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Marie-Thérèse KOUAO
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
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.
Crimes
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.
Arrest
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.
Trial
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.
Investigation
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.
Aftermath
“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
Timeline
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’.
ONE:
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.
TWO:
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).
THREE:
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.
FOUR:
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.
FIVE:
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.
SIX:
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
EIGHT:
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.
NINE:
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.
TEN:
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.
ELEVEN:
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.
TWELVE:
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.
Life
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.
Inquiry
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 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 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.
Aftermath
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".
Other
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.