in Tottenham
, in the London Borough of Haringey
. There is evidence that Climbié's abuse increased soon after moving into Manning's flat.
On 7 July 1999, Brent social services sent a letter to Nicoll Road, where Kouao and Climbié were staying, informing them of a home visit. On 14 July 1999, two social workers, Lori Hobbs and Monica Bridgeman, visited the address but found no answer: Kouao and Climbié had already moved out on 6 July 1999. Hobbs and Bridgeman made no further inquiries at the property that might have led to a trail on Climbié's whereabouts. Prior to the visit, they had not done any background checks and had only the "haziest idea" of what they were investigating. The Laming report suggests that no reports or follow-up notes were made and that the only information additional to the referral were the notes "Not at this address. Have moved."
The next day, on 14 July 1999, Cameron's daughter Avril took Climbié to see Marie Cader, a French teacher at her son's school. Cader advised that Climbié be taken to hospital. At 11:00 am the same day, Avril took Climbié to the emergency department
of Central Middlesex Hospital
. At 11:50 am, Climbié was seen by Dr Rhys Beynon, a senior house officer in the department. Beynon took Climbié's history from Avril and thought that there was a strong possibility that the injuries were non-accidental. Due to hospital child protection guidelines, he referred the case to Dr Ekundayo Ajayi-Obe, the on-call paediatric registrar. Beynon conducted only a cursory examination of Climbié because he believed she was going to be examined by the paediatric team. The Laming report said that "he exhibited sound judgement in his care of Victoria by referring her immediately to a paediatric registrar." Climbié arrived at Barnaby Bear ward where she was examined by Ajayi-Obe, who noted various injuries. When asked about the injuries, Climbié said they were self-inflicted, a claim the paediatrician did not think was credible. Ajayi-Obe's notes were detailed and thorough, in contrast to those of the other doctors that examined her. Having examined Climbié, the paediatrician was "strongly suspicious" that the injuries were non-accidental, and she decided to admit Climbié onto the ward.
The doctors alerted Brent police and social services, and she was placed under police protection, with a 72-hour protection order preventing her from leaving hospital. Kouao told the doctors that she had scabies
, and that the injuries were self-inflicted. Many doctors and nurses suspected that the injuries were non-accidental. However, Ruby Schwartz, the consultant
pediatrician
and named child protection doctor at the hospital, diagnosed scabies and decided that it was scratching that caused the injuries. She made the diagnosis without speaking to Climbié alone. Schwartz later admitted that she made a mistake. Another doctor, one of Schwartz' juniors, misleadingly wrote to social services saying there was no child protection
issue. When Michelle Hine, a child protection officer at Brent council, received a report notifying her of Climbié's injuries, she planned to open an investigation into the case. However, the next day she heard of Schwartz' diagnosis and downgraded Climbié's level of care, trusting Schwartz' judgement. She later expressed regret over her actions. Schwartz said in the inquiry that she expected social services to follow up the case. Neil Garnham QC
, counsel
to the inquiry following Climbié's death, later said to her, "there is a terrible danger here—is there not, doctor—of social services on the one hand and you on the other each expecting the other to do the investigation, with the result that nobody does". A police officer
from Brent council, Rachel Dewar, decided to lift the police protection, allowing Climbié to return home, when told by a social worker that she had scabies. Under the Children Act 1989
, Dewar was obliged to see Climbié and tell her she was under police protection, but she did not do this. She also failed to see Kouao or Manning. At the time of the decision, Dewar was attending a seminar on child protection. Garnham later said, "we will need to ask why it was thought more important for her to attend a seminar to learn how to deal with child protection cases than deal with the real child protection case for which she was responsible at the time". Kouao took Climbié home on 15 July 1999.
Some time in July, probably just before Climbié was admitted to the Central Middlesex Hospital, Kouao befriended a couple, Julien and Chantal Kimbidima. Climbié and Kouao visited their home several times over the following months. According to Chantal, Kouao would shout at Climbié all the time and never showed her affection.
On 24 July 1999, Climbié was taken by Kouao to the accident-and-emergency department
at North Middlesex Hospital
with severe scalding
to her head and other injuries. The hospital found no evidence of scabies. Consultant Mary Rossiter felt Climbié was being abused but still wrote 'able to discharge' on her notes. According to Maureen Ann Meates, another doctor at the hospital, when Rossiter had written that note, she had noted that Climbié was exhibiting signs of neglect, emotional abuse and physical abuse
. Later, in the inquiry, Rossiter said that by writing 'able to discharge', she did not mean she wanted Climbié to go home, merely that she was physically fit to leave. Garnham said, "quite how the subtlety of that distinction was to be ascertained from the notes is far from obvious". Rossiter admitted to the inquiry that she had expected police and social services to follow up on the case. For a brief period while she was in hospital, Enfield
social services took up the case before passing it to Haringey.
A social worker and police officer from Haringey council, Lisa Arthurworrey and Karen Jones, respectively, were assigned to her case, and were scheduled to make a home visit on 4 August 1999; however, the visit was cancelled once they heard about the scabies. Jones later said, "it might not be logical but I did not know anything about scabies". She said that she telephoned North Middlesex Hospital for information about the disease, but Garnham had evidence that the staff there dealt with no such inquiry. Jones was told by a doctor that Climbié's injuries were consistent with belt buckle marks, although she claimed in the inquiry there was no evidence of child abuse.
On 5 August 1999, a Haringey social worker, Barry Almeida, took Climbié to an NSPCC centre in Tottenham, where she was assigned to Sylvia Henry. There was some confusion as to why the centre was being referred to for the case. Henry later contacted Almeida and was told, according to Henry, that Climbié had moved out of the borough, thereby closing the case. Almeida said he could not remember whether this conversation did take place. On the same day, Kouao met Arthurworrey and Jones at the Haringey social services department, and claimed that Climbié had poured boiling water over herself to stop the itching caused by the scabies and that she had used utensils to cause the other injuries. The social worker and police officer believed her, deciding that the injuries were probably accidental, and allowed Climbié to return home the following day, which she did.
, but the health visitor said in the inquiry that she did not receive any contact. On 13 August 1999, Rossiter wrote to Petra Kitchman of Brent council, asking her to follow up on the Climbié case. Kitchman said in the inquiry that she contacted Arthurworrey, but Arthurworrey denied this. Later, on 2 September 1999, Rossiter sent a second letter. Kitchman said she spoke to Arthurworrey about this, but Arthurworrey denied this again. Arthurworrey made a visit to Climbié's home on 16 August 1999 and another one when Manning began forcing Climbié to sleep in the bath. Arthurworrey said in the inquiry that she was under the impression that Climbié seemed happy, but Garnham criticised Arthurworrey for not detecting any of the abuse, although Manning had described this visit as a "put up job". Arthurworrey and Climbié had met on four occasions, where they were together for a total of less than 30 minutes, barely speaking to each other.
From then on, Kouao kept Climbié away from hospitals, turning instead to churches. Kouao said to the pastors that she was the mother and that demons were inside
Climbié. The pastor at the Mission Ensemble Pour Christ, Pascal Orome, offered prayers for Climbié to cast out the devil, and thought that her injuries were due to demonic possession. On another occasion, Kouao took Climbié to a church run by the Universal Church of the Kingdom of God
, where the pastor, Alvaro Lima, suspected she was being abused, although he took no action. He said in the inquiry that Climbié told him that Satan
had told her to burn herself. The pastor did not believe her, but he still believed that a person could be possessed.
From October 1999 to January 2000, Manning forced Climbié to sleep in a bin liner in the bath in her own excrement. During a later police interview, Manning said this was because of her frequent bedwetting
. At Haringey social services on 1 November 1999, Kouao told social workers that Manning sexually assaulted
Climbié, but withdrew the accusation the following day. In one of Arthurworrey's visits, during a conversation about housing, Arthurworrey said that the council only accommodated children believed to be at serious risk. Laming said in his report, "it may be no coincidence that within three days of this conversation, Kouao contacted Ms. Arthurworrey to make allegations which, if true, would have placed Victoria squarely within that category". Jones sent a letter to Kouao, which was ignored, and no further action was taken. Manning later denied the allegation. Alan Hodges, the police sergeant
overseeing the investigation, claimed in the inquiry that the social workers were obstructing the police in dealing with child protection cases. Between December 1999 and January 2000, Arthurworrey made three visits to the flat, but she received no answer. She speculated to her supervisor, Carole Baptiste, that they had returned to France. Despite no evidence, her supervisor wrote on Climbié's file that they had left the area. On 18 February 2000 they wrote to Kouao saying that if they did not receive any contact from them, they would close the case. A week later, on 25 February 2000, they closed the case—on the same day that Climbié died.
On 24 February 2000, Victoria Climbié was taken semi-conscious
and suffering from hypothermia
, multiple organ failure
and malnutrition
, to the local Universal Church of the Kingdom of God church. After they left, the mini cab driver was horrified at Climbié's condition and took her straight to the accident-and-emergency department at North Middlesex Hospital; she was then transferred to the intensive-care
unit at St Mary's Hospital. The ambulance driver who drove her to St Mary's described how although Kouao had kept saying, "my baby, my baby", her concern seemed "not quite enough", and that Manning seemed "almost as if he was not there". Climbié died the following day at 3:15pm local time. The pathologist
who examined her body noted 128 separate injuries and scars on her body, and described it as the worst case of child abuse she had ever seen; Climbié had been burnt with cigarettes, tied up for periods of longer than 24 hours, and hit with bike chains, hammers and wires. During her life in England, Climbié was known to four local authorities (four social services departments and three housing departments), two child protection police teams, two hospitals, an NSPCC centre, and a few local churches. She was buried in Grand-Bassam
near her home town.
Kouao was arrested on the day that Climbié died, and Manning the following day. Kouao told police, "It is terrible, I have just lost my child". On 20 November 2000, at the Old Bailey
, the trial
into her death opened, where Kouao and Manning were charged with child cruelty
and murder. Kouao denied all charges, and Manning pleaded guilty to charges of cruelty and manslaughter
. The judge described the people in Climbié's case as "blindingly incompetent". In his diary, Manning described Climbié as Satan
, and said that no matter how hard he hit her, she did not cry or show signs that she was hurt. On 12 January 2001, both were found guilty and sentenced to life imprisonment
. The judge said to them, "what Victoria endured was truly unimaginable. She died at both your hands, a lonely drawn out death". Kouao went to Durham prison
and Manning went to Wakefield prison
.
, Alan Milburn
, and the home secretary
, Jack Straw
, appointed William Laming, Lord Laming
, former chief inspector of the Social Services Inspectorate (SSI), to conduct a statutory inquiry into Climbié's death. Laming was given the choice of staging a public inquiry
or a private inquiry; he chose a public inquiry. It was the first inquiry to be set up by two secretaries of state
. The inquiry was actually three separate inquiries, together called the Victoria Climbié Inquiry, as it had a statutory base
of three pieces of legislation
: section 81 of the Children Act 1989
, section 84 of the National Health Service Act 1977, and section 49 of the Police Act 1996. It drew together the involvement of social services, the National Health Service
, and the police, and became the first tripartite inquiry into child protection. The Counsel to the Inquiry was Neil Garnham QC
. The inquiry, based in Hannibal House
, Elephant and Castle
, London, cost £3.8 million, making it the most expensive child protection investigation in British history. The website victoria-climbie-inquiry.org.uk was created, where all the evidence and documents were made available freely.
