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Marie-Thérèse KOUAO





Classification: Murderer
Characteristics: Abuse (Climbié was burnt with cigarettes, tied up for periods of longer than 24 hours, and hit with bike chains, hammers and wires) - The death of Victoria Climbié led to a public inquiry and produced major changes in child protection policies in the United Kingdom
Number of victims: 1
Date of murder: February 25, 2000
Date of arrest: Same day
Date of birth: July 17, 1956
Victim profile: Victoria Adjo Climbié, an eight-year-old Ivorian girl
Method of murder: Torture (the Home Office pathologist finds 128 injuries)
Location: London, England, United Kingdom
Status: Sentenced to life imprisonment on January 12, 2001
photo gallery

House of Commons Health Committee

The Victoria Climbié Inquiry Report (272 Kb)
Government's response to the Health Committee (213 Kb)
The Protection of Children in England (1,00 Mb)
Every Child Matters: The Next Steps (399 Kb)

The Victoria Climbié Case

There were 12 chances to save the life of this eight year old girl. Instead, she died of 128 injuries. How could a child in Britain die like this?

On 25 February 2000, months of abuse and neglect finally overcome Victoria Climbié and she’s declared dead. The torture she’s suffered includes starvation, cigarette burns, repeated beatings with bike chains and belt buckles. And hammer blows to her toes.

But the London doctors who declare this little African girl dead believe her name is Anna.

Victoria becomes Anna

Victoria Climbié is born on 2 November 1991 in a small African village called Abobo which is near Abidjan, the former capital of the Ivory Coast. Victoria smiles, sings and dances as naturally as other children walk and talk. (In fact, she speaks both her local language and French, as her country is an ex French colony.) Victoria is definitely the ‘entertainer’ of the family. And her parents Francis Climbié and Berthe Amoissi want the very best for her. But their country is often torn apart by civil war, has endemic poverty, and illiteracy is extremely high amongst women.

So when, shortly before Victoria’s seventh birthday, her 42 year old great aunt, Marie-Therese Kouao offers to take their daughter back with her to France, it’s the opportunity of a lifetime.

“Kouao was somebody they knew well. She was the head of the family at the time. She was a French citizen, apparently, from their perception, incredibly wealthy. One of the analogies is…somebody offering you to send your child to Eton and Harrow and then educate them at Oxbridge.”

Margo Boye-Anawomah, Barrister for Mr and Mrs Climbié

Unknown to them, Marie-Therese only wants Victoria to help her access better state benefits back in France as she believes having a child will prioritise her on things like housing lists. To this end, Marie-Therese has already prepared a false passport in the name of her fictional daughter Anna. But the family of her intended target refused to let their Anna go. And it’s easier for the manipulative Marie-Therese to recruit another child of a different name, than change the passport. So she targets Victoria. To get her through border controls, she gives Victoria hair extensions. She now resembles the photo of Anna, the actual girl in the false passport.

Within 18 months, Marie-Therese, along with her new bus driving boyfriend, will be responsible for killing ‘Anna’.

Many will blame the Haringey social worker, Lisa Arthurworrey, for not doing more to prevent the abuse. But in reality, she will be just a scapegoat for a system that utterly fails to protect an innocent child.


Marie-Therese first takes Victoria to Paris, France. There she uses Victoria to fraudulently access child-benefit. Required to send her ‘daughter’ to school, Victoria only attends half the time. Marie-Therese has started abusing Victoria.

But the authorities threaten action over Victoria’s non-attendance. So after five months, Marie-Therese flees with Victoria. In April 1999 they arrive in Ealing, West London.

Victoria speaks no English.

Between 26 April and 7 July, Marie-Therese visits social workers 14 times trying to secure housing support. Victoria is with her on seven visits. One staff member thinks her dishevelled appearance is akin to a child on an ‘Action Aid poster’. But sometimes applicants present themselves as worse off than they are to secure sympathy and money.

This is the first chance to save the life of Victoria. There will be eleven more.

