Climbie inquiry demands overhaul
Updated on 28 January 2003
Lord Laming spent fifteen months considering the death of Victoria Climbie, yet his conclusion was simple and damning: "It would have taken nothing more than a manager reading a piece of paper or asking a question to save Victoria's life".
She was killed by her great aunt, found with 128 separate injuries on her body.
Yet again, this is about the child protection services which didn't protect. Lord Laming thinks a more direct line of accountability for the managers, and a commissioner for children in England is the answer.
Victoria Climbie lived in England for 308 days. For 211 of them she had an allocated social worker.
But as Lord Laming said in his report today child protection agencies knew little or nothing more about the eight-year-old girl when she died, than when she was first referred to Ealling social services 10 months earlier in April 1999.
Lord Laming found that:
- Failure to protect her was lamentable and inexcusable
- Nobody had the presence of mind to follow what are relatively straightforward procedures
- The basic disciplines of medical evaluation were not put into practice
- Victoria ultimately was the victim of widespread organisational malaise
- The inquiry chairman reserves his most testing criticism not to what he describes as the handful of hapless inexperienced front line staff but to the those above them.
It said: "The greatest failure rests with the managers and senior members of the authorities...some of whom have been appointed to other presumably better paid jobs."
Doctor Ruby Schwartz is one of them. She was the consultant paediatrician at Central Middlesex Hospital where Victoria's injuries were first examined.
She put them down to scratching, scabies and old insect bites. Not, in the words of the report, a diagnosis that withstands close analysis. She made assumptions and failed properly to assess the evidence.
Her notes written up by another doctor stated "no child protection concerns"
They among the 40,000 pages of this inquiry also included those running Haringay Council and its Social Services and police child protection teams, all hiding behind a cloak of corporate responsibility. Ultimately this was not about systems, but individuals.
And yet Lord Laming's main recommendations are built around constructing a non- ambiguous line of accountability and responsibility that goes all the way to the top.
They include:
- A Children and Families Board chaired by a Cabinet minister
A National Agency for Children and Families with regional offices headed by a chief executive with responsibilities of a Children's Commissioner
And below him each local authority to have yet another Committee made up of senior people from all the agencies to ensure co-ordination of services
But in the Commons there was no mention of these proposals by the Health Secretary Alan Milburn in his statement.
This inquiry is the legacy of previous ones, which has produced a sackfull of guidance, legislation and reviews.
There have been 35 independent investigations in the UK since 1973.
Maria Colwell's was one of the first where agencies were seen to have failed in their duty to protect her.
In 1984 Jasmine Beckford inquiry prompted yet further warnings.
The tragedies of Tyra Henry, and Kimberley Carlisle followed soon after.
And in the past year, the deaths of Lauren Wright and Ainlee Labonte have led to two more inquiries in the shadow of Victoria Climbie's.
Today Victoria's parents occupied a position that many in the past have had to sit through.