The inquiry was launched on 31 May 2001, and was split into two phases: phase one and phase two. Phase one investigated the involvement of people and agencies in Climbié's death, in the form of hearings
. Two hundred and seventy witness
es were involved. The phase one hearings began on 26 September 2001 and finished on 31 July 2002; it was originally supposed to end on 4 February 2002 but late documents caused delays. Phase two of the inquiry, taking place between 15 March 2002 and 26 April 2002, took the form of five seminars, which looked at the child protection system in general. It was chaired by Garnham and brought together experts in all aspects of child protection.
's social services department in 1990, a department which was strongly criticised for its handling of a child abuse case, and which had the local government ombudsman
making a finding of 'maladministration
with injustice' against them in 1995. The father of the child in the case said of Laming's appointment, "I don't see how he has the qualifications or experience to be able to lead an investigation into another borough which has been failing to protect a child in exactly the same manner that his own authority failed to protect a child in 1990". Liberal Democrat
spokesman Paul Burstow
said, "the findings of the ombudsman in the Hertfordshire case must give rise to questions about Lord Laming's appointment to head this inquiry"; and Conservative Party
spokesman Liam Fox
said, "I think the government maybe should have thought twice about this and maybe, even yet, they will think again". The Department for Health
, however, said that they were "fully confident that he is the right person to conduct the inquiry".
, had "virtually paralysed" the child protection service. She received contact from twelve senior practitioners and team managers criticising the proposals as "potentially dangerous and detrimental to the people to whom we offer a service". Richardson provided no substantive response to the memorandum. She did, however, say in the inquiry that the blame lay on "part of all of the line management responsibility". Gurbux Singh, the former chief executive of Haringey council (before becoming the chairman of the Commission for Racial Equality
), said that there was nothing he could have done to prevent Climbié's death. Garnham contrasted this with Rossiter's willingness to accept responsibility, saying, "that willingness to acknowledge error is at least at the root, is it not, of progress?"
Kouao herself was called to the inquiry, becoming the first convicted murderer to appear in person in a public inquiry. She initially refused to answer questions, and when she did, protested her innocence, first in French, then, raising her voice in anger, in English. Giving evidence by video link from prison, Manning apologised for his actions and said that it was not the fault of the various agencies that Climbié died. Broadcasters applied for access to this video, but Laming refused the application. Climbié's parents gave evidence and were present at most of the hearings, becoming distressed when hearing of Climbié's plight and seeing pictures of her injuries. They blamed Haringey council and its chief executive for Climbié's death.
Arthurworrey, a junior worker with only nineteen months of child protection experience when she took on Climbié's case, was found to have made mistakes in the case. She accused her employer of "making her a scapegoat
", and criticised her superiors and department for not guiding her properly. The inquiry heard that Arthurworrey was overworked, taking on more cases than guidelines allow. Carole Baptiste, Arthurworrey's first supervisor, initially refused to attend the hearings, but subsequently gave vague responses to the inquiry, and said that she had been suffering from mental illness
at the time. Baptiste's own child was taken into care a few months before Climbié's death. Arthurworrey said that, in their meetings, Baptiste spent most of the time discussing "her experiences as a black woman and her relationship with God", rather than child protection cases, and that she was frequently absent. Baptiste admitted she had not read Climbié's file properly. She was removed in November 1999 when she was found to be professionally unfit for her job, and replaced by Angella Mairs, who became Arthurworrey's new supervisor. Mairs was accused by Arthurworrey of not maintaining childcare standards and of removing an important document—which recommended that Climbié's case be closed—from Climbié's file on 28 February 2000, the day the news of the death was known; but she denied this. Mairs said that she had not read Climbié's file.
The inquiry heard that the number of child protection police officers in the Metropolitan Police Service
was reduced to increase the number of murder investigation officers because of the Stephen Lawrence case in 1993. A detective inspector supervising six child protection teams in London at the time of Climbié's death wrote a report criticising their competence. His former boss, however, claimed he had been lying when he said he only held "purely administrative" responsibility for the teams. The detective inspector was taken to hospital when a woman poured ink over his head while testifying. The new chief executive of Haringey council, David Warwick, Baptiste, the Metropolitan Police, and the NSPCC apologised for their failings in the case.
may have led to the inaction. In the hearings, Arthurworrey, who is African-Caribbean
, admitted that her assumptions about African–Caribbean families influenced her judgement, and that she had assumed Climbié's timidness in the presence of Kouao and Manning stemmed not from fear, but from the African–Caribbean culture of respect towards one's parents. Ratna Dutt, director of the Race Equality Unit (now the Race Equality Foundation), a charity that provides race-awareness training to social workers, later said, "the implicit message is that it's acceptable for ethnic minorities to receive poor services under the guise of superficial cultural sensitivity. This is absolutely shameful, as it allows people to argue that good practice is compromised by anti-racism
"; and, contrasting the outcomes of the white and black staff members involved, "for a large number of black frontline staff if the finger of blame is pointed at them they don't end up in jobs in other local authorities. That's how institutional racism
operates". Jacqui Smith
, Home Secretary
from 2007, said: "I have not seen widespread evidence that social workers are not taking action", and, "there are no cultures that condone child abuse. We are absolutely clear that social workers and social work departments have a responsibility to consider whether children are subjected to harm, and if they think they are, to take action". One chapter of the report following the inquiry looked at this issue.
The 400-page report made 108 recommendations in child protection reform. Regional and local committees for children and families are to be set up, with members from all groups involved in child protection. Previously each local authority managed their own child protection register, a list of children believed to be at risk, and no national register existed; this, combined with local authorities' tendency to suppress information about child abuse cases, led to the implementation of the child database. Two organisations to improve the care of children, the General Social Care Council
and the Social Care Institute for Excellence, had already been set up by the time the report was published.
in the Laming Report. The same weaknesses have led to the same mistakes, with the same missed opportunities to save a tortured child's life". Labour Party
member of parliament
Karen Buck
said, "the Bayswater families unit told me that there must be hundreds of other Climbié cases waiting to happen", and "the Victoria Climbié inquiry highlighted how easy it is for vulnerable families to fall through the net, especially if they do not have English as a first language and are highly mobile". The 1999 Department of Health document, Working Together to Sequestrate Children (now superseded), set out child protection guidance to doctors, nurses, and midwives. The Royal College of Nursing
, however, said that there was evidence that many nurses did not receive proper training in these areas. Denise Platt, chief inspector of the social services inspectorate (SSI), said doctors, police officers and teachers often thought their only responsibility was to help social services, forgetting that they had a distinct role to play. Mike Leadbetter, president of the Association of Directors of Social Services, said that many health professionals were "not engaged in child protection". After the inquiry, there was a feeling that senior managers had managed to escape responsibility and that only junior staff members were punished. Burstow said, "the majority of children who die from abuse or neglect in this country know the perpetrator; it is within the family and by 'friends' that most abuse occurs. As a society we are still in denial about that hard truth".
, "Laming's report focuses too heavily on the implementation of new structures and fails to understand the keen intuition that child protection work demands". He criticised the approach to child protection of focusing too much on the worst cases and trying too much to prevent them, rather than having an approach that also celebrates success; and said that focusing too much on any individual case and basing reforms on that was "deeply problematic". Laming responded to criticism by the Association of Directors of Social Services that his recommendations would require much more funding by saying that these arguments lacked "intellectual rigour", and he dismissed claims that his reforms would be too bureaucratic
. The Guardian
said that the report does not address the issues of frontline staff. Deryk Mead of NCH said, "I do believe that inquiry reports have made a positive difference to the child protection system, and I have every confidence that Lord Laming's report will do so too".
discussed the media attention surrounding the case, noticing how sensational
events received widespread coverage, yet important but less exciting events received less. It states that only it and The Independent
of the national newspapers gave significant coverage to the evidence in the hearings. A possible explanation is given as, "much of the evidence has been concerned with social services, which many other papers view as a politically correct
waste of money for the undeserving".
In August 2002, Baptiste was fined £500 after being found guilty of deliberately failing to attend the inquiry. Climbié's parents, speaking through a family friend, said, "we, the family, expected her to be dealt with more severely". This was the first time a person had been prosecuted for not attending a public inquiry. In September 2002, Arthurworrey and Mairs were sacked following disciplinary procedures. The education secretary
, Charles Clarke
, also added them to the Protection of Children Act 1999 List, banning them from working with children. In October 2004, Arthurworrey appealed against her dismissal, saying that she was duped by Kouao and Manning, misled by medical reports, badly advised by her managers, and that she was a scapegoat for other people's failures, but the appeal was rejected. In 2005, she appealed the ban preventing her from working with children and won the case. In 2004, Mairs appealed her ban preventing her from working from children and won; this decision was challenged in the High Court
but she prevailed. In 2004, six police officers involved in the case faced misconduct charges. All six kept their jobs, and some received reprimands and cautions. In 2004, the General Medical Council
dropped misconduct charges against Dr. Schwartz.
Haringey council held a debate in the council chambers to discuss the Laming report. The parents of Victoria Climbié were invited to speak at the council by Councillor Ron Aitken, but the Council leader George Meehan denied them permission. Only pressure from the opposition and local press got the decision reversed. As George Meehan only reversed his decision just before the meeting, a driver was rushed to Acton to escort Francis and Berthe Climbié and Mor Dioum, their interpreter, to the council. At the meeting, the Climbiés attacked the council, through their interpreter, for its handling of the case, especially in its dealing with the Laming Inquiry. (Mor Dioum later went on to be the Director of the Victoria Climbié Foundation.)
The government placed Haringey social services department under special measures
, requiring close supervision by the social services inspectorate. Allegations emerged that in 2004 and 2005, senior managers at Haringey council ignored child abuse cases and "became hostile" against a social worker who sought to expose the abuse.
Climbié's parents created the Victoria Climbié Foundation UK, a charity that seeks to improve child protection policies, and the Victoria Climbié Charitable Trust, an organisation to build a school in the Ivory Coast
. They are also involved in championing many child protection reforms. A playwright, Lance Nielsen
, wrote a play based on the events, staged at the Hackney Empire
throughout 2002.
After Climbié's death, commentators discussed the history of child protection and the various abuse and death cases, noting that there have been 70 public inquiries into child abuse since 1945, and comparing Climbié's case with that of many others, especially that of Maria Colwell in 1973. They pointed to the many children abused and killed by their guardians over the years and how the agencies involved in their care let them down. They noted similarly that their deaths also led to inquiries and reform policies—reforms that have not saved the many children killed following them. They pointed out that, "an average of 78 children are killed by parents or minders every year; a figure unaltered in the 30 years since Maria Colwell
's death provoked the first criticism of 'communications failure'". They expressed cynicism towards the possibility that these reforms would be different. Dr. Chris Harvey, director of operations at Barnardo's
, for example, said, "Victoria's tragic case is the latest in a sad roll-call of child deaths, each leading to fresh inquiries and a new but recurring set of recommendations". Ian Willmore, former deputy leader of Haringey council, said, "the 'script' for this kind of Iinquiry is now almost traditional. The Minister goes on TV to insist that: 'this must never happen again'. Responsibility is pinned on a few expendable front-line staff, all conveniently sacked in advance. Criticisms are made about poor communication, with earnest recommendations about better co-ordination and possible restructuring. Council officers—all new appointments—go on TV to say that everything has changed since the case began. Everyone looks very earnest. Voices crack with compassion. Nothing essential changes."