That June, Esther, a distant relative of Marie-Therese’s, anonymously rings Brent social workers saying she fears Victoria’s being abused. She’d seen Victoria soon after her arrival and so later notices a new scar. Marie-Therese explains Victoria fell on an escalator. Esther’s suspicious. So she visits them and is shocked to see how much weight Victoria has lost. Esther makes another call to Brent to check on progress and is reassured. A non-professional, non- specialist member of the public has noticed abuse and raised the alarm. Nothing is done.

In early July, Marie-Therese moves them into the Tottenham, North London flat of her new boyfriend, Carl Manning, a bus driver in his late 20s. She secures work so leaves Victoria with a child minder and her children. One of them, Avril, becomes so concerned over Victoria’s mounting injuries, she takes her to hospital. Following a two hour examination the doctor points along Victoria’s thigh:

Doctor: Do you know what these marks are?’

Avril: No

Doctor: These are cigarette burns

But the following morning, a senior consultant diagnoses scabies, an infectious disease that causes rashes on the skin. It’s accepted that Victoria’s been scratching herself because of scabies and the injuries are self-inflicted.

Marie-Therese takes Victoria home. Later that month, she’s admitted to North Middlesex Hospital suffering from scalding to her head and face. Marie-Therese explains Victoria tried to get rid of the scabies by holding her head under scalding water. The injuries are horrific.

One thing shines through the appalling facial disfigurement the photos record. Victoria is still smiling. And nurses take to her as she recuperates and give her a pair of pink wellies to play in. Her twirling figure down the wards entrances everyone.

But nurses note a change when Marie-Therese arrives. They record the relationship is more like ‘master and servant’ rather than ‘mother and daughter’. Other notes record a belt buckle mark on her body. Once, Victoria is so frightened when Marie-Therese arrives, she wets herself.

And during her fortnight hospital stay, social services never once ask Victoria what happened. Marie-Therese takes her back. Doctors now believe Victoria is being abused but mistakenly think the police and social services are also aware of this. A Police Constable is assigned to check up on Victoria. But PC Karen Jones doesn’t visit because she fears catching scabies from the furniture. And no health visitor makes a follow up visit after Victoria’s hospital admission.

As they’re now living with Carl, they’re considered the problem of his council, Haringey. Her assigned social worker is Lisa Arthurworrey. She’s just qualified with only 18 months experience. She needs to be closely supervised. She isn’t.

In August, Lisa makes her first of two visits to Carl Manning’s flat. The flat’s better than many she sees. It’s neat, clean and Victoria’s well presented. Lisa doesn’t speak to Victoria, however, or address the fact she’s not receiving education.

Lisa’s second visit, in October, is just days after Carl starts forcing Victoria to sleep in the bath every night. Fear and the beatings mean she’s become incontinent. She soaks the sofa on which she sleeps. So Carl makes her go to bed in a bin liner in the bath. Her hands are tied and then she’s tied into it. So she sleeps in her own excrement in a room without heat or light. It’s now winter.

They place food on a plastic plate. But her hands are tied.

“Victoria could only eat by pushing her face into the plate like a dog might, except of course, dogs aren’t normally tied up in black bin liners.”

Neil Garnham QC (Counsel to the Inquiry)

In November, Marie-Therese rings Haringey social services hysterically alleging Carl’s sexually assaulted Victoria. Three days before, Lisa told her they’ll only get better housing if Victoria’s at risk. Marie-Therese turns up at social services with Victoria. And her alleged abuser, Carl. When it’s explained to Marie-Therese that before she’ll receive her new council flat, Victoria will need to be examined, and Carl arrested, she withdraws the allegations. Haringey decide to arrange another meeting rather than investigate. There are 15 actions that Lisa should next do and she does them. She rings, writes, leaves messages and even tries to visit after work, in her own time. All are ignored.

For the remaining four months of her short life, Victoria is on her own. She is starved and tortured daily.

