1. Background and context
Non-accidental death and injury
6. The death of any child as the result of non-accidental injury is a tragedy. The fact that in England around 80 children die every year from abuse or neglect, and that this figure has remained relatively constant over more than 30 years, is shocking.[3 ] We wanted to understand what had happened to Victoria, and how the child protection system and medical care that should have protected her failed her so absolutely. More than this, we wanted to understand how the recommendations of the Laming Inquiry might improve things for the future.7. Since 1948 there have been around 70 public inquiries into major cases of child abuse.[4 ] The names of many of the children who have died have become well known, simply because of the terrible nature of their deaths. From Maria Colwell in 1973, to Jasmine Beckford and Tyra Henry (both in 1984), Kimberley Carlile (1986), Leanne White (1992), and Chelsea Brown in 1999, the deaths of these children all share many points of similarity. The pattern does not even end with the death of Victoria; since that time there have been at least two more high profile cases (Lauren Wright in 2000, and Ainlee Walker in 2002). In many of these cases the child has been the target of abuse from an adult who is not the natural parent (typically a step-father). While the particular circumstances of each case are different, there are also areas of considerable similarity. In particular, the following features recur time after time:
- Failure of communication between different staff and agencies.
- Inexperience and lack of skill of individual social workers.
- Failure to follow established procedures.
- Inadequate resources to meet demands.
8. As various commentators have pointed out, the Laming Inquiry was by no means the first to attempt to grapple with a hugely complex issue, "and his predecessors' reports have ended up on shelves gathering dust." [5 ] We therefore asked Lord Laming what would be different this time, and what confidence we could have that his report would not join those many others that created an initial flurry of interest and then were soon forgotten. Lord Laming pointed out that his inquiry differed from previous ones; indeed, it was unique in being set up under three different Acts of Parliament.[6 ] This gave Lord Laming a very wide-ranging brief, and his concern was not with the way in which just one agency had discharged its duties, but the way in which all the agencies involved (four social services departments, three housing departments, two specialist child protection teams in the Metropolitan Police, two different hospitals, and the NSPCC) had done so. Accordingly, Lord Laming told us that his recommendations were "geared towards improving the system as a whole."[7 ] We turn later in this report to examine the recommendations in greater detail.
9. It was not entirely apparent to us that the findings from all the previous inquiries had informed the deliberations of the Laming Inquiry. However, Lord Laming assured us that he had indeed read every one of these inquiry reports "from cover to cover", not in the course of the Inquiry, but in relation to his earlier responsibilities (as Director of Social Services in Hertfordshire, and then as Chief Inspector for Social Services in the Department of Health). He also told us that he had re-visited the various reports as Chair of the Inquiry.
What happened to Victoria?
10. In order to understand the Inquiry conducted by Lord Laming, it is important to set out briefly Victoria's story.[8 ] Victoria was born near Abidjan in the Ivory Coast on 2 November 1991, the fifth of seven children. According to her parents, she had a happy and healthy childhood, and did well when she started at school aged six. In October 1998, Marie-Therese Kouao, the aunt of Victoria's father visited the family. She had been living for some time in France and told Francis and Berthe Climbié that she was prepared to take one of their children back to France with her and to arrange for their education, and Victoria was chosen. As Lord Laming commented in his report, entrusting children to relatives in Europe who can offer opportunities that would not be available to them in the Ivory Coast was "not uncommon in Victoria's parents' society."[9 ]
11. Victoria travelled with Kouao to France, and stayed there for some five months. Initially Victoria attended school, but by December 1998 Victoria's absenteeism was causing concern. When she was in school, Victoria tended to fall asleep and appeared unwell. By February 1999 the school in Villepinte was sufficiently concerned to issue a Child at Risk Emergency Notification. Some time in spring 1999 Kouao informed the school that she was removing Victoria in order to take her to London for treatment. Victoria and Kouao arrived in London on 24 April 1999. They travelled on Kouao's passport, which described Victoria as her daughter named Anna. Anna was the name of another child that Kouao had previously planned to bring from the Ivory Coast, and throughout her life with Kouao, Victoria was known as Anna.
12. The day after their arrival in London, Kouao and Victoria went to Ealing Homeless Persons' Unit seeking accommodation. They were also in contact with Ealing Social Services. Kouao made contact with Esther Ackah, a distant relative living in Hanwell, West London. It was Ms Ackah who was first concerned about Victoria and who made two anonymous telephone calls to Brent Social Services.