In the United Kingdom, the Audit Commission
regulate social services; John Seddon
pointed out in The Times
that "Haringey Council was rated 4-star at the time of Victoria Climbié and Baby P's deaths".
programme, an initiative designed to improve the lives of children; the introduction of the Children Act 2004
, an Act of Parliament
that provides the legislative base for many of the reforms; the creation of ContactPoint, a database designed to hold information on all children in England and Wales
(now no longer in operation); and the creation of the post of children's commissioner
, who heads the Office of the Children's Commissioner, a national agency serving children and families.
Côte d'Ivoire
The Republic of Côte d'Ivoire or Ivory Coast is a country in West Africa. It has an area of , and borders the countries Liberia, Guinea, Mali, Burkina Faso and Ghana; its southern boundary is along the Gulf of Guinea. The country's population was 15,366,672 in 1998 and was estimated to be...
girl Victoria Adjo Climbié (2 November 1991 – 25 February 2000) was tortured and murdered by her guardians. Her death led to a public inquiry
Public inquiry
A Tribunal of Inquiry is an official review of events or actions ordered by a government body in Common Law countries such as the United Kingdom, Ireland or Canada. Such a public inquiry differs from a Royal Commission in that a public inquiry accepts evidence and conducts its hearings in a more...
and produced major changes in child protection
Child welfare
Child protection is used to describe a set of usually government-run services designed to protect children and young people who are underage and to encourage family stability...
policies in England.
Born in Abobo
Abobo
Abobo is a northern suburb of Abidjan and urban commune of this city in Côte d'Ivoire. Abobo is one of the most populated communes in the country with about 1,500,000 inhabitants in an area of 9,000 ha , a density of 167 inhabitants per hectare. It is home to a railway station located on the road...
, Ivory Coast, Climbié left the country with her great-aunt Marie-Thérèse Kouao, a French citizen, for an education in France, where they travelled, before arriving in London in April 1999. It is not known exactly when Kouao started abusing Climbié, although it is suspected to have worsened when Kouao and Climbié met and moved in with Carl Manning, who became Kouao's boyfriend. During the abuse, Climbié was burnt with cigarettes, tied up for periods of longer than 24 hours, and hit with bike chains, hammers and wires. Up to her death, the police, the social services
Social work
Social Work is a professional and academic discipline that seeks to improve the quality of life and wellbeing of an individual, group, or community by intervening through research, policy, community organizing, direct practice, and teaching on behalf of those afflicted with poverty or any real or...
department of four local authorities
Local government in the United Kingdom
The pattern of local government in England is complex, with the distribution of functions varying according to the local arrangements. Legislation concerning local government in England is decided by the Parliament and Government of the United Kingdom, because England does not have a devolved...
, the National Health Service
National Health Service
The National Health Service is the shared name of three of the four publicly funded healthcare systems in the United Kingdom. They provide a comprehensive range of health services, the vast majority of which are free at the point of use to residents of the United Kingdom...
, the National Society for the Prevention of Cruelty to Children (NSPCC), and local churches all had contact with her, and noted the signs of abuse. However, in what the judge in the trial following Climbié's death described as "blinding incompetence", all failed to properly investigate the case and little action was taken. Kouao and Manning were convicted of murder and sentenced to life imprisonment.
After Climbié's death, the parties involved in her case were widely criticised. A public inquiry, headed by Lord Laming
Herbert Laming, Baron Laming
William Herbert Laming, Baron Laming, CBE isa British social worker and Crossbench Peer in the House of Lords. On 29 June 2011, it was announced that he had been elected to succeed Baroness D'Souza as Convenor of the Crossbench Peers; he will take up the post in September 2011 when the House...
, was ordered. It discovered numerous instances where Climbié could have been saved, noted that many of the organisations involved in her care were badly run, and discussed the racial aspects surrounding the case, as many of the participants were black. The subsequent report by Laming made numerous recommendations related to child protection in England. Climbié's death was largely responsible for the formation of the Every Child Matters
Every Child Matters
Every Child Matters is a UK government initiative that was launched in 2003, at least partly in response to the death of Victoria Climbié...
initiative; the introduction of the Children Act 2004
Children Act 2004
The Children Act 2004 is an Act of the Parliament of the United Kingdom.The Act amended the Children Act 1989, largely in consequence of the Victoria Climbié inquiry....
; the creation of the ContactPoint project, a government database
Government database
Government databases collect personal information for various reasons .-Canada:...
designed to hold information on all children in England; and the creation of the Office of the Children's Commissioner chaired by the Children's Commissioner for England
Children's Commissioner for England
The post of Children's Commissioner for England was established under the Children Act 2004 . The Children's Commissioner has a duty to promote awareness of the views and interests of all children in England, in particular those whose voices are least likely to be heard, to the people who make...
.
Life
Victoria Climbié was born on 2 November 1991 in AboboAbobo
Abobo is a northern suburb of Abidjan and urban commune of this city in Côte d'Ivoire. Abobo is one of the most populated communes in the country with about 1,500,000 inhabitants in an area of 9,000 ha , a density of 167 inhabitants per hectare. It is home to a railway station located on the road...
near Abidjan
Abidjan
Abidjan is the economic and former official capital of Côte d'Ivoire, while the current capital is Yamoussoukro. it was the largest city in the nation and the third-largest French-speaking city in the world, after Paris, and Kinshasa but before Montreal...
, Ivory Coast, the fifth of seven children. Her parents were Francis Climbié and his wife Berthe Amoissi. Marie-Thérèse Kouao, Francis' aunt, was born on 17 July 1956 in Bonoua, Ivory Coast and lived in France with her three sons, claiming welfare benefits. She divorced her ex-husband in 1978 and he died in 1995. Kouao was attending her brother's funeral in the Ivory Coast when she visited the Climbié family in October 1998. She informed them that she wanted to take a child back to France with her and arrange for their education; this sort of informal fosterage
Fosterage
Fosterage, the practice of a family bringing up a child not their own, differs from adoption in that the child's parents, not the foster-parents, remain the acknowledged parents. In many modern western societies foster care can be organised by the state to care for children with troubled family...
is common in the family's society. Victoria Climbié was apparently happy to be chosen, and although her parents had only met Kouao a few times, they were satisfied with the arrangements.
From that point onwards, Kouao pretended that Climbié was her daughter. Kouao had originally planned to take another young girl called Anna Kouao, but Anna's parents changed their minds. Climbié travelled on a French passport in the name of Anna Kouao and was known as Anna throughout her life in England. It is not known exactly when Kouao started abusing Climbié. Climbié's parents received three messages about her from when she left them to her death, all saying she was in good health.
Kouao and Climbié left the Ivory Coast possibly in November 1998 and flew to Paris, France, where Climbié enrolled at school. By December 1998, however, Kouao began to receive warnings about Climbié's absenteeism
Absenteeism
Absenteeism is a habitual pattern of absence from a duty or obligation. Traditionally, absenteeism has been viewed as an indicator of poor individual performance, as well as a breach of an implicit contract between employee and employer; it was seen as a management problem, and framed in economic...
, and in February 1999, the school issued a child-at-risk notification and a social work
Social work
Social Work is a professional and academic discipline that seeks to improve the quality of life and wellbeing of an individual, group, or community by intervening through research, policy, community organizing, direct practice, and teaching on behalf of those afflicted with poverty or any real or...
er became involved. The school observed how Climbié tended to fall asleep in class, and the headteacher later recalled Kouao mentioning Climbié suffering from some form of dermatological
Dermatology
Dermatology is the branch of medicine dealing with the skin and its diseases, a unique specialty with both medical and surgical aspects. A dermatologist takes care of diseases, in the widest sense, and some cosmetic problems of the skin, scalp, hair, and nails....
condition and that, on her last visit to the school on 25 March 1999, Climbié had a shaven head and was wearing a wig. When they left France, Kouao owed the authorities £2,000, after being wrongly paid in child benefit
Child benefit
Child benefit is a social security payment disbursed to the parents or guardians of children. Child benefit is means-tested in some countries.-Australia:...
, and it is claimed that Kouao viewed Climbié as a useful tool for claiming benefits. Kouao had also been evicted from her home in France because of rent arrears.
England
On 24 April 1999, Kouao and Climbié left France and travelled to LondonLondon
London is the capital city of :England and the :United Kingdom, the largest metropolitan area in the United Kingdom, and the largest urban zone in the European Union by most measures. Located on the River Thames, London has been a major settlement for two millennia, its history going back to its...
, England, to the London Borough of Ealing
London Borough of Ealing
The London Borough of Ealing is a borough in west London.-Location:The London Borough of Ealing borders the London Borough of Hillingdon to the west, the London Borough of Harrow and the London Borough of Brent to the north, the London Borough of Hammersmith and Fulham to the east and the London...
. They had a reservation in a bed and breakfast at Twyford Crescent, Acton where they lived until 1 May 1999, when they moved to Nicoll Road, Harlesden
Harlesden
Harlesden is an area in the London Borough of Brent, northwest London, UK. Its main focal point is the Jubilee Clock which commemorates Queen Victoria's Golden Jubilee....
, in the London Borough of Brent
London Borough of Brent
In 1801, the civil parishes that form the modern borough had a total population of 2,022. This rose slowly throughout the 19th century, as the district became built up; reaching 5,646 in the middle of the century. When the railways arrived the rate of population growth increased...
. On 25 April 1999, Kouao and Climbié visited Esther Ackah, a distant relative of Kouao by marriage, and a midwife, counsellor and preacher. Ackah and her daughter noted that Climbié was wearing a wig and looked small and frail. On 26 April 1999, Kouao and Climbié visited the Homeless Persons' Unit of Ealing Council, where they were seen by Julie Winter, a homeless persons' officer. Together, Kouao and Winter completed a housing application form. Kouao explained that Climbié was wearing a wig because she had short hair, an explanation accepted by Winter. Although Winter was shown Climbié's passport (with a photograph of Anna), she paid no attention to them, believing that Kouao's application was ineligible on the grounds of habitual residence
Habitual residence
In conflict of laws, habitual residence is the standard used to determine the law which should be applied to determine a given legal dispute. It can be contrasted with the law on domicile, traditionally used in common law jurisdictions to do the same thing....
. Winter confirmed her decision with her duty senior and told Kouao that she was not eligible for housing. She telephoned the referral across to Pamela Fortune, a social worker in Ealing's Acton referral and assessment team. She did not produce a written or electronic documentation of the referral, however, something which would have helped in double-checking the accounts that Kouao gave.
Between 26 April and early July 1999, Kouao visited Ealing social services 18 times for housing and financial purposes. Climbié was with her on at least ten occasions. The staff there noted Climbié's unkempt appearance, with one staff member, Deborah Gaunt, thinking that she looked like a child from an ActionAid
ActionAid
ActionAid was founded in 1972 as a child sponsorship charity when 88 UK supporters sponsored 88 children in India and Kenya, the focus primarily being to provide children with an education. Global accounts are now reported in Euros and in 2007 and 2008 turnover was close to 180m Euros...
advertisement. However, they did not take any action and may have assumed that Climbié's appearance was a purposeful attempt to "persuade the authorities to hand out money". On 8 June 1999, Kouao got a job at Northwick Park Hospital
Northwick Park Hospital
Northwick Park Hospital is a large hospital in the northwest corner of the London Borough of Brent in Greater London, England.-Hospital role:...