Marie-Therese takes her to church where she says Victoria’s condition has been caused by devils.

On 24 February, Marie-Therese takes Victoria to church again. A member of the congregation sees Victoria and insists she’s taken to hospital.

On 25 February 2000, with no successful contacts made with Victoria, Haringey close the Victoria Climbié case.

“Complete Appropriate Paperwork. Then NFA”

Management instructions to Lisa regarding Victoria. ‘NFA’ stands for No Further Action.

That afternoon, at 3:30pm, in a London hospital, doctors declare an eight year old girl dead.


On admission, Victoria’s core temperature was so low doctors didn’t have any instruments with the capacity to record it.

Dr Nathaniel Carey, the Home Office pathologist assigned to examine Victoria finds 128 injuries. He believes it to be,

‘…the worst case of child abuse I’ve encountered.’

Marie-Therese is immediately arrested at the hospital and a murder investigation is launched. Police interview her but find her evasive and obstructive. She doesn’t co-operate in any way.

The following day, Carl is arrested at his flat. In his police interview, detectives are shocked by his openness. He talks of punching Victoria or of using a shoe to beat her. Other times, he’d take a bicycle chain to her body and head.

During police interviews both claim that Victoria was possessed by demons.

Detectives search their flat for forensic evidence and find Carl’s tried to cover up evidence of the abuse by cleaning it with bleach. Despite this, they recover blood samples from the bath and the walls. And there’s blood on the furniture in the living room; And in the bedroom.

“We managed to recover many, many samples of blood. Now, given that they had already been cleaned I think that gave an indication of exactly what had happened there. She had been assaulted regularly and severely and she had bled and even though they had attempted to cover this up, it must have been in abundance.”

Detective Superintendent Keith Niven, Metropolitan Police

In the bins, they find the discarded tapes used to bind Victoria’s feet and wrists.

hey also find a passport in the flat which seems to confirm the dead girl as Anna. But detectives soon realise the photo in the passport isn’t that of the girl who’s lying in a London mortuary.

They manage to track down and contact her real parents by establishing which family Marie-Therese targeted. Victoria’s parents then have to make the terrible 3,000 mile journey to identify their dead daughter.

Carl Manning and Marie-Therese Kouao are charged with the murder of Victoria Climbié.


Both Carl and Marie-Therese go to the Old Bailey in November 2000. Their trial lasts just over two months. They, and the ‘blindingly incompetent’ child protection authorities, are to be judged. Carl denies murder but pleads guilty to child cruelty and manslaughter. Marie-Therese denies all charges.

“Marie-Therese defence was that Victoria’s condition was due to the fact that she was possessed by demons. And she maintained that throughout. Carl Manning, realising from an early stage that he was probably going to have to accept his responsibility for ill-treating this child; his defence was, ‘although I am responsible for injuring her, at the time I injured her, I didn’t intend to cause her really serious bodily harm, and I certainly didn’t intend to kill her.”

Sally Howes QC, Counsel for the prosecution

Some of Carl’s statements are almost incomprehensible.

"You could beat her and she would not cry at all. She could take the beatings and pain like anything."

But while Carl does show some shame, Marie-Therese shows no remorse for her actions. And her behaviour in court shocks everyone:

“The way she chuckled in such a menacing way and laughed dismissively, yes, it made the hairs stand on the back of my neck. This is the only time I have genuinely felt myself in the presence of evil.”

Sally Howes QC, Counsel for the prosecution

It is during the trial that it emerges that Marie-Therese used a hammer to break Victoria's toes.

But neither Carl nor Marie-Therese once give a satisfactory explanation as to why they treated Victoria as they did. One suggestion is that Marie-Therese thought she may be able to access more benefits with a child. When this did not happen, she took her frustrations out on the child.

The jury takes four days to convict. Almost a year after Victoria’s death, they find both defendants guilty. Both are sentenced to life imprisonment.

In an unprecedented move, they will both have to give evidence at another inquiry.