13. From June 1999 Victoria was spending much of her time with a childminder (Priscilla Cameron) while Kouao went to work. Victoria would arrive at around 7 am and often not be collected until 10 pm. Mrs Cameron did not like the way that Kouao treated and spoke to Victoria who was very subdued when ever Kouao was present. Kouao had met Manning (driving a bus) in June, and the following month she and Victoria moved in to his flat in Somerset Gardens, Tottenham. From this time on, the abuse of Victoria seemed to increase. Both Ms Ackah and Mrs Cameron had noticed marks on Victoria, and these became more evident.
14. On 13 July 1999 Kouao asked Mrs Cameron to keep Victoria permanently because Manning did not want her living with them. Mrs Cameron was unable to do so, but kept Victoria overnight. Victoria had many injuries on her face which Kouao claimed were self-inflicted. The following day Mrs Cameron's adult daughter took Victoria to the Accident and Emergency department of the Central Middlesex hospital. The doctor who examined her believed there was a "strong possibility" that this was a case of non-accidental injury, and referred Victoria to the paediatric registrar. The registrar examined Victoria and found a large number of injuries, at least some of which it was thought could be non-accidental. Victoria was admitted to the hospital and Brent Social Services and the police were informed. Another doctor conducted an evening ward round and concluded that Victoria was suffering from scabies.
15. The next morning Kouao went to the hospital and took Victoria away. Kouao visited the Camerons to collect Victoria's things, and Mrs Cameron did not see Victoria again other than on one occasion when she saw her walking down the road with Kouao.
16. On 24 July 1999, just over a week later, Victoria was back in hospital. This time she was admitted to the North Middlesex hospital and had been taken there by Kouao with a scald to her face, which Kouao claimed Victoria had inflicted on herself by putting her head under the hot tap. Her burns were so severe that she was admitted to the paediatric ward and stayed there for 13 nights.
17. The senior house officer contacted Haringey Social Services, and a referral was also made by an Enfield social worker based at the hospital. On 28 July a meeting was held at Haringey's offices, and Victoria's case was allocated to a social worker (Lisa Arthurworrey).
18. During her time in hospital Kouao and Manning visited Victoria whose behaviour changed in their presence;
she appeared afraid of them. Ms Arthurworrey and a police constable visited Victoria on 6 August 1999 and decided it would be appropriate for her to be discharged back into Kouao's care. As Lord Laming's Report observed, "the brief interlude in her life in this country during which Victoria was safe, happy and well cared for ended."[10 ] She left the North Middlesex hospital on 6 August and returned to Manning's flat where she was to spend the remaining seven months of her life.
19. During these months Victoria had little contact with the outside world, and was seen by professionals on only four occasions, twice when she was visited by Arthurworrey, and twice when Kouao took her to Tottenham Social Services claiming that Victoria had been sexually abused by Manning (although she later withdrew this allegation). No one from the Tottenham Child and Family Centre (to which she had been referred by Haringey Social Services on 5 August 1999) ever visited Victoria.
20. Since moving in with Manning, Victoria had become at times incontinent of urine, and often wet herself and her bed. In October 1999, the sofabed on which she had been sleeping was thrown out of the flat, and Victoria began to spend her nights in an unheated and unlit bathroom.
21. During Authurworrey's two pre-announced visits to the flat, little attention was paid to Victoria and Arthurworrey did not speak to her directly. She believed that the main issue was the poor housing that the family were in, and that the priority was to move them to better accommodation. Manning later indicated that preparations had been made for Authurworrey's planned visits. The flat had been cleaned and Victoria had been told how to behave during the visit. Aurthurworrey told Kouao that the council only accommodated children at risk of serious harm. On 1 November Kouao telephoned Arthurworrey and made allegations about Manning sexually abusing Victoria. When questioned alone, Victoria repeated what Kouao had said virtually word for word, and it was believed that she had been coached in what to say. Nonetheless, Arthurworrey told Kouao that Victoria should stay elsewhere while the allegations were investigated. A person identified by Kouao as a friend (Mrs Kimbidima) who might help was telephoned. It is not clear if the friend then changed her mind, but having set off for her home in a taxi, by the end of the day Victoria and Kouao had both returned to Manning's flat. The following day Kouao withdrew her allegations of sexual harm. She was told that Victoria would still have to live elsewhere until any allegations had been investigated. Kouao said that they would remain with the Kimbidimas, but in fact they returned to Manning's flat.