. During her first month, no effort was made by Kouao or Ealing social services to enroll Climbié in educational or daycare activities.
On 8 June 1999, Kouao took Climbié to a GP
GP
- Business and media :* Georgia-Pacific LLC, a manufacturer and marketer of tissue, packaging, paper, pulp and building products* Gestair's IATA airline designator* Girard-Perregaux, a luxury brand of Swiss watches...
surgery. The practice nurse there did not carry out a physical examination as she was not reported to have any current health problems. By the middle of June 1999, Climbié was spending the majority of her days at the Brent home of Priscilla Cameron, an unregistered childminder, who Kouao met at her job at the hospital. There is no evidence that Climbié was treated badly during her time with Cameron, and she had a good relationship with Cameron's adult son, Patrick. On several occasions, Cameron observed small cuts to Climbié's fingers. When questioned by Cameron, Kouao said that they were caused by razor blades that Climbié played with. Kouao and Climbié met Ackah on the street on or around 14 June 1999. In what may have been early signs of deliberate physical harm, Ackah noted a scar on Climbié's cheek, which Kouao said was caused by a fall on an escalator. On 17 June 1999, in response to what she had seen three days earlier, Ackah visited Kouao and Climbié's home, and thought that the accommodation was unsuitable.
On 18 June 1999, Ackah anonymously telephoned Brent social services, expressing concern over Climbié's situation. Samantha Hunt, the customer-service officer who received the call at the One Stop Shop at Brent House, faxed the referral to the children's social work department on that same day. Nobody picked up the referral on that Friday afternoon, and what happened to it was—according to Lord Laming
Herbert Laming, Baron Laming
William Herbert Laming, Baron Laming, CBE isa British social worker and Crossbench Peer in the House of Lords. On 29 June 2011, it was announced that he had been elected to succeed Baroness D'Souza as Convenor of the Crossbench Peers; he will take up the post in September 2011 when the House...
, who headed the subsequent inquiry—the subject of "some of the most bizarre and contradictory evidence" the inquiry heard. A few days later, possibly on 21 June 1999, Ackah phoned Brent social services again to make sure her concerns were being addressed. Ackah said that she was told by the person on the other end of the telephone that "probably they [social services] had done something about it". This call, however, did not trigger a new, separate referral. The first referral was not seen until three weeks later on 6 July 1999, when Robert Smith, the group administrative officer, logged the details of the referral onto the computer, with details of Climbié's injuries. Laming said the delay constituted "a significant missed opportunity" to protect Climbié. Edward Armstrong, the team manager of the intake duty team, said that he completed a duty manager's action sheet not for the 18 June referral, which he said never arrived in his office, but for the 21 June referral, which was a less serious case than the first; Laming called this version of events "wholly unbelievable". Laming said that Armstrong's evidence was out of line with that of the other Brent witnesses, that the quality of it "[left] much to be desired", and that Armstrong's insistence that he dealt with the 21 June referral was an attempt to cover up his team's "inept handling" of a genuine child protection case.
On 14 June 1999, Kouao and Climbié met Carl Manning (born 31 October 1972) on a bus which he was driving. This was the start of Kouao and Manning's relationship which ended at the time of their arrest eight months later. She was his first girlfriend. The relationship developed quickly and on 6 July 1999, Kouao and Climbié moved into Manning's one-bedroom flat—described as a small bedsit
Bedsit
A bedsit, also known as a bed-sitting room, is a form of rented accommodation common in Great Britain and Ireland consisting of a single room and shared bathroom; they are part of a legal category of dwellings referred to as Houses in multiple occupation....
—at Somerset Gardens in Tottenham
Tottenham
Tottenham is an area of the London Borough of Haringey, England, situated north north east of Charing Cross.-Toponymy:Tottenham is believed to have been named after Tota, a farmer, whose hamlet was mentioned in the Domesday Book; hence Tota's hamlet became Tottenham...
, in the London Borough of Haringey
London Borough of Haringey
The London Borough of Haringey is a London borough, in North London, classified by some definitions as part of Inner London, and by others as part of Outer London. It was created in 1965 by the amalgamation of three former boroughs. It shares borders with six other London boroughs...
. There is evidence that Climbié's abuse increased soon after moving into Manning's flat.
On 7 July 1999, Brent social services sent a letter to Nicoll Road, where Kouao and Climbié were staying, informing them of a home visit. On 14 July 1999, two social workers, Lori Hobbs and Monica Bridgeman, visited the address but found no answer: Kouao and Climbié had already moved out on 6 July 1999. Hobbs and Bridgeman made no further inquiries at the property that might have led to a trail on Climbié's whereabouts. Prior to the visit, they had not done any background checks and had only the "haziest idea" of what they were investigating. The Laming report suggests that no reports or follow-up notes were made and that the only information additional to the referral were the notes "Not at this address. Have moved."
First hospital admission
On 13 July 1999, Kouao took Climbié to Cameron's house, asking her to take Climbié permanently because Manning did not want her. Cameron refused but agreed to take her for the night. Cameron, her son Patrick, and her daughter Avril, observed that Climbié had numerous injuries—including a burn on her face and a loose piece of skin hanging from her right eyelid—which Kouao said was self-inflicted. Manning's account in the subsequent inquiry differed and he said that he hit Climbié because of her incontinence, beginning with slaps, but progressing to using his fist by the end of July. It was highly likely that at least some of the injuries were the result of deliberate physical harm.The next day, on 14 July 1999, Cameron's daughter Avril took Climbié to see Marie Cader, a French teacher at her son's school. Cader advised that Climbié be taken to hospital. At 11:00 am the same day, Avril took Climbié to the emergency department
Emergency department
An emergency department , also known as accident & emergency , emergency room , emergency ward , or casualty department is a medical treatment facility specialising in acute care of patients who present without prior appointment, either by their own means or by ambulance...
of Central Middlesex Hospital
Central Middlesex Hospital
Central Middlesex hospital is in the centre of the Park Royal business estate, on the border of two London boroughs, Brent and Ealing.-Hospital role:CMH is a teaching hospital of Imperial College School of Medicine and part of the...
. At 11:50 am, Climbié was seen by Dr Rhys Beynon, a senior house officer in the department. Beynon took Climbié's history from Avril and thought that there was a strong possibility that the injuries were non-accidental. Due to hospital child protection guidelines, he referred the case to Dr Ekundayo Ajayi-Obe, the on-call paediatric registrar. Beynon conducted only a cursory examination of Climbié because he believed she was going to be examined by the paediatric team. The Laming report said that "he exhibited sound judgement in his care of Victoria by referring her immediately to a paediatric registrar." Climbié arrived at Barnaby Bear ward where she was examined by Ajayi-Obe, who noted various injuries. When asked about the injuries, Climbié said they were self-inflicted, a claim the paediatrician did not think was credible. Ajayi-Obe's notes were detailed and thorough, in contrast to those of the other doctors that examined her. Having examined Climbié, the paediatrician was "strongly suspicious" that the injuries were non-accidental, and she decided to admit Climbié onto the ward.
The doctors alerted Brent police and social services, and she was placed under police protection, with a 72-hour protection order preventing her from leaving hospital. Kouao told the doctors that she had scabies
Scabies
Scabies , known colloquially as the seven-year itch, is a contagious skin infection that occurs among humans and other animals. It is caused by a tiny and usually not directly visible parasite, the mite Sarcoptes scabiei, which burrows under the host's skin, causing intense allergic itching...
, and that the injuries were self-inflicted. Many doctors and nurses suspected that the injuries were non-accidental. However, Ruby Schwartz, the consultant
Consultant (medicine)
In the United Kingdom, Republic of Ireland, and parts of the Commonwealth, consultant is the title of a senior doctor who has completed all of his or her specialist training and been placed on the specialist register in their chosen specialty...
pediatrician
Pediatrics
Pediatrics or paediatrics is the branch of medicine that deals with the medical care of infants, children, and adolescents. A medical practitioner who specializes in this area is known as a pediatrician or paediatrician...
and named child protection doctor at the hospital, diagnosed scabies and decided that it was scratching that caused the injuries. She made the diagnosis without speaking to Climbié alone. Schwartz later admitted that she made a mistake. Another doctor, one of Schwartz' juniors, misleadingly wrote to social services saying there was no child protection
Child welfare
Child protection is used to describe a set of usually government-run services designed to protect children and young people who are underage and to encourage family stability...
issue. When Michelle Hine, a child protection officer at Brent council, received a report notifying her of Climbié's injuries, she planned to open an investigation into the case. However, the next day she heard of Schwartz' diagnosis and downgraded Climbié's level of care, trusting Schwartz' judgement. She later expressed regret over her actions. Schwartz said in the inquiry that she expected social services to follow up the case. Neil Garnham QC
Queen's Counsel
Queen's Counsel , known as King's Counsel during the reign of a male sovereign, are lawyers appointed by letters patent to be one of Her [or His] Majesty's Counsel learned in the law...
, counsel
Counsel
A counsel or a counselor gives advice, more particularly in legal matters.-U.K. and Ireland:The legal system in England uses the term counsel as an approximate synonym for a barrister-at-law, and may apply it to mean either a single person who pleads a cause, or collectively, the body of barristers...
to the inquiry following Climbié's death, later said to her, "there is a terrible danger here—is there not, doctor—of social services on the one hand and you on the other each expecting the other to do the investigation, with the result that nobody does". A police officer
Police officer
A police officer is a warranted employee of a police force...
from Brent council, Rachel Dewar, decided to lift the police protection, allowing Climbié to return home, when told by a social worker that she had scabies. Under the Children Act 1989
Children Act 1989
The Children Act 1989 is a British Act of Parliament that altered the law in regard to children. In particular, it introduced the notion of parental responsibility. Later laws amended certain parts of the Children Act...
, Dewar was obliged to see Climbié and tell her she was under police protection, but she did not do this. She also failed to see Kouao or Manning. At the time of the decision, Dewar was attending a seminar on child protection. Garnham later said, "we will need to ask why it was thought more important for her to attend a seminar to learn how to deal with child protection cases than deal with the real child protection case for which she was responsible at the time". Kouao took Climbié home on 15 July 1999.
Some time in July, probably just before Climbié was admitted to the Central Middlesex Hospital, Kouao befriended a couple, Julien and Chantal Kimbidima. Climbié and Kouao visited their home several times over the following months. According to Chantal, Kouao would shout at Climbié all the time and never showed her affection.