An eight year old girl has died despite being seen by dozens of social workers, nurses, doctors and police officers before she dies. All failed to spot and stop the abuse as she was slowly tortured to death.

In April 2001, the government announces a public inquiry. It is the first in Britain to use special powers to look at everything from the role of social services to police child protection arrangements.

A former chief inspector of social services, Lord Laming, heads the public inquiry into a case he calls the worst case of neglect of which he’s ever heard. Victoria’s parents fly over and attend almost every day of his inquiry. As witnesses in the criminal trial, they’ve been excluded from much of the evidence of how their daughter died. The details of their daughter’s injuries are sometimes too hard to bear.

In the first phase, it takes the testimony of more than 230 witnesses and in an unprecedented move it recalls the killers, Carl and Marie-Therese.

“It was an absolute pantomime from the minute she walked into the room.”

Margo Boye-Anawomah, Barrister for Mr and Mrs Climbié

Marie-Therese shrieks at the top of her voice, refusing to sit down, and when she does, despite being a convicted murderer, she denies any blame. Unbelievably, she tries to shift that onto those most undeserving. She turns on the parents of Victoria accusing them of not being properly married.

The barrister Neil Garnham exposes incompetence at every level as he interrogates the witnesses.

One of those witnesses is Lisa Arthurworrey, Victoria’s social worker. She is obviously in a very fragile state. The press has spent the intervening time demonising her. Lisa was responsible for Victoria for the last seven months of her life. In this time, Lisa saw her for a total of just 30 minutes. But she has been made a scapegoat for a complete system failure. Victoria’s Haringey social worker wasn’t evil. The truth was, she was young, inexperienced, overworked, and incompetently managed.

And two experienced senior doctors are also found to have failed Victoria. When Victoria’s child minder first admitted her to hospital, fearing abuse, it was Consultant Paediatrician, Dr Mary Schwartz who decided her cuts were due scabies. Two weeks later, when Victoria returned to hospital, the consultant, Dr Mary Rossiter did think Victoria was being abused, but confused colleagues by writing, ‘able to discharge’ on her notes.

In total there were 12 missed opportunities where professionals could have acted to save Victoria. Warning phone calls never followed up on, checks not made on stories told by Victoria’s great aunt, medical misdiagnoses and throughout, a total failure to engage with the little girl who should have been the centre of everybody’s concern. Her views were never sought.

There were also management failings. Middle ranking and senior staff did not have in place proper systems to monitor, support and supervise inexperienced subordinates. Haringey social services are described as shambolic, underfunded, and mismanaged.

Lord Laming’s inquiry identifies social services departments at four London boroughs, two police forces, two hospitals, and a specialist children’s unit who all failed to act when presented with evidence of abuse. The failings were he believed, ‘a disgrace’.

“In most cases, nothing more than a manager reading a file, or asking a basic question about whether standard practice had been followed, may have changed the course of these terrible events”

Lord Laming

After two years, Lord Laming concludes that a radical reform of child protection services is needed and especially that there should be a children’s commissioner to head a national agency. He concludes that it’s not a lack of law, but a lack of its implementation that has allowed the tragedy.


“This was not a failing on the part of one service; it was a failing on the part of every service”

Health Secretary Alan Milburn, statement to House of Commons

The whole child protection system is overhauled. A new act of parliament is brought in and new guidance issued to social workers. The government sets up a regulatory agency, the General Social Care Council as well as the Social Care Institute for Excellence, designed to promote higher standards of practice. Child protection officers in the Met have had a lowly status as shown by their nicknames, ‘the Cardigan Squad’ or ‘the baby sitters’. Their training and relevance is now seen as vital.

Victoria’s father, Francis Climbié, says he doesn’t regard Victoria’s life as ‘lost’ because of the chance it created to change childcare for the better. He and his wife start a campaign to build a school for children in the Ivory Coast. It’s hoped that by providing education there, other parents won’t feel the need to let their children be taken away.