22. This was the last occasion that any of the professionals involved in Victoria's case saw her until her admission to hospital the night before she died. Very little is known about the last four months of Victoria's life.
23. It is believed that Victoria spent most of this time in the Somerset Gardens flat, although there is some evidence that she made two brief trips to France with Kouao, where they stayed with Kouao's son. Back at Somerset Gardens Victoria continued to be forced to sleep in the bath, and was tied up inside a black plastic sack. As a result Victoria spent long periods lying in her own urine and faeces. The sack ceased to be used when Victoria's skin condition became so damaged that Manning said they were concerned that "undue questions" would be asked. While no longer being kept in a bag, Victoria spent most of her days and nights confined in the bathroom.
24. By the beginning of 2000 Victoria was also being given her food on a piece of plastic in the bathroom. Her hands were tied with masking tape and she would be pushed towards the food to eat it like a dog.
25. Victoria was also beaten regularly by Manning and Kouao. Manning later reported that Kouao struck Victoria on a daily basis, using various implements including a shoe, a coat hanger, a wooden spoon and a hammer. Victoria's blood was found on the walls of the flat, on Manning's football boots and trainers. He also admitted to beating Victoria with a bicycle chain.
26. By 19 February 2000 Victoria had become very ill. Kouao took Victoria with her to the Universal Church of the Kingdom of God on Seven Sisters Road. Kouao spoke to the minister (Pastor Lima) and told him of the problems she was having with Victoria, particularly with her incontinence. Pastor Lima expressed the view that Victoria was possessed by an evil spirit and advised Kouao to bring Victoria back to the church a week later. During the week Kouao telephoned the Pastor and reported that Victoria's behaviour and incontinence was improving. However, later in the week Kouao returned to the church with Victoria where Pastor Lima advised them to go to hospital and called a minicab.
27. The minicab driver took Victoria and Kouao to the nearby Tottenham Ambulance Station. Victoria was then taken by ambulance to North Middlesex hospital and admitted to casualty. Her temperature on arrival was 27 degrees Celsius (compared with a normal temperature of 36-37C), and attempts to warm her were unsuccessful. The paediatric consultant believed that Victoria needed specialist care, and a place was found for her at St Mary's Hospital Paddington. Victoria was transferred to St Mary's with severe hypothermia and multi-system failure. Her respiratory, cardiac and renal systems all began to shut down and Victoria went into cardiac arrest. Attempts at cardio-pulmonary resuscitation failed and Victoria was declared dead at 3.15 pm on 25 February 2000. Ironically, this was the very day that Haringey Social Services formally closed her case.[11 ]
28. A post-mortem was conducted the following day. The cause of death was found to be hypothermia caused by malnourishment, a damp environment and restricted movement. The pathologist found 128 separate injuries on Victoria's body caused by both sharp and blunt instruments. No part of her body was spared injury. Marks on her wrists and ankles indicated that Victoria had been tied up. The pathologist reported that it was "the worst case of deliberate harm to a child he had ever seen."[12 ]
29. Later on 25 February 2000 Kouao was arrested on suspicion of neglect, Manning was arrested the following day. Both were subsequently charged with Victoria's murder. They were convicted on 12 January 2001 and are serving sentences of life imprisonment.[13 ]
30. Victoria's story highlights the system going badly wrong at every step. Lord Laming told us:
Had this tragedy of Victoria Climbié been because one doctor, one social worker, one police officer, had failed to see one telling sign indicating deliberate harm, frankly there is no system in the world that can prevent that; any one of us can make mistakes. However, when you get the whole system engaged, when the second day this child was in the country she was referred under the Children Act as a child in need, and the very day that she died the case was being closed as no further action was needed, that was the day she was in the third hospital when her life could not be saved, I am strongly of the view that nothing more was known about Victoria Climbié at the end of the process than was not in the first referral on the second day she was in this country. Never once was an assessment of need made; never once, whether by the hospital, social services or the police service. What happened to this little girl was shocking in the extreme.[14 ]
31. It is the reasons for this systematic failure that must be understood and addressed if further tragedies of this nature are to be avoided. It is to these issues that we now turn.
3 HC Deb, 23 January 2003, col 738 (Alan Milburn MP, Secretary of State, Commons Statement on the Victoria Climbié Report) Back
5 Snell J (2003), 'Relief as prospect of child protection agency recedes-for the time being', Community Care. 30 January-5 February, pp. 16-17. Back