Second hospital admission
Emergency department
An emergency department , also known as accident & emergency , emergency room , emergency ward , or casualty department is a medical treatment facility specialising in acute care of patients who present without prior appointment, either by their own means or by ambulance...
at North Middlesex Hospital
North Middlesex Hospital
The North Middlesex University Hospital, known locally as North Mid, is a District General Hospital in Edmonton, in the London Borough of Enfield, within the area served by the Enfield Primary Care NHS Trust.- History :...
with severe scalding
Burn (injury)
A burn is a type of injury to flesh caused by heat, electricity, chemicals, light, radiation or friction. Most burns affect only the skin . Rarely, deeper tissues, such as muscle, bone, and blood vessels can also be injured...
to her head and other injuries. The hospital found no evidence of scabies. Consultant Mary Rossiter felt Climbié was being abused but still wrote 'able to discharge' on her notes. According to Maureen Ann Meates, another doctor at the hospital, when Rossiter had written that note, she had noted that Climbié was exhibiting signs of neglect, emotional abuse and physical abuse
Physical abuse
Physical abuse is abuse involving contact intended to cause feelings of intimidation, injury, or other physical suffering or bodily harm.-Forms of physical abuse:*Striking*Punching*Belting*Pushing, pulling*Slapping*Whipping*Striking with an object...
. Later, in the inquiry, Rossiter said that by writing 'able to discharge', she did not mean she wanted Climbié to go home, merely that she was physically fit to leave. Garnham said, "quite how the subtlety of that distinction was to be ascertained from the notes is far from obvious". Rossiter admitted to the inquiry that she had expected police and social services to follow up on the case. For a brief period while she was in hospital, Enfield
London Borough of Enfield
The London Borough of Enfield is the most northerly London borough and forms part of Outer London. It borders the London Boroughs of Barnet, Haringey and Waltham Forest...
social services took up the case before passing it to Haringey.
A social worker and police officer from Haringey council, Lisa Arthurworrey and Karen Jones, respectively, were assigned to her case, and were scheduled to make a home visit on 4 August 1999; however, the visit was cancelled once they heard about the scabies. Jones later said, "it might not be logical but I did not know anything about scabies". She said that she telephoned North Middlesex Hospital for information about the disease, but Garnham had evidence that the staff there dealt with no such inquiry. Jones was told by a doctor that Climbié's injuries were consistent with belt buckle marks, although she claimed in the inquiry there was no evidence of child abuse.
On 5 August 1999, a Haringey social worker, Barry Almeida, took Climbié to an NSPCC centre in Tottenham, where she was assigned to Sylvia Henry. There was some confusion as to why the centre was being referred to for the case. Henry later contacted Almeida and was told, according to Henry, that Climbié had moved out of the borough, thereby closing the case. Almeida said he could not remember whether this conversation did take place. On the same day, Kouao met Arthurworrey and Jones at the Haringey social services department, and claimed that Climbié had poured boiling water over herself to stop the itching caused by the scabies and that she had used utensils to cause the other injuries. The social worker and police officer believed her, deciding that the injuries were probably accidental, and allowed Climbié to return home the following day, which she did.
Post-hospital events
On 7 August 1999, Kouao visited Ealing social services; they said it was a housing issue and that the case was closed. Ealing social services would later be described as 'chaotic'. As a follow-up measure, a staff member at the hospital contacted a health visitorHealth visitor
Health visitors are UK community health nurses who have undertaken further training to work as part of a primary health care team. As their name suggests, their role is to promote mental, physical and social well-being in the community by giving advice and support to families in all age groups...
, but the health visitor said in the inquiry that she did not receive any contact. On 13 August 1999, Rossiter wrote to Petra Kitchman of Brent council, asking her to follow up on the Climbié case. Kitchman said in the inquiry that she contacted Arthurworrey, but Arthurworrey denied this. Later, on 2 September 1999, Rossiter sent a second letter. Kitchman said she spoke to Arthurworrey about this, but Arthurworrey denied this again. Arthurworrey made a visit to Climbié's home on 16 August 1999 and another one when Manning began forcing Climbié to sleep in the bath. Arthurworrey said in the inquiry that she was under the impression that Climbié seemed happy, but Garnham criticised Arthurworrey for not detecting any of the abuse, although Manning had described this visit as a "put up job". Arthurworrey and Climbié had met on four occasions, where they were together for a total of less than 30 minutes, barely speaking to each other.
From then on, Kouao kept Climbié away from hospitals, turning instead to churches. Kouao said to the pastors that she was the mother and that demons were inside
Demonic possession
Demonic possession is held by many belief systems to be the control of an individual by a malevolent supernatural being. Descriptions of demonic possessions often include erased memories or personalities, convulsions, “fits” and fainting as if one were dying...
Climbié. The pastor at the Mission Ensemble Pour Christ, Pascal Orome, offered prayers for Climbié to cast out the devil, and thought that her injuries were due to demonic possession. On another occasion, Kouao took Climbié to a church run by the Universal Church of the Kingdom of God
Universal Church of the Kingdom of God
Universal Church of the Kingdom of God is a Pentecostal Christian organisation established in Brazil on July 9, 1977, with a presence in many countries...
, where the pastor, Alvaro Lima, suspected she was being abused, although he took no action. He said in the inquiry that Climbié told him that Satan
Satan
Satan , "the opposer", is the title of various entities, both human and divine, who challenge the faith of humans in the Hebrew Bible...
had told her to burn herself. The pastor did not believe her, but he still believed that a person could be possessed.
From October 1999 to January 2000, Manning forced Climbié to sleep in a bin liner in the bath in her own excrement. During a later police interview, Manning said this was because of her frequent bedwetting
Bedwetting
Nocturnal enuresis, commonly called bedwetting, is involuntary urination while asleep after the age at which bladder control usually occurs. Nocturnal enuresis is considered primary when a child has not yet had a prolonged period of being dry...
. At Haringey social services on 1 November 1999, Kouao told social workers that Manning sexually assaulted
Child sexual abuse
Child sexual abuse is a form of child abuse in which an adult or older adolescent uses a child for sexual stimulation. Forms of child sexual abuse include asking or pressuring a child to engage in sexual activities , indecent exposure with intent to gratify their own sexual desires or to...
Climbié, but withdrew the accusation the following day. In one of Arthurworrey's visits, during a conversation about housing, Arthurworrey said that the council only accommodated children believed to be at serious risk. Laming said in his report, "it may be no coincidence that within three days of this conversation, Kouao contacted Ms. Arthurworrey to make allegations which, if true, would have placed Victoria squarely within that category". Jones sent a letter to Kouao, which was ignored, and no further action was taken. Manning later denied the allegation. Alan Hodges, the police sergeant
UK police ranks
Most of the police forces of the United Kingdom use a standardised set of ranks, with a slight variation in the most senior ranks for Greater London's Metropolitan Police Service and the City of London Police...
overseeing the investigation, claimed in the inquiry that the social workers were obstructing the police in dealing with child protection cases. Between December 1999 and January 2000, Arthurworrey made three visits to the flat, but she received no answer. She speculated to her supervisor, Carole Baptiste, that they had returned to France. Despite no evidence, her supervisor wrote on Climbié's file that they had left the area. On 18 February 2000 they wrote to Kouao saying that if they did not receive any contact from them, they would close the case. A week later, on 25 February 2000, they closed the case—on the same day that Climbié died.
Death and trial
Unconsciousness
Unconsciousness is the condition of being not conscious—in a mental state that involves complete or near-complete lack of responsiveness to people and other environmental stimuli. Being in a comatose state or coma is a type of unconsciousness. Fainting due to a drop in blood pressure and a...
and suffering from hypothermia
Hypothermia
Hypothermia is a condition in which core temperature drops below the required temperature for normal metabolism and body functions which is defined as . Body temperature is usually maintained near a constant level of through biologic homeostasis or thermoregulation...
, multiple organ failure
Multiple organ dysfunction syndrome
Multiple organ dysfunction syndrome ', previously known as multiple organ failure or multisystem organ failure , is altered organ function in an acutely ill patient requiring medical intervention to achieve homeostasis...
and malnutrition
Malnutrition
Malnutrition is the condition that results from taking an unbalanced diet in which certain nutrients are lacking, in excess , or in the wrong proportions....
, to the local Universal Church of the Kingdom of God church. After they left, the mini cab driver was horrified at Climbié's condition and took her straight to the accident-and-emergency department at North Middlesex Hospital; she was then transferred to the intensive-care
Intensive care medicine
Intensive-care medicine or critical-care medicine is a branch of medicine concerned with the diagnosis and management of life threatening conditions requiring sophisticated organ support and invasive monitoring.- Overview :...
unit at St Mary's Hospital. The ambulance driver who drove her to St Mary's described how although Kouao had kept saying, "my baby, my baby", her concern seemed "not quite enough", and that Manning seemed "almost as if he was not there". Climbié died the following day at 3:15pm local time. The pathologist
Pathology
Pathology is the precise study and diagnosis of disease. The word pathology is from Ancient Greek , pathos, "feeling, suffering"; and , -logia, "the study of". Pathologization, to pathologize, refers to the process of defining a condition or behavior as pathological, e.g. pathological gambling....
who examined her body noted 128 separate injuries and scars on her body, and described it as the worst case of child abuse she had ever seen; Climbié had been burnt with cigarettes, tied up for periods of longer than 24 hours, and hit with bike chains, hammers and wires. During her life in England, Climbié was known to four local authorities (four social services departments and three housing departments), two child protection police teams, two hospitals, an NSPCC centre, and a few local churches. She was buried in Grand-Bassam
Grand-Bassam
Grand-Bassam is a city in Côte d'Ivoire, lying east of Abidjan. It was the French colonial capital city from 1893 until 1896, when the administration was transferred to Bingerville after a bout of yellow fever. The city remained a key seaport until the growth of Abidjan from the...
near her home town.
Kouao was arrested on the day that Climbié died, and Manning the following day. Kouao told police, "It is terrible, I have just lost my child". On 20 November 2000, at the Old Bailey
Old Bailey
The Central Criminal Court in England and Wales, commonly known as the Old Bailey from the street in which it stands, is a court building in central London, one of a number of buildings housing the Crown Court...
, the trial
Trial (law)
In law, a trial is when parties to a dispute come together to present information in a tribunal, a formal setting with the authority to adjudicate claims or disputes. One form of tribunal is a court...
into her death opened, where Kouao and Manning were charged with child cruelty
Child abuse
Child abuse is the physical, sexual, emotional mistreatment, or neglect of a child. In the United States, the Centers for Disease Control and Prevention and the Department of Children And Families define child maltreatment as any act or series of acts of commission or omission by a parent or...
and murder. Kouao denied all charges, and Manning pleaded guilty to charges of cruelty and manslaughter
Manslaughter
Manslaughter is a legal term for the killing of a human being, in a manner considered by law as less culpable than murder. The distinction between murder and manslaughter is said to have first been made by the Ancient Athenian lawmaker Dracon in the 7th century BC.The law generally differentiates...
. The judge described the people in Climbié's case as "blindingly incompetent". In his diary, Manning described Climbié as Satan
Satan
Satan , "the opposer", is the title of various entities, both human and divine, who challenge the faith of humans in the Hebrew Bible...
, and said that no matter how hard he hit her, she did not cry or show signs that she was hurt. On 12 January 2001, both were found guilty and sentenced to life imprisonment
Life imprisonment
Life imprisonment is a sentence of imprisonment for a serious crime under which the convicted person is to remain in jail for the rest of his or her life...