That dream has become a reality and their newly built school now teaches 360 children.

And her parents finally laid Victoria to rest in her home town in the Ivory Coast.

"Do not let Victoria's death be in vain"

Francis Climbié


NOTE: The twelve instances where intervention could have saved Victoria are numbered below.

7 January 1973

One of the first infamous cases of child abuse is discovered when Maria Colwell, aged seven, is taken to hospital. She is terribly thin and has been badly beaten. Her death leads to a public inquiry that is one of the first major attempts designed to protect children from abuse.

October 1998

Marie-Therese Kouao proposes to Victoria’s family to take her back to France for a better life. What this head of the family is offering her parents is a life changing opportunity. Her parents buy Victoria a new pink tracksuit for the colder weather and send her off with her favourite doll.

April 1999

Marie-Therese arrives in England with her ‘daughter’, ‘Anna’.

Spring 1999

Marie-Therese visits social workers seven times with Victoria. They’re concerned that it’s not a normal mother-daughter relationship, and by Victoria’s appearance.

June 1999

Ester Ackah, a distant relative by marriage of Marie-Therese anonymously rings Brent Social workers warning them that she suspects abuse. She notices little blisters around Victoria’s hairline where she wore a wig but Marie-Therese explains Victoria’s had an accident with some hot water. Senior social worker Edward Armstrong later denies his team received details of a serious child protection case. He says they were told of a child not being in school. Other experts argue non school attendance can be an indicator of abuse. (And it was when Victoria was in France and started failing to attend school).

14 July 1999.

Victoria is admitted to Central Middlesex hospital as Avril Cameron, the daughter of Victoria’s childminder, believes Victoria has been scratched and cut. Dr Ekundayo Ajaye-Obe doesn’t believe Marie-Therese’s explanation that Victoria has been scratching at scabies sores. But a consultant paediatrician, Dr Ruby Schwartz over rules him. Another doctor writes a letter saying there were no child protection issues.

15 July 1999

Marie-Therese visits Ealing Social Services but they consider the case a housing issue, and close it.

Marie-Therese moves Victoria in with Carl Manning. His three room flat has only a kitchen, a living room with a bed in it and a bathroom. They will make the bath Victoria’s bed.

24 July 1999

Victoria is admitted to North Middlesex Hospital suffering from scalding to her head and face. Over the next two weeks of her hospital stay, Social Services never ask Victoria what happened. She’s again taken back by Marie-Therese. As they’re now living with Carl, it’s considered Haringey’s problem. PC Karen Jones doesn’t visit Marie-Therese or Carl because she fears catching scabies. Doctors now believe that Victoria is being abused but mistakenly believe that the police and social work are aware of this situation.

5 August 1999

Barry Almeida, a senior Haringey social worker refers Victoria’s case to the Tottenham Child and Family Centre. The Centre looks at the notes and are confused but when they try to clarify them, they’re told the family has moved and the case is closed. Mr Almeida says he doesn’t remember this subsequent conversation.

SEVEN: After the hospital admission, there is no health visitor follow up

13 August 1999

Mary Rossiter, the consultant paediatrician at North Middlesex Hospital writes to Petra Kitchman, Haringey’s child protection link with the hospital saying she has ‘enormous concerns’. Ms Kitchman says she doesn’t receive the letter for the next seven days. When she does, she says she tells Victoria’s social worker. Lisa Arthurworrey denies this.

16 August 1999

Social worker Lisa Arthurworrey makes her first of two visits to Carl Manning flat. Her second will be just days after he starts forcing her to sleep in the bath. She doesn’t speak to Victoria or address the fact she’s not receiving an education.

2 September 1999

Rossiter again writes to Kitchman, but the latter is on leave. When she returns, Kitchman says she raises this with Arthurworrey. Arthurworrey denies this.

28 October 1999

Lisa Arthurworrey visits Carl and Marie-Therese again to say their housing application has been unsuccessful. The coached Victoria asks ‘Why can’t you find us a home. You do not respect my mummy.’ Lisa explains she can only find accommodation if Victoria is at risk.