. The judge said to them, "what Victoria endured was truly unimaginable. She died at both your hands, a lonely drawn out death". Kouao went to Durham prison
Durham (HM Prison)
HM Prison Durham is a local Category B men's prison, located in the Elvet area of Durham in County Durham, England. The prison is operated by Her Majesty's Prison Service.-History:...
and Manning went to Wakefield prison
Wakefield (HM Prison)
HM Prison Wakefield is a Category A men's prison, located in Wakefield, West Yorkshire, England. The prison is operated by Her Majesty's Prison Service, and is the largest maximum security prison in the United Kingdom...
.
Inquiry
On 20 April 2000, the health secretarySecretary of State for Health
Secretary of State for Health is a UK cabinet position responsible for the Department of Health.The first Boards of Health were created by Orders in Council dated 21 June, 14 November, and 21 November 1831. In 1848 a General Board of Health was created with the First Commissioner of Woods and...
, Alan Milburn
Alan Milburn
Alan Milburn is a British Labour Party politician, who was the Member of Parliament for Darlington from 1992 until 2010...
, and the home secretary
Home Secretary
The Secretary of State for the Home Department, commonly known as the Home Secretary, is the minister in charge of the Home Office of the United Kingdom, and one of the country's four Great Offices of State...
, Jack Straw
Jack Straw
Jack Straw , British politician.Jack Straw may also refer to:* Jack Straw , English* "Jack Straw" , 1971 song by the Grateful Dead* Jack Straw by W...
, appointed William Laming, Lord Laming
Herbert Laming, Baron Laming
William Herbert Laming, Baron Laming, CBE isa British social worker and Crossbench Peer in the House of Lords. On 29 June 2011, it was announced that he had been elected to succeed Baroness D'Souza as Convenor of the Crossbench Peers; he will take up the post in September 2011 when the House...
, former chief inspector of the Social Services Inspectorate (SSI), to conduct a statutory inquiry into Climbié's death. Laming was given the choice of staging a public inquiry
Public inquiry
A Tribunal of Inquiry is an official review of events or actions ordered by a government body in Common Law countries such as the United Kingdom, Ireland or Canada. Such a public inquiry differs from a Royal Commission in that a public inquiry accepts evidence and conducts its hearings in a more...
or a private inquiry; he chose a public inquiry. It was the first inquiry to be set up by two secretaries of state
Secretary of State (United Kingdom)
In the United Kingdom, a Secretary of State is a Cabinet Minister in charge of a Government Department ....
. The inquiry was actually three separate inquiries, together called the Victoria Climbié Inquiry, as it had a statutory base
Statute
A statute is a formal written enactment of a legislative authority that governs a state, city, or county. Typically, statutes command or prohibit something, or declare policy. The word is often used to distinguish law made by legislative bodies from case law, decided by courts, and regulations...
of three pieces of legislation
Legislation
Legislation is law which has been promulgated by a legislature or other governing body, or the process of making it...
: section 81 of the Children Act 1989
Children Act 1989
The Children Act 1989 is a British Act of Parliament that altered the law in regard to children. In particular, it introduced the notion of parental responsibility. Later laws amended certain parts of the Children Act...
, section 84 of the National Health Service Act 1977, and section 49 of the Police Act 1996. It drew together the involvement of social services, the National Health Service
National Health Service
The National Health Service is the shared name of three of the four publicly funded healthcare systems in the United Kingdom. They provide a comprehensive range of health services, the vast majority of which are free at the point of use to residents of the United Kingdom...
, and the police, and became the first tripartite inquiry into child protection. The Counsel to the Inquiry was Neil Garnham QC
Queen's Counsel
Queen's Counsel , known as King's Counsel during the reign of a male sovereign, are lawyers appointed by letters patent to be one of Her [or His] Majesty's Counsel learned in the law...
. The inquiry, based in Hannibal House
Hannibal House
Hannibal House is an icon of 1960s office architecture positioned above the Elephant and Castle shopping centre in Southwark, south London.Until 2005, the building housed various bodies and agencies of the British Department of Health, including the Devices section of the Medicines and Healthcare...
, Elephant and Castle
Elephant and Castle
The Elephant and Castle is a major road intersection in south London, England, located in the London Borough of Southwark. It is also used as a name for the surrounding area....
, London, cost £3.8 million, making it the most expensive child protection investigation in British history. The website victoria-climbie-inquiry.org.uk was created, where all the evidence and documents were made available freely.
The inquiry was launched on 31 May 2001, and was split into two phases: phase one and phase two. Phase one investigated the involvement of people and agencies in Climbié's death, in the form of hearings
Hearing (law)
In law, a hearing is a proceeding before a court or other decision-making body or officer, such as a government agency.A hearing is generally distinguished from a trial in that it is usually shorter and often less formal...
. Two hundred and seventy witness
Witness
A witness is someone who has firsthand knowledge about an event, or in the criminal justice systems usually a crime, through his or her senses and can help certify important considerations about the crime or event. A witness who has seen the event first hand is known as an eyewitness...
es were involved. The phase one hearings began on 26 September 2001 and finished on 31 July 2002; it was originally supposed to end on 4 February 2002 but late documents caused delays. Phase two of the inquiry, taking place between 15 March 2002 and 26 April 2002, took the form of five seminars, which looked at the child protection system in general. It was chaired by Garnham and brought together experts in all aspects of child protection.
Laming controversy
Laming's appointment was controversial as he had been director of Hertfordshire county councilHertfordshire
Hertfordshire is a ceremonial and non-metropolitan county in the East region of England. The county town is Hertford.The county is one of the Home Counties and lies inland, bordered by Greater London , Buckinghamshire , Bedfordshire , Cambridgeshire and...
's social services department in 1990, a department which was strongly criticised for its handling of a child abuse case, and which had the local government ombudsman
Local Government Ombudsman
A Local Government Ombudsman is an official employed by the Commission for Local Administration in England , a body of commissioners established under the Local Government Act 1974 to investigate complaints about councils and certain other bodies in England. Each of three Local Government Ombudsmen...
making a finding of 'maladministration
Maladministration
Maladministration is a political term which describes the actions of a government body which can be seen as causing an injustice.The law in the United Kingdom says Ombudsman must investigate ‘maladministration’...
with injustice' against them in 1995. The father of the child in the case said of Laming's appointment, "I don't see how he has the qualifications or experience to be able to lead an investigation into another borough which has been failing to protect a child in exactly the same manner that his own authority failed to protect a child in 1990". Liberal Democrat
Liberal Democrats
The Liberal Democrats are a social liberal political party in the United Kingdom which supports constitutional and electoral reform, progressive taxation, wealth taxation, human rights laws, cultural liberalism, banking reform and civil liberties .The party was formed in 1988 by a merger of the...
spokesman Paul Burstow
Paul Burstow
Paul Kenneth Burstow , British politician, is the Liberal Democrat Member of Parliament for Sutton and Cheam. In May 2010 he was appointed Minister of State for the Department of Health.-Early life:...
said, "the findings of the ombudsman in the Hertfordshire case must give rise to questions about Lord Laming's appointment to head this inquiry"; and Conservative Party
Conservative Party (UK)
The Conservative Party, formally the Conservative and Unionist Party, is a centre-right political party in the United Kingdom that adheres to the philosophies of conservatism and British unionism. It is the largest political party in the UK, and is currently the largest single party in the House...
spokesman Liam Fox
Liam Fox
Liam Fox MP is a British Conservative politician, Member of Parliament for North Somerset, and former Secretary of State for Defence....
said, "I think the government maybe should have thought twice about this and maybe, even yet, they will think again". The Department for Health
Department of Health (United Kingdom)
The Department of Health is a department of the United Kingdom government with responsibility for government policy for health and social care matters and for the National Health Service in England along with a few elements of the same matters which are not otherwise devolved to the Scottish,...
, however, said that they were "fully confident that he is the right person to conduct the inquiry".
Obstruction of evidence
Several documents were submitted late or in suspicious circumstances to the inquiry. A report by the SSI was submitted late because the SSI presumed the document was not relevant to the inquiry. The report was produced in April 2001 but was not handed over to the inquiry until 2002. An earlier report by the Joint Review about Haringey social services, which was heavily relied upon during the inquiry, said that service users were "generally well served"; the SSI report said that the former report presented "an overly positive picture of Haringey's social services, particularly children's services". Further documents were received late, when Haringey council handed in 71 case documents five months after the hearings began. Laming said, "it shows a blatant and flagrant disregard to the work of this inquiry". The people involved were threatened with disciplinary action. This was not the first time that Haringey council did not produce documents on time, which led Laming to say to its chief executive, "it is a long sad and sorry saga of missed dates and missed timetables". Garnham warned that Haringey senior managers, who had access to the documents, would enjoy an unfair advantage in the inquiry, but Laming said he was "determined that Haringey is not given any advantage". The inquiry found contradictory information in the NSPCC's files. One file said that Climbié's case was "accepted for ongoing service", whilst another computer record, made after Climbié's death, said that "no further action" was to be taken, suggesting the possibility that records may have been changed. Documents given to the inquiry may also have been altered: the NSPCC provided photocopies of an original document, which had alterations in them, saying that the originals were lost; however, the originals were later produced with pressure from the inquiry. The NSPCC held an internal investigation but found no evidence of deception.Findings of the hearings
The inquiry heard that many of the councils were under-staffed, under-funded, and poorly managed. The chief executive of Brent council said its social services department was "seriously defective". The inquiry was told that many cases at Brent social services were closed inappropriately before inspection by the social services inspectorate, that children were being placed unaccompanied in bed-and-breakfast accommodation, and that children in need were turned away. The inquiry heard how Edward Armstrong had previously been ordered not to work with children over his handling of a case in 1993. Haringey and Brent councils diverted £18.7 million and over £26 million, respectively, in the two years 1997/98 and 1998/99, from its social services department into services such as education, for other purposes; both underspent their budgets for children's services, totalling £28m, by more than £10m in 1998–99, causing a deteriorating of child protection services. The inquiry heard how Haringey council failed to assign social workers to 109 children in May 1999, a short period before they took on Climbié's case. Again in January 2002, Haringey council failed to assign social workers to about 50 children. Haringey council wrote a letter to Laming claiming that social workers who gave evidence were being questioned more harshly than other witnesses. Laming condemned the letter, saying "I will not tolerate any covert attempt to influence the way in which the inquiry is conducted." Mary Richardson, the director of social services at Haringey from 1 April 1998 until 31 March 2000, had been responsible for a restructuring of the department which, according to the union UnisonUNISON
UNISON is the largest trade union in the United Kingdom with over 1.3 million members.The union was formed in 1993 when three public sector trade unions, the National and Local Government Officers Association , the National Union of Public Employees and the Confederation of Health Service...
, had "virtually paralysed" the child protection service. She received contact from twelve senior practitioners and team managers criticising the proposals as "potentially dangerous and detrimental to the people to whom we offer a service". Richardson provided no substantive response to the memorandum. She did, however, say in the inquiry that the blame lay on "part of all of the line management responsibility". Gurbux Singh, the former chief executive of Haringey council (before becoming the chairman of the Commission for Racial Equality
Commission for Racial Equality
The Commission for Racial Equality was a non-departmental public body in the United Kingdom which aimed to tackle racial discrimination and promote racial equality. Its work has been merged into the new Equality and Human Rights Commission.-History:...
), said that there was nothing he could have done to prevent Climbié's death. Garnham contrasted this with Rossiter's willingness to accept responsibility, saying, "that willingness to acknowledge error is at least at the root, is it not, of progress?"
Kouao herself was called to the inquiry, becoming the first convicted murderer to appear in person in a public inquiry. She initially refused to answer questions, and when she did, protested her innocence, first in French, then, raising her voice in anger, in English. Giving evidence by video link from prison, Manning apologised for his actions and said that it was not the fault of the various agencies that Climbié died. Broadcasters applied for access to this video, but Laming refused the application. Climbié's parents gave evidence and were present at most of the hearings, becoming distressed when hearing of Climbié's plight and seeing pictures of her injuries. They blamed Haringey council and its chief executive for Climbié's death.
Arthurworrey, a junior worker with only nineteen months of child protection experience when she took on Climbié's case, was found to have made mistakes in the case. She accused her employer of "making her a scapegoat
Scapegoat
Scapegoating is the practice of singling out any party for unmerited negative treatment or blame. Scapegoating may be conducted by individuals against individuals , individuals against groups , groups against individuals , and groups against groups Scapegoating is the practice of singling out any...
", and criticised her superiors and department for not guiding her properly. The inquiry heard that Arthurworrey was overworked, taking on more cases than guidelines allow. Carole Baptiste, Arthurworrey's first supervisor, initially refused to attend the hearings, but subsequently gave vague responses to the inquiry, and said that she had been suffering from mental illness
Mental illness
A mental disorder or mental illness is a psychological or behavioral pattern generally associated with subjective distress or disability that occurs in an individual, and which is not a part of normal development or culture. Such a disorder may consist of a combination of affective, behavioural,...
at the time. Baptiste's own child was taken into care a few months before Climbié's death. Arthurworrey said that, in their meetings, Baptiste spent most of the time discussing "her experiences as a black woman and her relationship with God", rather than child protection cases, and that she was frequently absent. Baptiste admitted she had not read Climbié's file properly. She was removed in November 1999 when she was found to be professionally unfit for her job, and replaced by Angella Mairs, who became Arthurworrey's new supervisor. Mairs was accused by Arthurworrey of not maintaining childcare standards and of removing an important document—which recommended that Climbié's case be closed—from Climbié's file on 28 February 2000, the day the news of the death was known; but she denied this. Mairs said that she had not read Climbié's file.
The inquiry heard that the number of child protection police officers in the Metropolitan Police Service
Metropolitan Police Service
The Metropolitan Police Service is the territorial police force responsible for Greater London, excluding the "square mile" of the City of London which is the responsibility of the City of London Police...
was reduced to increase the number of murder investigation officers because of the Stephen Lawrence case in 1993. A detective inspector supervising six child protection teams in London at the time of Climbié's death wrote a report criticising their competence. His former boss, however, claimed he had been lying when he said he only held "purely administrative" responsibility for the teams. The detective inspector was taken to hospital when a woman poured ink over his head while testifying. The new chief executive of Haringey council, David Warwick, Baptiste, the Metropolitan Police, and the NSPCC apologised for their failings in the case.
Racial considerations
In his opening speech on 26 September 2001, Garnham said that race may have played a part in the case, due to the fact that a black child was murdered by her black carers, and the social worker and police officer most closely involved in the case were black. He said that the fear of being accused of racismRacism
Racism is the belief that inherent different traits in human racial groups justify discrimination. In the modern English language, the term "racism" is used predominantly as a pejorative epithet. It is applied especially to the practice or advocacy of racial discrimination of a pernicious nature...
may have led to the inaction. In the hearings, Arthurworrey, who is African-Caribbean
British African-Caribbean community
The British African Caribbean communities are residents of the United Kingdom who are of West Indian background and whose ancestors were primarily indigenous to Africa...
, admitted that her assumptions about African–Caribbean families influenced her judgement, and that she had assumed Climbié's timidness in the presence of Kouao and Manning stemmed not from fear, but from the African–Caribbean culture of respect towards one's parents. Ratna Dutt, director of the Race Equality Unit (now the Race Equality Foundation), a charity that provides race-awareness training to social workers, later said, "the implicit message is that it's acceptable for ethnic minorities to receive poor services under the guise of superficial cultural sensitivity. This is absolutely shameful, as it allows people to argue that good practice is compromised by anti-racism
Anti-racism
Anti-racism includes beliefs, actions, movements, and policies adopted or developed to oppose racism. In general, anti-racism is intended to promote an egalitarian society in which people do not face discrimination on the basis of their race, however defined...
"; and, contrasting the outcomes of the white and black staff members involved, "for a large number of black frontline staff if the finger of blame is pointed at them they don't end up in jobs in other local authorities. That's how institutional racism
Institutional racism
Institutional racism describes any kind of system of inequality based on race. It can occur in institutions such as public government bodies, private business corporations , and universities . The term was coined by Black Power activist Stokely Carmichael in the late 1960s...
operates". Jacqui Smith
Jacqui Smith
Jacqueline Jill "Jacqui" Smith is a member of the British Labour Party. She served as the Member of Parliament for Redditch from 1997 until 2010 and was the first ever female Home Secretary, thus making her the third woman to hold one of the Great Offices of State — after Margaret Thatcher and...
, Home Secretary
Home Secretary
The Secretary of State for the Home Department, commonly known as the Home Secretary, is the minister in charge of the Home Office of the United Kingdom, and one of the country's four Great Offices of State...
from 2007, said: "I have not seen widespread evidence that social workers are not taking action", and, "there are no cultures that condone child abuse. We are absolutely clear that social workers and social work departments have a responsibility to consider whether children are subjected to harm, and if they think they are, to take action". One chapter of the report following the inquiry looked at this issue.
Laming report
When both phases of the inquiry were completed, Laming began writing the final report. The Laming report, published on 28 January 2003, found that the agencies involved in her care had failed to protect her, and that on at least twelve occasions, workers involved in her case could have prevented her death, particularly condemning the senior managers involved. On the day of the launch of the report, Climbié's mother sang her daughter's favourite song as a tribute.The 400-page report made 108 recommendations in child protection reform. Regional and local committees for children and families are to be set up, with members from all groups involved in child protection. Previously each local authority managed their own child protection register, a list of children believed to be at risk, and no national register existed; this, combined with local authorities' tendency to suppress information about child abuse cases, led to the implementation of the child database. Two organisations to improve the care of children, the General Social Care Council
General Social Care Council
The General Social Care Council is a the regulator of social workers and social work students in England. The GSCC protects the public by requiring high standards of education, conduct and practice of social workers by ensuring that only those who are properly trained and committed to high...
and the Social Care Institute for Excellence, had already been set up by the time the report was published.
Criticism of agencies
Following Victoria Climbié's death, the agencies in the case, as well as the child services system in general, were widely criticised. Milburn said, "this was not a failing on the part of one service, it was a failing on the part of every service". Fox said Climbié's case amounted to "a shocking tale of individual professional failure and systemic incompetence". Burstow said, "there is a terrible sense of déjà vuDéjà vu
Déjà vu is the experience of feeling sure that one has already witnessed or experienced a current situation, even though the exact circumstances of the prior encounter are uncertain and were perhaps imagined...
in the Laming Report. The same weaknesses have led to the same mistakes, with the same missed opportunities to save a tortured child's life". Labour Party
Labour Party (UK)
The Labour Party is a centre-left democratic socialist party in the United Kingdom. It surpassed the Liberal Party in general elections during the early 1920s, forming minority governments under Ramsay MacDonald in 1924 and 1929-1931. The party was in a wartime coalition from 1940 to 1945, after...
member of parliament
Member of Parliament
A Member of Parliament is a representative of the voters to a :parliament. In many countries with bicameral parliaments, the term applies specifically to members of the lower house, as upper houses often have a different title, such as senate, and thus also have different titles for its members,...
Karen Buck
Karen Buck
Karen Patricia Buck is a British Labour Party politician, who has been the Member of Parliament for Regent's Park and Kensington North since 1997, and is a former Parliamentary Under Secretary of State at the Department for Transport....
said, "the Bayswater families unit told me that there must be hundreds of other Climbié cases waiting to happen", and "the Victoria Climbié inquiry highlighted how easy it is for vulnerable families to fall through the net, especially if they do not have English as a first language and are highly mobile". The 1999 Department of Health document, Working Together to Sequestrate Children (now superseded), set out child protection guidance to doctors, nurses, and midwives. The Royal College of Nursing
Royal College of Nursing
The Royal College of Nursing is a union membership organisation with over 395,000 members in the United Kingdom. It was founded in 1916, receiving its Royal Charter in 1928, Queen Elizabeth II is the patron...
, however, said that there was evidence that many nurses did not receive proper training in these areas. Denise Platt, chief inspector of the social services inspectorate (SSI), said doctors, police officers and teachers often thought their only responsibility was to help social services, forgetting that they had a distinct role to play. Mike Leadbetter, president of the Association of Directors of Social Services, said that many health professionals were "not engaged in child protection". After the inquiry, there was a feeling that senior managers had managed to escape responsibility and that only junior staff members were punished. Burstow said, "the majority of children who die from abuse or neglect in this country know the perpetrator; it is within the family and by 'friends' that most abuse occurs. As a society we are still in denial about that hard truth".
Criticism of the report
The Laming report was criticised by Caroline Abrahams and Deborah Lightfoot of NCH as too narrow, focusing too much on the particular case of Victoria Climbié and not on general child protection. According to Harry Ferguson, a professor of social work at the University of the West of EnglandUniversity of the West of England
The University of the West of England is a university based in the English city of Bristol. Its main campus is at Frenchay, about five miles north of the city centre...
, "Laming's report focuses too heavily on the implementation of new structures and fails to understand the keen intuition that child protection work demands". He criticised the approach to child protection of focusing too much on the worst cases and trying too much to prevent them, rather than having an approach that also celebrates success; and said that focusing too much on any individual case and basing reforms on that was "deeply problematic". Laming responded to criticism by the Association of Directors of Social Services that his recommendations would require much more funding by saying that these arguments lacked "intellectual rigour", and he dismissed claims that his reforms would be too bureaucratic
Red tape
Red tape is excessive regulation or rigid conformity to formal rules that is considered redundant or bureaucratic and hinders or prevents action or decision-making...
. The Guardian
The Guardian
The Guardian, formerly known as The Manchester Guardian , is a British national daily newspaper in the Berliner format...
said that the report does not address the issues of frontline staff. Deryk Mead of NCH said, "I do believe that inquiry reports have made a positive difference to the child protection system, and I have every confidence that Lord Laming's report will do so too".
Other
The GuardianThe Guardian
The Guardian, formerly known as The Manchester Guardian , is a British national daily newspaper in the Berliner format...
discussed the media attention surrounding the case, noticing how sensational
Sensationalism
Sensationalism is a type of editorial bias in mass media in which events and topics in news stories and pieces are over-hyped to increase viewership or readership numbers...
events received widespread coverage, yet important but less exciting events received less. It states that only it and The Independent
The Independent
The Independent is a British national morning newspaper published in London by Independent Print Limited, owned by Alexander Lebedev since 2010. It is nicknamed the Indy, while the Sunday edition, The Independent on Sunday, is the Sindy. Launched in 1986, it is one of the youngest UK national daily...
of the national newspapers gave significant coverage to the evidence in the hearings. A possible explanation is given as, "much of the evidence has been concerned with social services, which many other papers view as a politically correct
Political correctness
Political correctness is a term which denotes language, ideas, policies, and behavior seen as seeking to minimize social and institutional offense in occupational, gender, racial, cultural, sexual orientation, certain other religions, beliefs or ideologies, disability, and age-related contexts,...
waste of money for the undeserving".