1 November 1999

Marie-Therese rings Haringey social services alleging that Carl’s sexually assaulted Victoria. Despite withdrawing the allegation, Haringey decide to arrange a meeting. A vital opportunity for the police and social services to investigate is missed.

23 December 1999

Ms Arthurworrey makes one of three unsuccessful visits to Carl’s flat. Thinking, without any evidence, that the pair have returned to France, she writes in her notes, they had ‘left the area’.

24 February 2000

Victoria is rushed to North Middlesex Hospital suffering from malnutrition and hypothermia. Her core temperature is so low, doctors can’t read it on their normal equipment.

25 February 2000

In the early hours, she is transferred to the intensive care unit at St Mary’s hospital, Paddington. Victoria Climbié, utterly let down by the system supposed to protect her, finally gives into the months of abuse and neglect, and is declared dead.

Marie-Therese is arrested and the following day, so is Carl Manning.

March 2000

Lisa Arthurworrey and her manager Angella Mairs are suspended on full pay.

November 2000

Carl and Marie-Therese trial begins.

12 January 2001

Nearly a year after Victoria’s death, Carl and Marie-Therese are found guilty of her murder. Both are sentenced to life imprisonment.

May 2001 Lord Laming inquiry begins.

7 January 2002

Two year old Ainlee Walker is found dead on her parent’s table. Dennis Henry and Leanne Labonte had cruelly starved and abused her until she died of her 64 injuries. Professionals had failed to visit.

9 July 2002

Lord Laming attacks Denise Platt, head of the Social Services Inspectorate for not submitting a vital report about the competence of Haringey Social Services. She apologises but doesn’t attend the hearing.

August 2002

Carole Baptiste, one of the key social workers in the case, is found guilty of failing to attend the inquiry and is fined. Lisa had attacked Carole, her boss, earlier. She says she spent her staff supervision time talking about what it meant to be a black woman and her relationship with God. Carole fails to respond to these allegations and becomes the first person ever to be prosecuted and fined for failing to give evidence at a public inquiry. When she finally does take part, she fights back against Lisa but admits she didn’t read Victoria’s file properly and asks her parents for forgiveness.

12 November 2002

Lisa Arthurworrey and her manager Angella Mairs are dismissed for gross misconduct following disciplinary proceedings

17 July 2008

Berthe Climbié, Victoria’s mother, rebukes criticism of her for letting Victoria go with Marie-Therese. She explains how the African extended family places much more trust in relatives than in the West. She remembers how Marie-Therese held up a bible and swore on it to convince them.


Murder of Victoria Climbié

In 2000 in London, 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 the United Kingdom.

Born in Abobo, Côte d’Ivoire, 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 (now defunct after closure by the government of 2010); and the creation of the Office of the Children's Commissioner chaired by the Children's Commissioner for England.


Victoria Climbié was born on 2 November 1991 in Abobo 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 former 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 the United Kingdom. It is not known exactly when Kouao started abusing Climbié. Climbié's parents received three messages about her from when she left them until 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 worker 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.

United Kingdom

On 24 April 1999, Kouao and Victoria Climbié left France and travelled to the United Kingdom, where they settled in Ealing, west 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, 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 local 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. 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 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."

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 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 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 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".

The police officer allocated to Climbié's case for the Brent Child Protection team, 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.

Second hospital admission

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.

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 visitor, 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.

Death and trial

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.

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 crew 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 3:15 pm 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 Britain, 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.


On 20 April 2000, the health secretary, 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 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 witnesses 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 council'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".

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 original documents, 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 understaffed, underfunded, 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 UNISON, 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.

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 racism 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.


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 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 vu 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".

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 England, "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".


The Guardian 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".

Child protection changes

Climbié's death was largely responsible for various changes in child protection in England, including the formation of the Every Child Matters 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.


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