In August 2002, Baptiste was fined £500 after being found guilty of deliberately failing to attend the inquiry. Climbié's parents, speaking through a family friend, said, "we, the family, expected her to be dealt with more severely". This was the first time a person had been prosecuted for not attending a public inquiry. In September 2002, Arthurworrey and Mairs were sacked following disciplinary procedures. The education secretary
Secretary of State for Education and Skills
The Secretary of State for Education is the chief minister of the Department for Education in the United Kingdom government. The position was re-established on 12 May 2010, held by Michael Gove....
, Charles Clarke
Charles Clarke
Charles Rodway Clarke is a British Labour Party politician, who was the Member of Parliament for Norwich South from 1997 until 2010, and served as Home Secretary from December 2004 until May 2006.-Early life:...
, also added them to the Protection of Children Act 1999 List, banning them from working with children. In October 2004, Arthurworrey appealed against her dismissal, saying that she was duped by Kouao and Manning, misled by medical reports, badly advised by her managers, and that she was a scapegoat for other people's failures, but the appeal was rejected. In 2005, she appealed the ban preventing her from working with children and won the case. In 2004, Mairs appealed her ban preventing her from working from children and won; this decision was challenged in the High Court
High Court of Justice
The High Court of Justice is, together with the Court of Appeal and the Crown Court, one of the Senior Courts of England and Wales...
but she prevailed. In 2004, six police officers involved in the case faced misconduct charges. All six kept their jobs, and some received reprimands and cautions. In 2004, the General Medical Council
General Medical Council
The General Medical Council registers and regulates doctors practising in the United Kingdom. It has the power to revoke or restrict a doctor's registration if it deems them unfit to practise...
dropped misconduct charges against Dr. Schwartz.
Haringey council held a debate in the council chambers to discuss the Laming report. The parents of Victoria Climbié were invited to speak at the council by Councillor Ron Aitken, but the Council leader George Meehan denied them permission. Only pressure from the opposition and local press got the decision reversed. As George Meehan only reversed his decision just before the meeting, a driver was rushed to Acton to escort Francis and Berthe Climbié and Mor Dioum, their interpreter, to the council. At the meeting, the Climbiés attacked the council, through their interpreter, for its handling of the case, especially in its dealing with the Laming Inquiry. (Mor Dioum later went on to be the Director of the Victoria Climbié Foundation.)
The government placed Haringey social services department under special measures
Special measures
Special measures is a status applied by Ofsted and Estyn, the schools inspection agencies, to schools in England and Wales, respectively, when it considers that they fail to supply an acceptable level of education and appear to lack the leadership capacity necessary to secure improvements...
, requiring close supervision by the social services inspectorate. Allegations emerged that in 2004 and 2005, senior managers at Haringey council ignored child abuse cases and "became hostile" against a social worker who sought to expose the abuse.
Climbié's parents created the Victoria Climbié Foundation UK, a charity that seeks to improve child protection policies, and the Victoria Climbié Charitable Trust, an organisation to build a school in the Ivory Coast
Côte d'Ivoire
The Republic of Côte d'Ivoire or Ivory Coast is a country in West Africa. It has an area of , and borders the countries Liberia, Guinea, Mali, Burkina Faso and Ghana; its southern boundary is along the Gulf of Guinea. The country's population was 15,366,672 in 1998 and was estimated to be...
. They are also involved in championing many child protection reforms. A playwright, Lance Nielsen
Lance Nielsen
Lance Nielsen is an outspoken and controversial English screenwriter and playwright whose work focuses predominantly on topics set in social and political arenas. He frequently explores themes of grief, loss, love and friendship...
, wrote a play based on the events, staged at the Hackney Empire
Hackney Empire
The Hackney Empire is a theatre on Mare Street, in the London Borough of Hackney, built in 1901 as a music hall.-History:Hackney Empire is a grade II* listed building...
throughout 2002.
After Climbié's death, commentators discussed the history of child protection and the various abuse and death cases, noting that there have been 70 public inquiries into child abuse since 1945, and comparing Climbié's case with that of many others, especially that of Maria Colwell in 1973. They pointed to the many children abused and killed by their guardians over the years and how the agencies involved in their care let them down. They noted similarly that their deaths also led to inquiries and reform policies—reforms that have not saved the many children killed following them. They pointed out that, "an average of 78 children are killed by parents or minders every year; a figure unaltered in the 30 years since Maria Colwell
Maria Colwell
Maria Colwell was an English child who was killed by her stepfather in 1973. The case was widely reported at the time and resulted in a public enquiry....
's death provoked the first criticism of 'communications failure'". They expressed cynicism towards the possibility that these reforms would be different. Dr. Chris Harvey, director of operations at Barnardo's
Barnardo's
Barnardo's is a British charity founded by Thomas John Barnardo in 1866, to care for vulnerable children and young people. As of 2010, it spends over £190 million each year on more than 400 local services aimed at helping these same groups...
, for example, said, "Victoria's tragic case is the latest in a sad roll-call of child deaths, each leading to fresh inquiries and a new but recurring set of recommendations". Ian Willmore, former deputy leader of Haringey council, said, "the 'script' for this kind of Iinquiry is now almost traditional. The Minister goes on TV to insist that: 'this must never happen again'. Responsibility is pinned on a few expendable front-line staff, all conveniently sacked in advance. Criticisms are made about poor communication, with earnest recommendations about better co-ordination and possible restructuring. Council officers—all new appointments—go on TV to say that everything has changed since the case began. Everyone looks very earnest. Voices crack with compassion. Nothing essential changes."
In the United Kingdom, the Audit Commission
Audit Commission
The Audit Commission is a public corporation in the United Kingdom.The Commission’s primary objective is to improve economy, efficiency and effectiveness in local government, housing and the health service, directly through the audit and inspection process and also through value for money...
regulate social services; John Seddon
John Seddon
John Seddon is a British occupational psychologist, author and "management guru", specialising in the service industry. He is lead consultant of Vanguard, a consultancy company he formed in 1985 and the inventor of 'The Vanguard Method'....
pointed out in The Times
The Times
The Times is a British daily national newspaper, first published in London in 1785 under the title The Daily Universal Register . The Times and its sister paper The Sunday Times are published by Times Newspapers Limited, a subsidiary since 1981 of News International...
that "Haringey Council was rated 4-star at the time of Victoria Climbié and Baby P's deaths".
Child protection changes
Climbié's death was largely responsible for various changes in child protection in England, including the formation of the Every Child MattersEvery Child Matters
Every Child Matters is a UK government initiative that was launched in 2003, at least partly in response to the death of Victoria Climbié...
programme, an initiative designed to improve the lives of children; the introduction of the Children Act 2004
Children Act 2004
The Children Act 2004 is an Act of the Parliament of the United Kingdom.The Act amended the Children Act 1989, largely in consequence of the Victoria Climbié inquiry....
, an Act of Parliament
Act of Parliament
An Act of Parliament is a statute enacted as primary legislation by a national or sub-national parliament. In the Republic of Ireland the term Act of the Oireachtas is used, and in the United States the term Act of Congress is used.In Commonwealth countries, the term is used both in a narrow...
that provides the legislative base for many of the reforms; the creation of ContactPoint, a database designed to hold information on all children in England and Wales
England and Wales
England and Wales is a jurisdiction within the United Kingdom. It consists of England and Wales, two of the four countries of the United Kingdom...
(now no longer in operation); and the creation of the post of children's commissioner
Children's Commissioner for England
The post of Children's Commissioner for England was established under the Children Act 2004 . The Children's Commissioner has a duty to promote awareness of the views and interests of all children in England, in particular those whose voices are least likely to be heard, to the people who make...
, who heads the Office of the Children's Commissioner, a national agency serving children and families.
In culture
A song by the steampunk band Abney Park, entitled "Victoria", is based on the life of Victoria Climbie. http://en.wikipedia.org/wiki/Aether_Shanties_%28Abney_Park_album%29Sources
- Laming, WilliamHerbert Laming, Baron LamingWilliam Herbert Laming, Baron Laming, CBE isa British social worker and Crossbench Peer in the House of Lords. On 29 June 2011, it was announced that he had been elected to succeed Baroness D'Souza as Convenor of the Crossbench Peers; he will take up the post in September 2011 when the House...
(January 2003). Report of an Inquiry. The Stationery OfficeThe Stationery OfficeThe Stationery Office is a British publishing company that was created in 1996 when the publishing arm of Her Majesty's Stationery Office was privatised. TSO is the official publisher and the distributor for legislation, command and house papers, select committee reports, Hansard, and the London,...
. Hosted at the Department for EducationDepartment for EducationThe Department for Education is a department of the UK government responsible for issues affecting people in England up to the age of 19, including child protection and education....
website. - Health CommitteeHealth Select CommitteeThe Health Select Committee is one of the Select Committees of the British House of Commons. It oversees the operations of the Department of Health and its associated bodies.-Membership:...
. House of Commons. The Victoria Climbié Inquiry Report: Sixth Report of Session 2002–2003. The Stationery OfficeThe Stationery OfficeThe Stationery Office is a British publishing company that was created in 1996 when the publishing arm of Her Majesty's Stationery Office was privatised. TSO is the official publisher and the distributor for legislation, command and house papers, select committee reports, Hansard, and the London,...
. 25 June 2003. - Every Child Matters. The Stationery OfficeThe Stationery OfficeThe Stationery Office is a British publishing company that was created in 1996 when the publishing arm of Her Majesty's Stationery Office was privatised. TSO is the official publisher and the distributor for legislation, command and house papers, select committee reports, Hansard, and the London,...
. September 2003. Every Child Matters consultation page. - Consultation page.
External links
- The Victoria Climbié Inquiry (hosted at The National Archives) • Chronology • Evidence • News
- Victoria Climbié inquiry, BBC NewsBBC NewsBBC News is the department of the British Broadcasting Corporation responsible for the gathering and broadcasting of news and current affairs. The department is the world's largest broadcast news organisation and generates about 120 hours of radio and television output each day, as well as online...
• Timeline - The Climbié inquiry, The GuardianThe GuardianThe Guardian, formerly known as The Manchester Guardian , is a British national daily newspaper in the Berliner format...
• Climbié inquiry • Timelines: General • Inquiry phase one • Inquiry phase two - Victoria Climbié Inquiry Data Corpus Online, University of HuddersfieldUniversity of HuddersfieldThe University of Huddersfield is a university located in Huddersfield, West Yorkshire, England.- History :The University traces its roots back to a Science and Mechanic Institute founded in 1825...
- Victoria Climbié Foundation
- Background to Every Child Matters, Department for Children, Schools and FamiliesDepartment for Children, Schools and FamiliesThe Department for Children, Schools and Families was a department of the UK government, between 2007 and 2010, responsible for issues affecting people in England up to the age of 19, including child protection and education...
- Every Child Matters consultation, Department for EducationDepartment for EducationThe Department for Education is a department of the UK government responsible for issues affecting people in England up to the age of 19, including child protection and education....